Nurse Educator

Nurse Educator Vol. 40, No. 6, pp. 313-317 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.

Leveraging Quality and Safety Education for Nurses to Enhance Graduate-Level Nursing Education and Practice Jean Johnson, PhD, RN, FAAN & Karen Drenkard, PhD, RN, NEA-BC, FAAN Esther Emard, MSN, RN, MSLIR & Kathy McGuinn, MSN, RN, CPHQ The purpose of this article is to provide information about the efforts to educate faculty teaching in graduate programs about the Quality and Safety Education for Nurses (QSEN) competencies, provide examples of teaching strategies for each graduate competency, and finally provide information about the outcomes of the graduate-faculty QSEN project. Examples are given of the critical QSEN work that remains to be done to ensure that care for patients and communities is high quality, safe, and reliable. Keywords: graduate nursing education; nursing education; Quality and Safety Education for Nurses (QSEN); teaching strategies

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he Quality and Safety Education for Nurses (QSEN) initiative grew out of a 1999 report, To Err Is Human,1 in which the Institute of Medicine (IOM) detailed that an estimated 98 000 patients were dying in hospitals of preventable medical errors. In a subsequent report from 2003, the IOM identified a core set of competencies that all health professionals should possess: (1) provide patient-centered care, (2) work in interprofessional teams, (3) use evidence-based practice, (4) apply quality improvement (QI), and (5) utilize informatics.2 More recently, the Patient Protection and Affordable Care Act passed in 2010 identified its main goal as the Triple Aim across all forms of health care. The Triple Aim includes (1) improve the health of populations, (2) enhance the patient experience of care (including quality and satisfaction), and (3) reduce the percapita cost of health care. QSEN addresses the challenge of preparing those charged with educating the next generation of nurses with the IOM competencies while focusing on improving health care outcomes for individual patients and populations that is consistent with the Triple Aim.

Author Affiliations: Founding Dean and Professor (Dr Johnson), School of Nursing, George Washington University, Washington, DC; Chief Clinical/ Nursing Officer (Dr Drenkard), GetWellNetwork, Bethesda, Maryland; Former COO (Ms Emard), National Committee for Quality Assurance Faculty, The George Washington University/School of Nursing; Director of Special Projects (Ms McGuinn), American Association of Colleges of Nursing, Washington, DC. The authors declare no conflicts of interest. Correspondence: Dr Johnson, 2030 M St, NW Ste 300, Washington, DC 20036 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: April 4, 2015 Published ahead of print: May 19, 2015 DOI: 10.1097/NNE.0000000000000177

Nurse Educator

Nurse educators who completed a QSEN faculty development institute have met the knowledge, skills, and attitudes (KSA) objectives for each of the 6 QSEN competencies. To date, the Robert Wood Johnson Foundation (RWJF) supported 4 phases of QSEN, including separate efforts to prepare undergraduate and graduate program faculty. Fortunately, QSEN continues to live on through the collaborative efforts of the American Association of Colleges of Nursing (AACN) and Case Western Reserve University (CWRU) School of Nursing. AACN has created a free faculty development resource for nurse educators teaching in undergraduate- and graduate- level programs. Cutting-edge, interactive Web-based modules are on the AACN Web site related to the QSEN competencies. Faculty have the opportunity to earn American Nurses Credentialing Center contact hours for each QSEN learning module. CWRU hosts the qsen.org Web site and facilitates the annual National QSEN Forums, which provide robust evidence-based resources and information for faculty. The purposes of this paper are to describe briefly the history of the QSEN project leading to the development of graduate-level KSA attitudes and to provide information about the efforts to educate faculty teaching in graduate programs about the QSEN competencies, examples of teaching strategies for each graduate competency, and finally information about the outcomes of the graduate-faculty QSEN project.

QSEN Background Developing the graduate-level QSEN KSAs was the fourth and final phase of the RWJF-funded QSEN project, which spanned nearly a decade. The first phase focused on the integration of quality and safety into every undergraduate curriculum in the country. KSAs were developed for each of the 6 competencies published in a special issue of Nursing Outlook,3 Volume 40 & Number 6 & November/December 2015

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and the QSEN Institute Web site4 was launched. The second phase funded schools of nursing from various types of institutions with varying levels of educational programs to pilot innovative mechanisms for introducing the KSAs. Phase 3 included 2 prongs of work to develop and enhance the QSEN Web site to make information about teaching strategies related to each competency available to a broad audience and initiate the National QSEN Forum for presentations of research related to quality and innovative ways of teaching the competencies. A grant to AACN supported the development of a ‘‘train the trainer’’ approach to disseminating information about how to integrate the competencies into entry-level nursing programs. Phase 4 focused on developing the KSAs for each competency aimed at graduate education.

Graduate-Level KSA Development and Dissemination KSA Development An advisory group was identified that included both clinicians and educators. Individuals from organizations that represented all 4 advanced practice RN roles as well as other master’s-level specialty areas participated. This group met in May 2012 and used the 2009 Nursing Outlook article5 on advanced QSEN competencies and the latest version of The Essentials of Master’s Education in Nursing6 to inform the work. The 2011 Master’s Essentials focused on competency expectation for graduates from a wide range of specialty areas, including education, administration, public health, and informatics. The advisory group used an iterative process to develop KSAs relevant to graduate education. Initial work was done in a face-to-face meeting that led to an initial draft of the KSAs. The draft was circulated back to the advisory group members for further comment. A second draft was done and recirculated for a final review. Eight nursing organizations reviewed and endorsed the KSAs, which were then posted on the AACN Web site in September 2012.7 KSA Dissemination Resource materials, learning modules accessible through the Web, and interactive case studies were developed. Five faculty development workshops were held that reached 490 nursing faculty from 276 institutions (more than half of all schools with graduate programs) in 48 states. During the 1-day workshops, 3 expert QSEN consultants presented theory bursts related to each of the QSEN competencies, and in breakout sessions, participants had the opportunity to network and develop QSEN competency learning experiences for graduate-level curricula. Representatives from academic institutions were strongly encouraged to bring clinical partners to the train-the-trainer workshops.

Overview of the QSEN Competencies and Examples of Teaching Strategies The QSEN KSAs at the graduate level build on the foundation previously developed for all prelicensure-prepared nurses. The advisory group recommended keeping several of the undergraduate KSAs for each of the competencies because they felt the KSAs were applicable to both undergraduate and graduate students. The advisory group also 314

defined competencies using the higher level of Bloom’s Taxonomy verbs, for example, analyze and synthesize. The following summarizes the competencies and provides 2 teaching strategies for each. For graduate level teaching tips, see Table, Supplemental Digital Content 1, http://links.lww.com/ NE/A223.8,9

Quality Improvement QI involves the use of data to monitor care processes combined with systematic methods to design and test changes to continuously improve the quality and safety of health care systems.3 Numerous measures have been developed to reflect specific aspects of care, including those that reflect the quality of nursing care such as the measures included in the National Database for Nursing Quality Indicators.10 Graduate-prepared nurses in all settings must be leaders in QI processes, including knowing what measures to monitor, characteristics of valid and reliable measures, strategies for engaging all staff in QI activities, and processes to improve care. The following teaching strategies have emerged from the work done on QI: Assignment 1: Assign students to complete an analysis of the QI requirements to be recognized as a patient-centered medical home (PCMH) by the National Committee for Quality Improvement and create a plan to address them. This will familiarize the student with the requirements for a PCMH and learn about the systems changes required to be PCMH. Activities: Students explore the specific requirements, assess a practice’s readiness to become a PCMH, and develop a plan to meet the requirements and identify the metrics of a successful implementation. Evaluation: Evaluation includes completeness of the assessment, plan, and evaluation. Assignment 2: Assign students to a project where the clinical site uses Health Care Effectiveness Data and Information Set measures as a benchmark to identify a problem and do a plan, do, study, act (PDSA) activity. Activities: Students identify a measure to be reported and below a national or institutional benchmark. They evaluate trend data to the extent possible, conduct a PDSA, and develop a strategy to address the problem, including recommendations on improving processes and engaging staff. Evaluation: Student performance is based on the completeness and appropriateness of the PDSA and recommendations. Informatics Health informatics is the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making.3 Managing and using knowledge have become complex. Evaluating Web sites, blogs, and social media can be time consuming for clinicians in keeping up with information that patients are gathering from an array of sources that include opinion and anecdotes. In addition, vast amounts of patient data are being produced through the use of electronic records that need to be used more effectively to improve care. Electronic health records will soon be fully implemented in all settings, which will allow patient data to be stored in the cloud and shared across setting as systems cross the interoperable divide. However, given the digital nature of patient data, cyber security is a major concern. The following are 2 suggested teaching strategies relevant to health informatics:

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Assignment 1: Assign a student or group of students to review evidence related to the effect of handheld devices in the management of a chronic illness. Activities: Assess the evidence of effectiveness of communications from patients to providers as well as communications from providers to patients using handheld devices in managing the illness. In addition, search for findings related gender, age, and culture to handheld device use. Based on review of the evidence, the student designs a program to manage a highly prevalent chronic illness using handheld electronic devices for communication. The plan should include an assessment of readiness of clinical agency to implement chronic illness management with personal devices, steps necessary to create acceptance of the project, cost of implementation, and a detailed evaluation plan. Evaluation: Student performance could be evaluated based on assessment of completeness of the review and all aspects of the plan. Assignment 2: Assign a student or group of students to do an assessment of an information technology system that supports a clinical practice to identify how information flows in the system: who gets what information and how the information is used by patients, providers, and administrative staff. Activities: The students assess how informatics affects workflow efficiency, support for teamwork, and use of information to support decisions. The students need to find a tool for evaluation of information flow or develop criteria for assessment. A final product of this exercise is a written report of findings with recommendations including specific action items. In addition, students could present the findings to the clinical agency. This project could be extended to have students implement the strategies included in the recommendations. Evaluation: Evaluation is based on the quality of the report with special attention to the recommendations for change.

Teamwork and Collaboration Teamwork and collaboration are defined as having the ability to function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.3 Teamwork is critical within practice settings as well as between settings. As the Affordable Care Act is implemented, patients will experience an increasing number of transitions of care given that the goal is to move the delivery of care outside the acute care settings.11 These transitions will require increased coordination of care achieved through teamwork and collaboration. Key aspects of teamwork include the knowledge to assess the scope of practice of the various team member roles and effectively influence the partnerships needed to improve care and care transitions.12 Teaching strategies related to teamwork include the following: Assignment 1: Assign students from different disciplines to work on a QI problem embedded in a case study of an outpatient setting to appreciate the power of teamwork. Activities: Students use the case studies to facilitate appreciation of how teamwork can lead to better outcomes by each student first independently analyzing the case and developing a plan of care and recommendations, and then as a team sharing strategies and negotiating a collective care plan. Evaluation: Evaluation is based on the quality of the negoNurse Educator

tiated plan of care by the teams. In addition, the teams should evaluate their teamwork, using 1 of the standardized Agency for Healthcare Research and Quality team surveys on team effectiveness, and identify the areas of opportunity for improvement. Assignment 2: Assign the students to view a mock scenario video based on an actual situation that has been written by faculty to better understand the roles and responsibilities of other health team members. Activities: Students analyze their own potential role and those of the other team members and how they are contributing to addressing the patient’s needs and recommend team strategies that could improve their effectiveness. Evaluation: Evaluation is based on the ability of students to demonstrate their valuing the contributions of other team members and assessment of the potential patient outcomes from how the team addresses the scenario.

Safety Safety is defined as minimizing the risk of harm to patients and providers through both system effectiveness and individual performance.3 Safety is considered the first domain of quality, and patients have a right to expect care that is both high quality and safe. The IOM has identified that inefficiently delivered services create excess costs to the health care system of $750 billion because of care fragmentation, preventable complications, and inefficiencies at the care delivery site.13 There are numerous public and private initiatives that demand an improvement in care, such as the Leapfrog Group’s annual public release of a single safety score for every hospital and the Center for Medicare & Medicaid Services’ ‘‘never events’’ denied payment policies. A student’s understanding of safety principles and concepts is evident by valuing teamwork and communication and using human factors and systems theory to address safety considerations. Teaching strategies for safety include the following: Assignment 1: Assign a group of students to study a potential safety situation or adverse event that has occurred to gain an understanding of patient safety issues and the applications of risk assessment methods. Activities: Students analyze data related to a patient safety event including the use of tools such as root-cause analysis, failure mode effect analysis, fault tree analysis, and tracer methodology. A full safety plan, including measures of success, is developed. Evaluation: Evaluation is based on the comprehensiveness of the safety plan, including the use of quantifiable measures, benchmarks, sound data collection methodology, barrier identification, and implementation/change strategies. Assignment 2: Students select a measure endorsed by the National Quality Forum such as the Use of High Risk Medications in the Elderly or the Nurse-Sensitive Measure of Falls Prevention or Pressure Ulcers, which are being used in many pay-for-performance quality programs. Students gain a comprehensive understanding of how performance measures are developed and used in current value based programs. Activities: Students evaluate the measure’s goals, specifications, and data collection methodology and then apply them to a current acute or post–acute care setting. Next, students develop a plan to improve the measure results based on the current evidence-based practice recommendations. Evaluation: Evaluation is based on the accuracy of the assessment of the Volume 40 & Number 6 & November/December 2015

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measure, its application to the setting, exclusions, criteria, and appropriate strategies to improve the measure’s results.

Evidence-Based Practice Evidence-based practice can be defined as applying the best available research results (evidence) into practice with the integration of clinical expertise and patient preferences and values.3 Safe, effective delivery of patient care requires the use of nursing practice consistent with the best available knowledge. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology. The following are 2 suggested teaching strategies relevant to evidence-based practice: Assignment 1: Assign students to the ‘‘Sacred Cows Contest’’ to encourage students to become aware of practice areas that may or may not be based on evidence. Activities: Students engage in a contest to identify ‘‘sacred cows’’ in practice. Each student interviews a clinician and asks them: (1) What is the most traditional nursing practice done in this clinical area? (2) What is the least logical nursing practice happening in your area? (3) What is the most time-consuming practice in your area? Once the interviews are complete, students do a literature search to obtain evidence about the practices identified and then determine if a change in practice would be necessary based on the evidence. Students should incorporate consideration of how patient preferences might be linked to the practices. Evaluation: Evaluation includes identification of practices that may not be based on evidence as well as the quality of the gathered evidence. Assignment 2: Assign students to develop a practice change based on evidence. Activities: Students work closely with the clinical site to develop recommendations based on the evidence-based practice process steps, prepare an environment for change, and implement a practice change. Evaluation: This assignment lends itself to evaluation by the student, clinical site, and faculty member: how effective was the practice change? Patient-Centered Care QSEN defines patient-centered care as recognizing 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.3 There are 6 dimensions of patient-centered care: (1) respect for patients’ values, preferences, and expressed needs; (2) coordination and integration of care through collaboration and teamwork; (3) accessibility and free flow of information, communication, and education; (4) physical comfort; (5) sensitivity to nonmedical and the spiritual dimension of care; and (6) involvement of family and friends. Two teaching strategies are described that relate to patient- and family-centered care. Assignment 1: Assign students to interview a patient to get the patient’s perspective of a care experience—good or bad. Activities: Students write a narrative about the care experience, read each other’s narratives, and answer the following questions: (1) Was the patient the source of control? (2) Was the care compassionate, coordinated, and reflective of the patient preferences, values, and needs? (3) How was the experience and narrative shaped by the nurses profes316

sional practice? (4) What were the patient-directed aspects of care? What aspects were provider directed? (5) What were missed opportunities to meet patient needs? (6) What promoted patient and family engagement? What were the barriers? Evaluation: Evaluation is based on the identification of changes in the care process that would more fully engage patients in their care based on descriptions of patient experiences. Assignment 2: Assign students to assess organizational readiness for patient-centered care. Activities: Student completes an assessment of an organization’s state of readiness to support patient- and family-centered care. Students could use an assessment tool from the QSEN Web site or a group of students could develop criteria for an assessment and then each student could use them. Based on the results, students assume the role of a unit or clinic leader charged with improving the patient experience. After analyzing and evaluating the data, students obtain best practice information and develop an action plan for improving patient satisfaction scores. Evaluation: Completion of the assessment and quality of recommendations for improvement for the clinical site and feedback from the faculty and the practice site could inform the evaluation process.

Evaluation To disburse the graduate-level QSEN competencies to a national audience, 5 regional faculty workshops were held during the 2012-2014 period. Presurvey data were obtained in addition to a 6-month postworkshop survey. The preworkshop data indicated that 92% of the attendees came from institutions that had incorporated the prelicensure QSEN competencies to some degree into their curriculum. Six-month postworkshop survey (n = 155) revealed that 57.4% of the attendees had incorporated a QI project, 43.2% a teamwork and collaboration simulation exercise, and 40.6% an evidence-base practice exercise in clinical decision making. Most attendees were planning to conduct a gap analysis after the workshop of the current graduate-level content to determine the extent to which current QSEN competencies need to be incorporated. Faculty indicated that their greatest familiarity was with the evidence-based practice and patient safety content, whereas the area of greatest challenge was informatics. The development of teaching strategies to assess students’ attitudes related to each of the competencies was identified as an area needing further teaching and evaluation strategy development.

Conclusion and Next Steps Between 2012 and 2014, QSEN phase 4 was able to both expand the QSEN competencies to the graduate level and provide faculty development workshops. Further work that needs to be done includes interprofessional faculty workshops and team training to support cross-discipline commitment to improving the caliber of teaching about quality and safety, improved alignment between schools of nursing and practice settings and extension of the work of QSEN to include continuing education opportunities for nurses; and simulation activities between clinical and academic partners with practicing nurses and graduate students integrated for such activities. This should be expanded to include other professionals within the academic and practice communities;

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continued faculty development workshops at both the regional and school of nursing levels with participation by clinical partners; continued evaluation of the integration of the QSEN competencies into both prelicensure and graduatelevel curricula; development of programs to advance education about the QSEN competencies for practicing nurses through innovative residency and pathways degree program offerings; consultation to schools to assess the current level of integration of QSEN competencies in graduate level coursework, with recommendations for improvement; and ongoing presentations and development of a national speaker’s bureau. While the health care system has focused for the past decade on improving quality and safety, much work remains to be done. Nurses are critical to improving care in all settings. Providing competency-based education for practitioners is a critical foundation to ensuring that care for patients and communities is safe and reliable.

References 1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999. 2. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academy Press; 2003. 3. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook. 2007;55(3):122-131. 4. QSEN Institute Web site. Available at http://qsen.org. Accessed May 26, 2014.

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5. Cronenwett L, Sherwood G, Pohl J, et al. Quality and safety education for advanced nursing practice. Nurs Outlook. 2009; 57(6):338-348. 6. American Association of Colleges of Nursing. The Essentials of Master’s Education in Nursing. Washington, DC: AACN. 7. American Association of Colleges of Nursing. Graduate-Level QSEN Competencies. Knowledge, Skills and Attitudes. QSEN Education Consortium Web Site. September 24, 2012. Available at http://www.aacn.nche.edu/faculty/qsen/competencies.pdf. Accessed May 26, 2014. 8. D’Amico M, Jaffee L. Lighten up your classroom. In: Bradshaw M, Lowenstein AJ, eds. Innovative Teaching Strategies in Nursing and Related Health Professions. 6th ed. Sudbury, MA: Jones and Bartlett; 2014. 9. Woodring B, Woodring R. Lecture is not a 4 letter word. In: Bradshaw M, Lowenstein AJ, eds. Innovative Teaching Strategies in Nursing and Related Health Professions. 4th ed. Sudbury MA: Jones and Bartlett; 2006:112-130. 10. American Nurses Association. 2014 Nursing Sensitive Indicators. Available at http://www.nursingworld.org/MainMenuCategories/ ThePracticeofProfessionalNursing/PatientSafetyQuality/ResearchMeasurement/The-National-Database/Nursing-SensitiveIndicators_1.aspx. Accessed June 30, 2014. 11. Health Policy Brief: care transitions. Health Aff. 2012;31(9): 2002-2009. 12. Eisler R, Potter M. Transforming Interprofessional Partnerships: A New Framework for Nursing and Partnership-Based Health Care. Indianapolis, IN: Sigma Theta Tau International; 2014. 13. Institute of Medicine. Best Care at Lower Cost. Washington, DC: National Academies Press; 2012.

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Leveraging Quality and Safety Education for Nurses to Enhance Graduate-Level Nursing Education and Practice.

The purpose of this article is to provide information about the efforts to educate faculty teaching in graduate programs about the Quality and Safety ...
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