Quality and Safety Education for Nurses

1. Quality and Safety Education for Nurses 2007 Jowers Lecture Linda Cronenwett, PhD, RN, FAAN December 5, 2007

2. Greetings from the University of North Carolina - Chapel Hill School of Nursing • Quality and Safety Education for Nurses (QSEN) • Linda Cronenwett • Principal Investigator, • Professor and Dean • Gwen Sherwood • Co-Investigator, • Professor and Associate • Dean for Academic Affairs

3. U.S. Institute of Medicine Quality Chasm Reports • To Err Is Human: Building a Safer Health System (2000) • Crossing the Quality Chasm: A New Health System for the 21st Century (2001) • Health Professions Education: A Bridge to Quality (2003) • Patient Safety: Achieving a New Standard for Care (2004) • Identifying and Preventing Medication Errors (2007)

4. Development of Safety Sciences • Worldwide, scientists in other industries uncovering knowledge about the interventions that produced safe systems • Lean, zero defect production systems • Aviation • Nuclear energy • Health care remains committed to the ideal of the individual professional as source of quality and safety

5. Impetus for Change • Variations in outcomes shown to be related to systems of care rather than individual patient characteristics • U.S. hospitals adopt quality improvement and safety science methods in the late 1990’s • Health care professionals in hospitals taught, one by one, about quality and safety • Yet -- • No health professions education on QI/safety

6. Impetus for Change in Nursing • People become nurses in order to relieve suffering and contribute to the overall health of communities and individuals • Quality care is an essential value • As nurses work in systems where quality is eroded, joy in work diminishes • Less joy in work leads to work force shortages • Health professionals run our systems -- they can improve our systems if they possess the competencies required to make improvement a part of daily work

7. Health Professions Education: A Bridge to Quality (2003) All health professionals should be educated to deliver patient-centered careas members of aninterdisciplinary team,emphasizingevidence-based practice, quality improvementapproaches, andinformatics.

8. Relative Focus of Education in the Health Professions • Professional knowledge • Individual learning • Individual consequences for error • Disciplinary focus • Systems knowledge • Team/Group learning • Learning from error • Interprofessional/ patient focus

9. Medicine’s Translation of General Competencies(Adopted February, 1999 by ACGME) • Patient Care • Medical Knowledge • Practice-based Learning and Improvement • Professionalism • Interpersonal and Communication Skills • Systems-based Practice

10. Goals • To alter nursing’s professional ‘identity’ so that when we think of what it means to be a respected nurse, we think not only of caring, knowledge, honesty and integrity…. • But also, that it means that we value, possess, and collectively support the development of quality and safety competencies

11. Quality and Safety Education for Nurses (QSEN) • Long-Range Goal • To reshape professional identity formation in nursing so that it includes commitment to the development and assessment of quality and safety competencies • Phase I: October 2005 – March 2007 • Phase II: April 2007 – September 2008

12. QSEN Personnel • QSEN Leaders based in UNC-Chapel Hill • QSEN Faculty – Experts in quality and safety from throughout the U.S. • QSEN Advisory Board – Leaders of organizations that set standards for nursing regulation, certification, and accreditation of nursing programs

13. QSEN Core Faculty • Jane Barnsteiner U Pennsylvania • Lisa Day UC San Francisco • Joanne Disch U Minnesota • Carol Durham UNC – Chapel Hill • Pamela Ironside Indiana U • Jean Johnson George Washington U • Pamela Mitchell* U Washington, Seattle • Shirley Moore Case Western Reserve • Dori Taylor Sullivan Sacred Heart, CT • Judith Warren U Kansas * Phase II: Deborah Ward U Washington, Seattle

14. QSEN Advisory Board Members • Paul Batalden IHI, ACGME • Geraldine Bednash AACN • Karen Drenkard AONE • Leslie Hall HPEC, ACT • Polly Johnson NCSBN • Maryjoan Ladden ACT • Audrey Nelson ANA Safe Patient Handling • Joanne Pohl NONPF • Elaine Tagliareni NLN * Phase II: Jeanne Floyd ANCC

15. QSEN Phase I • Define the territory (desired competencies) • Describe the knowledge, skills, and attitudes (KSAs) expected to be developed in prelicensure curricula • Disseminate/seek feedback and build consensus for inclusion of competencies in prelicensure curricula • Develop teaching strategies for classroom, group work, simulation, clinical site teaching, interprofessional learning • Create website resource for faculty

16. IOM/QSEN Competencies Cronenwett, Sherwood, Barnsteiner et al, 2007 • Patient-centered care: Recognize 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 • Teamwork and collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

17. IOM/QSEN Competencies Cronenwett, Sherwood, Barnsteiner et al, 2007 • Evidence-based practice: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care • Quality improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems

18. IOM/QSEN Competencies Cronenwett, Sherwood, Barnsteiner et al, 2007 • Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance • Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making

19. QSEN Assumptions • Competency definitions could serve the profession as: • Curricular threads • Foci of accreditation of nursing programs • Foci of licensure or certification exams • Foci of transition to work (residency) program development • Foci of criteria for recertification or relicensure

20. Current Assessments of Quality and Safety Education Smith, E. L., Cronenwett, L., & Sherwood, G. (2007). Current assessments of quality and safety education in nursing. Nursing Outlook, 55 (3), 132-137.

21. Summary • The overwhelming majority of schools reported that they • include content/learning experiences • are satisfied with students’ competency achievement, and • have the faculty expertise to teach the competencies patient-centered care, teamwork and collaboration, and safety

22. Summary • EBP, QI and Informatics are the competencies where a significant minority (25-43%) of schools reported desire for more content/learning experiences (but it was a minority, not majority, reporting they need to do something more) • These same competencies elicited mean ratings below “satisfied” for level of satisfaction with student competency achievement • These same competencies elicited lower ratings of faculty expertise to teach the topics

23. Prelicensure Knowledge, Skills and Attitudes (KSAs) by Competency Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P, & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131.

24. Example: Patient-centered care Cronenwett, Sherwood, Barnsteiner et al, 2007

25. Example: Safety Cronenwett, Sherwood, Barnsteiner et al, 2007

26. Examples: Focus Group Feedback • Faculty didn’t understand many KSAs (particularly related to safety, informatics and QI) • Faculty said “we’re not doing it – but we want to - tell us how” • Students/new grads said ‘Not only did we not learn this content, our faculty couldn’t have taught it” • Faculty report that nursing students can graduate never having had a meaningful patient-centered conversation with a physician

27. QSEN Publications • NCSBN Leader to Leader article – April 2007 • Special issue of Nursing Outlook May-June 2007 - five articles plus commentaries from AACN and NLN Presidents • Mailed to every nursing education program in country (using NCSBN mailing list) • Two NO articles the most frequently downloaded articles from January-June 2007

28. Policy Strategies • Shared products with professional organizations involved in licensure and certification or in accreditation of prelicensure programs

29. What and How Do We Guide Student Learning? www.qsen.org and Pilot School Learning Collaborative

30. QSEN Assumptions • Faculty and students are committed to quality and safety in all they do • Learning experiences aimed only at knowledge acquisition will be insufficient for development of competencies • Invitations to select from and experiment with a variety of curricular strategies will yield greater long-term gains than being highly prescriptive

31. Teaching Resource: QSEN Website • www.qsen.org • Competency definitions and KSAs • Annotated references by competency • Teaching strategies for classroom, clinical, skills/simulation labs, and interprofessional learning • Opportunity for all faculty to upload ideas and evaluations of teaching strategies Share your teaching strategies NOW

32. Website Sessions

33. QSEN Assumptions Each competency can be, indeed needs to be, taught or reinforced in multiple methods and sites Classroom Skills/simulation Lab Clinical Teaching Sites Interprofessional Courses Nursing Courses Papers Readings Web Modules Case Studies Reflective practice PBL

34. QSEN Phase II: Prelicensure Education • Pilot School Learning Collaborative • Goal: Engage prelicensure faculty members in developing and testing teaching strategies for the QSEN competencies • Call for proposals mailed to all nursing education programs in March, 2007 • 15 schools selected July 2007 from 53 applications

35. Augustana College (SD) Catholic University (DC) Charleston Southern Univ (SC) Curry College (MA) Emory University (GA) Lasalle University (PA) St. John’s College of Nursing/Southwest Baptist (MO) University of Colorado at Denver University of Massachusetts-Boston University of Nebraska Medical Center University of South Dakota, Sioux Falls University of Tennessee Health Science Center, Memphis University of Wisconsin-Madison University of Pittsburgh Medical Center-Shadyside School of Nursing (PA) Wright State University (OH) QSEN Learning Collaborative

36. QSEN Learning Collaborative • All have committed practice partners • Associate degree, diploma, BSN programs in schools without graduate programs, and BSN programs in universities • Our “edgerunners” • Some focusing on simulation • Some focusing on innovations in clinical teaching • Some focusing on curriculum as a whole

37. QSEN Learning Collaborative • Collaborative meetings (October, 2007 and June, 2008) • Evaluate one class of graduating students’ perceptions of competency achievement • Produce a curricular map with the quality and safety KSAs integrated into their pre-licensure curriculum • Develop and evaluate teaching strategies for classroom, clinical, and simulation/skills laboratories • Share teaching strategies through submissions to the QSEN website • Document specific challenges encountered in the process of curricular change • Share successful strategies for overcoming challenges with others in collaborative conferences and conference calls

38. QSEN Assumptions • Nurses in practice settings are critical partners in accomplishing competency development • Examples: • Staff are role models for how these competencies define what it means to be a respected and qualified nurse • Students and faculty know the safety and QI initiatives – always know the ‘next likely error’ in the setting • Students learn from staff what “good care” is and how “local care” compares to that standard

39. QSEN Assumptions • Students use information technology during clinical practice • Students see team skills in action in communications between nurses and other health professionals • Students see patients and families involved as partners in care • Health professions students in a setting interact with each other in improvement work • Transition to practice programs build on the competency development from pre-licensure programs

40. Quality and Safety Education for Nurses Graduate Education

41. Phase I: Graduate Education • Sought feedback from major APN organizations about KSAs: Can they represent all of nursing? • Added NONPF representative to Advisory Board

42. QSEN Phase II: Graduate Education • April, 2007 workshop • Representatives of nurses in advanced practice responsible for: • Standards of practice • Accreditation of education programs • Certification of APNs • QSEN faculty and advisory board

43. Graduate Education Initial conversation: • Focus on advanced practice rather than all advanced roles • Focus on advanced practice rather than the type of program in which the graduate student is prepared • Focus on goal of assisting faculty who wish to develop quality and safety competencies already identified as essential elements

44. Graduate Education Workshop Topics • Are the competency definitions relevant to APNs? All of nursing? • Which of the prelicensure KSAs are also relevant objectives for APN education? • What new KSAs, if any, should be added at the graduate level? • Will KSAs vary by specialty and role or can they encompass all APNs?

45. Graduate Education KSAs On the following slides: • Green represents language of prelicensure KSA • Black represents that same KSA in language proposed for APN education • Blue represents an item without a correlary in the prelicensure KSAs

46. Example: Patient-centered Care

47. Example: Teamwork and Collaboration

48. Example: Evidence-based Practice

49. Example: Quality Improvement

50. Example: Safety