Quality and Safety
Education for Nurses
2007 Jowers Lecture
Linda Cronenwett, PhD, RN, FAAN
December 5, 2007
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
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)
Development of Safety Sciences
 Worldwide, scientists in other industries
uncovering knowledge about the
interventions that produced safe systems

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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
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
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
Health Professions Education: A
Bridge to Quality (2003)
All health professionals should be educated to
deliver patient-centered care as members of an
interdisciplinary team, emphasizing evidencebased practice, quality improvement
approaches, and informatics.
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
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
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
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
QSEN Personnel
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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
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

QSEN Advisory Board Members
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Paul Batalden
Geraldine Bednash
Karen Drenkard
Leslie Hall
Polly Johnson
Maryjoan Ladden
Audrey Nelson
Joanne Pohl
 Elaine Tagliareni
* Phase II: Jeanne Floyd

IHI, ACGME
AACN
AONE
HPEC, ACT
NCSBN
ACT
ANA Safe Patient
Handling
NONPF
NLN
ANCC
QSEN Phase I
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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
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 interprofessional teams, fostering open
communication, mutual respect, and shared
decision-making to achieve quality patient
care
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
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
QSEN Assumptions

Competency definitions could serve the
profession as:
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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
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.
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
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
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.
Example: Patient-centered care
Knowledge
Skills
Attitudes
Examine common
barriers to active
involvement of patients
in their own health care
process
Remove barriers to
presence of families and
other designated
surrogates based on
patient preferences
Respect patient
preferences for degree of
active engagement in
care process
Describe strategies to
empower patients or
families in all aspects
of the health care
process
Engage patients or
designated surrogates in
active partnerships that
promote health, safety
and well-being, and selfcare management
Respect patient’s right to
access to personal health
records
Cronenwett, Sherwood, Barnsteiner et al, 2007
Example: Safety
Knowledge
Discuss effective
strategies for reducing
reliance on memory
Describe processes
used in understanding
causes of error and
allocation of
responsibility (such as,
root cause analysis)
Skills
Use appropriate
strategies for reducing
reliance on memory
(such as, forcing
functions and checklists)
Use organizational error
reporting systems for
near miss and error
reporting
Engage in root cause
analysis rather than
blaming when errors or
near misses occur
Attitudes
Appreciate the cognitive
and physical limits of
human performance
Value own role in
preventing errors
Value vigilance and
monitoring (even of own
performance of care
activities) by patients,
families, and other
members of the health
care team
Cronenwett, Sherwood, Barnsteiner et al, 2007
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
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
Policy Strategies
 Shared products with professional
organizations involved in licensure and
certification or in accreditation of prelicensure
programs
What and How Do We
Guide Student Learning?
www.qsen.org
and
Pilot School Learning Collaborative
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
Teaching Resource: QSEN Website
 www.qsen.org
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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
Website Sessions
QSEN Assumptions
Each competency can be, indeed needs to be,
taught or reinforced in multiple methods and
sites
Classroom
Skills/simulation Lab
Interprofessional
Courses
Web
Modules
PBL
Papers
Clinical Teaching Sites
Nursing Courses
Readings
Case
Studies
Reflective
practice
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
QSEN Learning Collaborative
 Augustana College (SD)
 Catholic University (DC)
 Charleston Southern Univ
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(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 MassachusettsBoston
 University of Nebraska
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Medical Center
University of South Dakota,
Sioux Falls
University of Tennessee
Health Science Center,
Memphis
University of WisconsinMadison
University of Pittsburgh
Medical Center-Shadyside
School of Nursing (PA)
Wright State University (OH)
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”
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Some focusing on simulation
Some focusing on innovations in clinical
teaching
Some focusing on curriculum as a whole
QSEN Learning Collaborative
 Collaborative meetings (October, 2007 and June, 2008)
 Evaluate one class of graduating students’ perceptions of
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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
QSEN Assumptions
 Nurses in practice settings are critical partners
in accomplishing competency development
 Examples:
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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
QSEN Assumptions
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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
Quality and Safety
Education for Nurses
Graduate Education
Phase I: Graduate Education
 Sought feedback from major APN
organizations about KSAs: Can they
represent all of nursing?
 Added NONPF representative to Advisory
Board
QSEN Phase II: Graduate Education
 April, 2007 workshop
 Representatives of
nurses in advanced
practice responsible for:
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Standards of
practice
Accreditation of
education programs
Certification of APNs
NONPF (2)
ONCC (1)
NACNS (2)
CCNE (2)
ACNM (1)
APNA (1)
Council on
AACN Cert
Accreditation Board (1)
of CRNAs (1) (critical care)
 QSEN faculty and
advisory board
ANCC (2)
ANA (2)
Ped Nurs
Cert Board 2)
Graduate Education
Initial conversation:
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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
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?
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
Example: Patient-centered Care
Knowledge
Discuss principles of
effective
communication
---------------------Integrate principles of
effective
communication with
knowledge of quality
and safety
competencies
Describe process of
reflective practice
Skills
Participate in building
consensus or resolving
conflict in the context of
patient care
--------------------Provide leadership in
building consensus or
resolving conflict in the
context of patient care
Attitudes
Respect patient
preferences for degree of
active engagement in
care process
-----------------------Valued shared decisionmaking with empowered
patients and families,
even when conflict occurs
Create or change
Value cultural humility
organizational cultures
so that patient and family Value the process of
preferences are
reflective practice
assessed and supported
Example: Teamwork and Collaboration
Knowledge
Skills
Attitudes
Describe own
strengths, limitations,
and values in
functioning as a
member of a team
---------------------Analyze own strengths,
limitations, and values
as a member of a team
Clarify roles and
accountabilities under
conditions of potential
overlap in team-member
functioning
--------------------Guide the team in
managing areas of
overlap in team member
functioning
Acknowledge own
potential to contribute to
effective team functioning
-----------------------Acknowledge own
contributions to effective
or ineffective team
functioning
Analyze impact of own
advanced practice role
and its contributions to
team functioning
Initiate and sustain
effective health care
teams
Appreciate the
importance of interprofessional collaboration
Example: Evidence-based Practice
Knowledge
Explain the role of
evidence in
determining best
clinical practice
----------------------Analyze how the
strength of available
evidence influences the
provision of care
(assessment, dx, tx,
and evaluation)
Skills
Read original research
and evidence reports
related to area of
practice
----------------------------Critically appraise
original research and
evidence summaries
related to area of
practice
Exhibit contemporary
Determine evidence
knowledge of best
gaps within the practice evidence related to
specialty
practice specialty
Attitudes
Appreciate the
importance of regularly
reading relevant
professional journals
---------------------------Value knowing the
evidence base for
practice area
Value public policies that
support evidence-based
practice
Recognize importance of
search skills in locating
best evidence
Example: Quality Improvement
Knowledge
Skills
Describe strategies for
learning about the
outcomes of care in the
setting in which one is
engaged in practice
----------------------------Describe strategies for
improving outcomes of
care in the setting in
which one is engaged
in practice
Seek information about
outcomes of care for
populations served in
care setting
-----------------------------Use a variety of sources
of information to review
outcomes of care and
identify potential areas for
improvement
Assert leadership in
Explain common
shaping the dialogue and
causes of variation in
providing leadership for
outcomes of care in the the introduction of best
practice specialty
practices
Attitudes
Appreciate how
unwanted variation
affects care
----------------------------Appreciate the
importance of data that
allows one to estimate
the quality of local care
Appreciate that all
improvement is change
but not all change is
improvement
Example: Safety
Knowledge
Discuss effective
strategies to reduce
reliance on memory
--------------------------Evaluate effective
strategies to reduce
reliance on memory
Skills
Participate appropriately
in analyzing errors and
designing system
improvements
----------------------------Design and implement
microsystem changes in
response to identified
hazards and errors
Describe best practices
that promote patient and
provider safety in the
Report errors and support
practice specialty
members of the health
care team to be
forthcoming about errors
and near misses
Attitudes
Value own role in
preventing errors
-----------------------------Value own role in reporting
and preventing errors
Appreciate the importance
of being a safety mentor
and role model
Value the use of
organizational error
reporting systems
Example: Informatics
Knowledge
Describe examples of
how technology and
information
management are related
to quality and safety of
patient care
--------------------------Describe and critique
taxonomic and
terminology systems
used in national efforts
to enhance
interoperability of
information and
knowledge management
systems
Skills
Navigate the electronic
health record
----------------------------Model behaviors that
support implementation
and appropriate use of
electronic health records
Attitudes
Value technologies that
support clinical decisionmaking, error prevention,
and care coordination
-----------------------------Appreciate the need for
consensus and
collaboration in developing
systems to manage
Participate in the design
of clinical decision-making information for patient care
supports and alerts
Appreciate the contribution
of technological alert
systems
Participant Responses
 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?
Graduate Education: Next Steps
 Draft 2 under review by all participants and
their organizations
 Feedback received in November, awaiting
full analysis
 Dissemination