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Assessing quality and safety competencies of graduating prelicensure nursing students
Assessing quality and safety competencies of graduating prelicensure nursing students Dori Taylor Sullivan, PhD, RN, NE-BC, CNL, CPHQ Denise Hirst, MSN, RN Linda Cronenwett, PhD, RN, FAAN
The Quality and Safety Education for Nurses (QSEN) project is focused on enhancing nursing curricula and fostering faculty development to support student achievement of quality and safety competencies. The purpose of this descriptive study was to assess student perspectives of quality and safety content in their nursing programs along with self-reported levels of preparedness and perceived importance of the 6 QSEN competencies. Graduating students (n ¼ 565) from 17 US schools of nursing completed an electronic student evaluation survey. Students reported exposure to QSEN knowledge areas, more often in classroom and clinical learning settings than in skills lab/simulation settings. Clinical experience outside of formal education was associated with perceptions of a higher level of preparedness for QSEN skills in several competencies. In general, students reported relatively high levels of preparedness in all types of prelicensure nursing programs and endorsed the importance of quality and safety competencies to professional practice.
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ver the last 5 years, increasing focus on the need to better prepare nursing graduates for the realities of the practice environment has centered on patient safety and quality topics. A major national initiative, Quality and Safety Education for Nurses (QSEN), funded by the Robert Wood Johnson Foundation, sought to define competencies for prelicensure nursing students using an adapted version of the Institute of Medicine
Dori Taylor Sullivan, PhD, RN, NE-BC, CNL, CPHQ, is Associate Dean for Academic Affairs and Clinical Professor, Duke University School of Nursing, Durham, NC. Denise Hirst, MSN, RN, is QSEN Project Director and Clinical Assistant Professor, University of North Carolina at Chapel Hill, NC. Linda Cronenwett, PhD, RN, FAAN, is Professor, School of Nursing, University of North Carolina at Chapel Hill, NC. Corresponding author: Dr. Dori Taylor Sullivan, Associate Dean for Academic Affairs, Duke University School of Nursing, 307 Trent Drive, DUMC 3322, Durham, NC 27710. E-mail: [email protected] Nurs Outlook 2009;57:323-331. 0029-6554/09/$–see front matter Copyright ª 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2009.08.004
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competencies.1 QSEN’s primary goal is to ‘‘address the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems in which they work.’’2 The QSEN competencies include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Each QSEN competency is defined and further explicated through statements regarding KSAs that should be developed during prelicensure nursing education programs. After defining the quality and safety competencies and KSAs, QSEN continued its work through identification and sharing of effective teaching tools and related materials via a website (http://www.qsen.org) and through selection of pilot schools willing to participate in the QSEN Learning Collaborative. The QSEN Learning Collaborative called for participating schools to design and implement curricular innovations reflecting quality and safety content that would be disseminated to other schools to promote shared learning. A description of the activities and outcomes of the QSEN Learning Collaborative is included in a companion article in this issue.3 During the first QSEN Learning Collaborative meeting, there was consensus among the QSEN faculty and pilot school representatives that evaluation of student perceptions of quality and safety content and competencies was an important goal. Furthermore, given the paucity of knowledge about how to evaluate quality and safety competency development, it was considered appropriate to begin by assessing student perceptions. This article describes the development, administration, and results of a survey measuring student perceptions of the extent to which they had acquired KSAs essential to the development of quality and safety competencies during their prelicensure programs. Specific aims included (1) determining student perceptions of whether and in what manner they were exposed to knowledge related to quality and safety competencies, (2) assessing student perceptions of how prepared they were to perform quality and safety skills, (3) assessing student attitudes about the importance of learning skills
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The final instrument consisted of 26 items with three subscales: knowledge, skills, and attitudes. As in earlier studies,5–8 students’ patient safety knowledge and skills increased significantly after relevant curricular content was incorporated. In summary, there is budding interest in assessing the KSAs associated with quality and safety competencies among samples of healthcare providers in practice and health professional students. Most of the emphasis has been on the competencies of patient safety, informatics, and evidence-based practice. Some studies uncovered gaps in students and practicing nurses’ knowledge and skills through survey techniques, although response rates were typically low. No instrument was sufficiently developed to accomplish the aims of this study with respect to all 6 QSEN competencies.
fundamental to quality and safety competencies, (4) assessing the impact of clinical experience outside of nursing school on student preparedness ratings, and (5) determining whether student perceptions of quality and safety education vary by type of prelicensure program.
REVIEW OF LITERATURE Early efforts to assess KSAs related to quality and safety competencies focused primarily on patient safety, as exemplified by a national education needs assessment survey of nurses and physicians4 and measurement of cultures of safety among both students and practicing professionals across nursing, medicine, and other health disciplines.5–7 A variety of approaches to educational program content and methods was found to develop increased knowledge of safety and quality, and improved skill levels along with the positive attitudes believed to enhance consistent application of these concepts in practice. During the early phase of the QSEN project, a descriptive study using survey methodology was undertaken to document the current state of prelicensure nursing education, with respect to the 6 QSEN competencies in Bachelor of Science in Nursing (BSN) (n ¼ 195) and Associate Degree in Nursing (ADN) (n ¼ 23) programs.8 More than 95% of respondents indicated that content related to each QSEN competency was threaded through their curricula, with 10–18% reporting that they had dedicated courses. Of the QSEN competencies, quality improvement and informatics content were least often included in curricula, whereas patient-centered care and safety content were most often included. Several investigators focused on specific competencies in nursing populations, with informatics and evidencebased practice most frequently addressed. In studies of information technology skills, including computer usage and information literacy, McNeil et al.9 reported greater focus on computer skills than information literacy skills in 80% of 266 schools, and Fetter10 found that graduating baccalaureate nurses in a pilot sample of 42 students reported their ability as moderate. Recommendations for enhancing curricular integration of informatics suggested by both studies included improving faculty skills and attitudes, and clearer competency expectations for prelicensure nursing education. Two large studies of practicing staff nurses have assessed familiarity of this population with the term ‘‘evidence-based practice.’’ Fewer than half of registered nurses (RNs) surveyed by Pravikoff et al.11 in 2005 reported awareness of evidence-based practice. Cadmus et al.12 in a comparable study 3 years later found that 82% were familiar with this term. Schnall et al.13 developed a 35-item self-report instrument to measure student KSAs concerning patient safety. The instrument was tested with 285 students in year 1 of a BSN-to-MSN advanced practice nursing program. 324
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THE QSEN STUDENT EVALUATION SURVEY (SES) Development of the QSEN Student Evaluation Survey (SES) The QSEN KSAs for each of the 6 competencies represented the domain of interest for the QSEN student evaluation survey (SES). Inclusion of all KSA elements was not feasible, however, because the length of the survey would have created too great a participant burden to achieve acceptable response rates. Therefore, expert reviewers (the QSEN Principal Investigators, Advisory Board, and Faculty) proposed sets of items that would represent each competency. The items comprising the SES were approved for pilot testing and prepared for administration using the Survey Monkey online platform. The SES consists of 3 primary questions related to (1) knowledge: whether and where 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. Student respondents identified their schools for purposes of aggregate reporting. The ‘‘knowledge’’ scale of the survey included 19 knowledge objectives from the QSEN competencies and asked students to indicate the venues in which they had learned content pertaining to each topic using a set of 5 categorical response options (classroom, course assignments/readings, clinical experiences, lab/ simulations, not covered). The 19 items were drawn from each of the 6 QSEN competencies, thus allowing assessment of responses by competency as well as by individual items. Self-reported levels of preparedness to perform skills in all 6 QSEN competencies were assessed in the ‘‘skills’’ scale of the survey with 22 items, each scored on a 4-point Likert-type scale with response options of: ‘‘very unprepared,’’ ‘‘somewhat unprepared,’’ ‘‘somewhat prepared,’’ and ‘‘very prepared.’’ Finally, the ‘‘attitudes’’ scale of the survey asked respondents to rate the importance of the 22 skill items O
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Table 1. SES Items by QSEN Competencies for Knowledge and Skills/ Attitudes Scales QSEN Competency Knowledge scale PC Patient-centered care EB Evidence-based practice TC Teamwork and collaboration QI Quality improvement
Number of Items
Sample Items
4 2 5
Strategies to empower patients or families as partners in care The role of evidence in determining best clinical practice Scopes of practice and roles of other professionals on the healthcare team Approaches to improving processes of care (quality improvement) Role of human factors and basic safety design principles in assuring safety How technology and information management are related to the quality and safety of patient care
3
S Safety
4
I
1
Informatics
TOTAL Skills and attitudes scales PC Patient-centered care EB Evidence-based practice TC Teamwork and collaboration QI Quality improvement S Safety I Informatics TOTAL
19 5
Engage patients or designated surrogates in partnerships to promote health, safety, well-being, and self-care Consult with clinical experts before deciding to deviate from evidence-based protocols Demonstrate awareness of own strengths and limitations as a care team member Use quality improvement tools such as flow charts, cause/effect diagrams Use organizational systems for near miss and error reporting Document and plan patient care in an electronic health record
4 3 3 3 4 22
from the skills scale (regardless of the level of preparation they had reported) using a 4-point Likert-type scale with response options of: ‘‘very unimportant,’’ ‘‘somewhat unimportant,’’ ‘‘somewhat important,’’ and ‘‘very important.’’ Table 1 provides sample items of the SES, with the number of items representing each QSEN competency within the KSA scales.
Pilot Testing of the QSEN SES Sample and Methods. After obtaining appropriate Institutional Review Board approvals for the overall survey project (pilot testing and subsequent survey administration among the QSEN Learning Collaborative Schools), 3 schools of nursing not involved with the QSEN initiative (1 BSN and 1 ADN school in North Carolina, and 1 ADN school in Florida) agreed to participate in a pilot test of the SES. Prelicensure students within 6 months of their graduation dates completed the SES (n ¼ 25) and then participated in focus groups (n ¼ 23) conducted by 2 of the authors using a semistructured question format. Student Responses. Students who completed the pilot survey thought that it reflected topics important to their practice as a professional nurse. Several items were reworded to enhance clarity in response to pilot N
feedback. Most importantly, the potential influence of work experience in a clinical setting (most often as some type of clinical assistant) either before or during nursing school emerged during the focus groups. Therefore, an additional demographic question was added to the SES to capture the amount and type of students’ patient care experience outside of formal nursing school education. An ‘‘other comments’’ section was added to the survey in case survey respondents wished to share additional insights.
Administration of the QSEN SES Sample. The SES was administered to eligible students at the 15 QSEN pilot schools (listed in the table in a companion article in this issue3), and at 2 BSN programs in which professors were QSEN core faculty (see Acknowledgments). Eligible students were defined as those enrolled in prelicensure nursing programs who were within 6 months of graduation. This range was necessary to accommodate varying graduation dates from several programs. The sample included 2 (12%) ADN programs, 14 (82%) BSN programs, and 1 (6%) diploma school of nursing from a total of 14 US states. Methods. For each school, a primary faculty contact agreed to provide information to eligible students about the QSEN project and forward a list of eligible student
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systems for near-miss and error reporting (3.1). Students felt most prepared to perform skills and actions related to a) assess presence and extent of pain and suffering (3.6); b) demonstrate awareness of own strengths and limitations as a care team member (3.5); and c) communicate observations or concerns related to hazards or errors in the care environment (3.5). Table 3 shows mean preparedness scores for the total sample on skill items in each of the 6 QSEN competencies and means by program type: Bachelor of Science with graduate programs (BSG), Bachelor of Science program only (BSN), and Associate degree programs (ADN). Because only one diploma school was included in the sample, those responses are included in the ‘‘All Responses’’ column but are not listed separately. Students across all schools reported that they were somewhat or very prepared in skills representing each of the 6 competencies. Respondents felt most prepared in skills related to patient-centered care and informatics and least prepared in skills related to evidence-based practice and quality improvement. Although mean scores varied across the 17 schools, there was almost no variability in mean ratings by program type. Attitudes: Student Ratings of Importance of Quality and Safety Competencies. Students were asked to rate the importance of the 22 skill items as a proxy for their attitudes regarding quality and safety competencies. Response options ranged from 1 (very unimportant) to 4 (very important). The mean of all responses regarding importance of items was 3.8, with an individual item mean range of 3.4–3.8. The skills students cited as most important for nurses to be able to perform in their first year of practice included: a) assess presence and extent of pain and suffering (3.8); b) communicate care provided and needed at each transition in care (referred to as hand-offs) to minimize risk (3.8); and c) demonstrate effective use of strategies to reduce risk of harm to self or others (3.8). Although mean scores on all items were 3.4 or higher, the items receiving the lowest ratings of importance were: a) use quality improvement tools such as flow charts, cause/effect diagrams (3.4); b) locate evidence reports related to clinical practice topics and guidelines (3.4); and c) evaluate the effect of practice changes using quality improvement methods and measures (3.4). Table 4 shows the mean importance ratings for each of the 6 QSEN competencies by program type. As in the results for self-rated levels of preparedness on skill items, respondents said that the most important skills for new nurses were in the areas of patient-centered care and the least important were in evidence-based practice and quality improvement. However, safety was seen as the second most important competency (vs. informatics in the preparedness section). Again, although mean scores across the 17 schools varied, there was limited variability by program type.
e-mail addresses for electronic delivery of the SES. Surveys were distributed via e-mail using Survey Monkey between April and June of 2008, with 1 school delayed until September 2008. E-mailed reminders using Survey Monkey were sent at 2 and 4 weeks.
Results of the QSEN SES Response Rates. The SES was distributed to 1665 students via e-mail. A total of 575 students completed the SES, for a response rate of 35%. Student response rates among the 17 participating schools varied from 16–56%. Surveys with substantial missing data, defined as those missing responses on more than 25% of items (n ¼ 10, 1.7%), were excluded from the analysis. Other surveys with fewer skipped questions (n ¼ 64, 11%) were retained in the analysis along with the fully completed surveys. In the final sample (n ¼ 565), the frequency of items with missing data was similar across the three scales (knowledge: 11%; skills: 12%; attitudes: 13%). Knowledge: Student Perceptions of Quality and Safety Curriculum Content. Student respondents indicated whether and in what learning venues each of the 19 topics had been included. Table 2 lists the three knowledge content areas that were perceived by students as most frequently and least frequently taught for each of the 4 learning venues. In addition, it lists the 3 items most often identified by students as ‘‘not covered.’’ Also listed is the percentage of respondents who reported having been taught the item. All of the most frequently included items in the curriculum in each of the 4 learning venues (the 12 items listed in Table 2) belonged to 3 of the 6 competencies: patient-centered care, safety, and evidence-based practice. In contrast, 10 of the 12 items least frequently included belonged to the Quality Improvement and Teamwork and Collaboration competencies, as did the 3 items most commonly reported as not covered in any learning venue. As indicated in Figure 1, in all but 1 QSEN competency (patient-centered care), students reported that QSEN knowledge objectives were most frequently learned in the classroom, followed (in order of decreasing frequency) by course assignments/readings, clinical experience, and lab/simulation. Skills: Self-Reported Student Preparedness for Skills Related to Quality and Safety Competencies. Students were asked to self-report their preparedness to perform a list of actions or skills derived from the KSAs from the 6 QSEN competencies, with higher scores indicating perceptions of being better prepared. The mean of all responses to all skill items was 3.3 (3 ¼ somewhat prepared, 4 ¼ very prepared), with means for individual skill items ranging from 3.0–3.6. The lowest scores across the entire sample were for the following skills: a) consult with clinical experts before deciding to deviate from evidence-based protocols (3.0); b) evaluate the effect of practice changes using quality improvement methods and measures (3.0); and c) use organizational 326
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Table 2. Knowledge Topics Most and Least Frequently Reported to be in the Curriculum, with Associated QSEN Competencies* Mean, Total Most Frequent Items
Range by School
Sample
High
Low
95%
100%
87%
Principles of effective communication with patients (PC)
91%
100%
86%
Diverse cultural, ethnic, and social backgrounds as sources of patient, family and community values (PC)
90%
100%
85%
Classroom Concepts of pain and suffering and associated nursing interventions (PC)
Course assignments/ readings Diverse cultural, ethnic, and social backgrounds as sources of patient, family and community values (PC)
83%
85%
68%
Concepts of pain and suffering and associated nursing interventions (PC)
82%
84%
71%
The role of evidence in determining best clinical practice (EB)
81%
86%
70%
87%
92%
81%
86%
87%
83%
79%
92%
68%
40%
49%
13%
Clinical experiences Concepts of pain and suffering and associated nursing interventions (PC)
Principles of effective communication with patients (PC) Benefits and limitations of safety enhancing technologies (eg, bar coding, medication pumps, alarms) (S) Lab/simulations General types of hazards and errors in care (S)
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Mean, Total Least Frequent Items
Sample
High
Low
61%
70%
55%
70%
76%
54%
73%
100%
68%
43%
49%
30%
49%
62%
43%
55%
71%
46%
27%
31%
24%
33%
83%
24%
49%
59%
46%
5%
9%
0%
Classroom Methods for determining how care quality in a local setting compares to national benchmarks (QI) Impact of perceived power differentials among healthcare team roles on teamwork and patient safety (nursing and other disciplines) (TC) Processes used in analyzing causes of errors (e.g., root cause analysis) (QI) Course assignments/ readings Methods for determining how care quality in a local setting compares to national benchmarks (QI) Impact of perceived power differentials among health care team roles on teamwork and patient safety (nursing and other disciplines) (TC) Processes used in analyzing causes of errors (eg, root cause analysis) (QI) Clinical experiences Methods for determining how care quality in a local setting compares to national benchmarks (QI) Processes used in analyzing causes of errors (eg, root cause analysis) (QI) Reliable sources for locating evidence-based reports and clinical practice guidelines (EB) Lab/simulations Methods for determining how care quality in a local setting compares to national benchmarks (QI)
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Table 2. Continued
Most Frequent Items Benefits and limitations of safety enhancing technologies (eg, bar coding, medication pumps, alarms) (S) Role of human factors and basic safety design principles in assuring safety (S)
Range by School
Mean, Total Sample
High
Low
39%
53%
29%
38%
47%
33%
Range by School
Mean, Total Sample
High
Low
Health care organization characteristics that influence effective team functioning (TC)
10%
21%
6%
Diverse cultural, ethnic, and social backgrounds as sources of patient, family, and community values (PC)
10%
13%
10%
11%
23%
5%
15% 24%
19% 35%
11% 13%
Least Frequent Items
Not covered in any learning venue Impact of perceived power differentials among healthcare team roles on teamwork and patient safety (nursing and other disciplines) (TC) Processes used in analyzing causes of errors (eg, root cause analysis) (QI) Methods for determining how care quality in a local setting compares to national benchmarks (QI)
*PC, Patient-centered care; EB, evidence-based practice; TC, teamwork and collaboration; QI, Quality improvement; S, safety; I, informatics.
students from ADN programs had higher ratings than students from BSG programs (by Tukey’s HSD posthoc comparison). No significant differences between type of program or experience were found for skill preparedness related to evidence-based practice, patientcentered care, or quality improvement. Students with patient care experiences outside of nursing school had a higher mean total skill preparedness score (F[1471] ¼ 4.64, p ¼ .03), but there was no significant difference among program types. No effect of program type or interaction of program type with clinical experience was found on the individual competency or total scores for ratings of the importance (attitudes) of the 6 competency domains. As noted previously, the results reported from the student sample as a whole mask variation that was found across individual schools. Referring back to Tables 3 and 4, the range of school means shows substantial variation among schools, with mean differences as high as 1.0 and 1.5 for quality improvement preparedness and importance ratings, respectively. Variation in the extent of student experience outside of the nursing program was one factor in explaining these differences. Thematic Analysis of Respondent Comments. Fortysix (46) respondents posted comments at the end of the SES. Of these, 31 relevant responses were content-analyzed, yielding 4 themes. The most frequent comments related to the quality of the nursing program attended (48% positive quality, 6% negative quality). The 3 remaining themes in descending order of frequency were perceptions of the gap between theoretical classroom
Impact of Clinical Experience and Program Type on Ratings of Preparedness and Importance of QSEN Competencies. Overall, 372 of 565 students (66%) reported having patient care experiences outside of their nursing education programs. More than half of those with experience had been certified nursing assistants, and 37% of these had 1–2 years of experience. There were no significant differences between types of schools, with respect to the proportions of students with experience outside of nursing school, although there was wide variation across individual schools. A two-way analysis of variance (ANOVA) was used to examine the effects of program type, experience outside of nursing school (a dichotomous yes-or-no response), and the interaction of those factors on ratings of the QSEN competencies. Scores were calculated for students’ ratings of their preparedness (skills) and perceptions of importance (attitudes) by QSEN competencies separately and across all competencies in total scores. The interaction of program type and experience did not have a significant effect on any of the ratings of skills preparedness; therefore, the ANOVAs for the scores related to preparedness were re-estimated with only the main effects of program type and experience. Students with patient care experiences outside of nursing school had higher mean scores on Teamwork and Collaboration (F[1463] ¼ 5.27, p ¼ .02], informatics (F[1465] ¼ 5.42, p ¼ .02), and safety (F[1462] ¼ 14.01, p < .01]. The ratings of skills preparedness for the safety domain also differed by type of school (F[2462] ¼ 5.15, p < .01]; 328
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KNOWLEDGE 100
Averaged % Response
80
60
40
20
0
PC
TC
EB
QI
S
I
QSEN Competencies Learning Venues:
Course Assignment
Classroom
Clinical
Lab/Simulation
Figure 1. Learning venues reported by students as sources of knowledge about QSEN competencies. Key to competencies: PC, patient-centered care; TC, teamwork and collaboration; EB, evidence-based practice; QI, quality improvement; S, safety; I, informatics.
retical and the real world application gets lost. It’s taught during lecture, but no clinical instructor has ever taken us aside to show us what an incident report entails – or describes different avenues for implementing quality improvement on a unit. We talk about EBP and questioning the way things are done, but the actual avenues to create a change are a bit of a mystery. I wish there was a way to translate the theory from the classroom into real world clinical skills. We only started looking
content and the realities of clinical practice (26%); comments about aspects of safety and teamwork and collaboration, including understanding the role of health team members and the need for communication and conflict resolution training (26%); and suggestions that programs should have more clinical time (13%). The following partial quote expresses some of the themes described: I think the problem with learning quality and patient safety in school is that it’s presented as theo-
Table 3. Skills: Levels of Perceived Preparedness by QSEN Competency and Program Type* Program Type* Total Sample (n ¼ 503) QSEN Competencies† PC I S TC EB QI
Range of School Means (n ¼ 17 schools)
BSG (n ¼ 327)
BSN (n ¼ 34)
ADN (n ¼ 118)
Mean
SD
High
Low
Mean
Mean
Mean
3.4 3.4 3.3 3.3 3.2 3.1
0.7 0.8 0.7 0.8 0.8 0.8
3.8 3.6 3.7 3.5 3.6 3.5
3.2 2.9 3.0 2.9 3.0 2.5
3.4 3.4 3.3 3.3 3.2 3.0
3.5 3.3 3.5 3.4 3.4 3.2
3.5 3.5 3.5 3.4 3.2 3.2
*Program types are identified as: BSG, BSN in school with graduate program; BSN, BSN in school without graduate program; ADN, Associate Degree in Nursing program. †QSEN competencies are listed in descending order from highest to lowest mean levels of perceived preparedness. PC, Patientcentered care; I, informatics; S, safety; TC, teamwork and collaboration; EB, evidence-based practice; QI, quality improvement.
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Table 4. Attitudes: Perceived Importance of Learning QSEN Skills by QSEN Competency and Program Type* Program Type* Total Sample (n ¼ 497) QSEN Competencies†
Range of School Means (n ¼ 17 schools)
BSG (n ¼ 327)
BSN (n ¼ 31)
ADN (n ¼ 115)
Mean
SD
High
Low
Mean
Mean
Mean
3.8 3.8 3.7 3.7 3.6 3.5
0.6 0.6 0.7 0.7 0.7 0.8
4.0 4.0 3.8 3.9 3.9 3.8
3.0 2.7 2.9 2.6 2.6 2.3
3.8 3.8 3.7 3.7 3.7 3.5
3.7 3.6 3.5 3.6 3.6 3.5
3.8 3.7 3.7 3.7 3.6 3.5
PC S I TC EB QI
*Program types are identified as follows: BSG, BSN in school with graduate program; BSN, BSN in school without graduate program; ADN, Associate Degree in Nursing program. †QSEN competencies are listed in descending order from highest to lowest mean levels of perceived importance. PC, Patient-centered care; S, safety; I, informatics; TC, teamwork and collaboration; EB, evidence-based practice; QI, Quality improvement.
formatics, with half of the most frequently occurring content belonging to the patient-centered care competency domain. Students felt least prepared for skills in the areas of evidence-based practice and quality improvement, especially using quality improvement tools and evaluating effects of practice changes. Graduating students indicated strong support for the importance and value of the QSEN competencies in their professional nursing practice. In many cases, the reported importance ratings exceeded self-reported levels of preparedness. In view of comments regarding gaps between theoretical presentation of quality and safety information, and demonstrated application in practice, further assessment of faculty familiarity with contemporary quality and safety practices might help reduce the gap, along with a redesign of curriculum content and development of new teaching strategies. Particular attention is needed to developing competency in the area of quality improvement. Perhaps it would make a positive difference if the introduction of students to a clinical setting included a presentation by unit staff of information about local quality improvement projects, including data about that unit’s care indicators compared with national benchmarks. With one exception (ADN students scored higher than BSG students in the safety competency domain), there were no significant differences in levels of self-reported preparedness by program type. In contrast, the strong relationship between clinical experience outside of the formal nursing program and student perceptions of skill preparedness was remarkable. Further study of what students actually learned from these external patient care experiences would be valuable, along with attempts to discover whether or how that learning could be shared with other students.
into health care quality as seniors and I feel like it’s too little too late..
DISCUSSION Prelicensure students from BSN, ADN, and diploma programs, in high percentages, reported that quality and safety knowledge and skills were addressed in their curricula. The knowledge topics perceived as present by the highest percentages of students reflected content from 3 of 6 competencies: patient-centered care, safety, and evidence-based practice. In contrast, the topics perceived as being addressed least frequently belonged to the quality improvement and teamwork and collaboration competencies. Faculty members rely on classroom activities to deliver most of the quality and safety content. A minority of students reported that faculty used skills lab and simulation activities to teach the knowledge content, focusing on specific items of safety knowledge (such as safety technologies and general hazards and errors) rather than the full spectrum of quality and safety competencies. Apparently, there is substantial opportunity to enhance learning in this venue. Several quality and safety items were addressed in more than one learning venue. It is not known whether the placement of specific content in various learning venues reflected faculty judgments regarding the most effective teaching-learning strategies, a desire for repetition and enhancement, logistical and convenience factors, or a combination of multiple rationales. Collectively, these results are similar to previous findings from the quality and safety curriculum program survey of prelicensure program leaders.8 Students believed they were most prepared to perform skills in the areas of patient-centered care and in330
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To be prepared for practice, new nurses must develop the full spectrum of quality and safety competencies. The results of this study suggest that efforts to meaningfully and effectively incorporate all of the QSEN KSAs into prelicensure curricula are welcomed by students. Furthermore, students appear to have views consistent with those of their faculties regarding the areas in which they are prepared and the areas where improvements are needed.8
Limitations Low response rates and response rates that differed significantly across participating schools are some limitations of this study. In addition, the sample was comprised of schools already highly motivated to improve quality and safety education and contained an overrepresentation of BSN students. Thus, the results reported here may not be representative of all US schools of nursing. Variation in the timing and focus of Learning Collaborative schools’ curricular projects may also have influenced student responses. Comments indicated that students were generally proud of their schools, and this sentiment may have contributed to a positive response bias. Nonetheless, the pattern of student responses, although more positive than expected, parallels the pattern of faculty responses previously reported by Smith et al.8
SUMMARY Prelicensure nursing students from 17 schools of nursing perceived QSEN quality and safety competencies as very important to their future professional nursing practice. Many aspects of quality and safety content were perceived to be present in curricula, although the level of inclusion varied across the 6 QSEN competencies and the learning venues used. Quality improvement was consistently cited as the competency with the lowest perceived skill level and among the topics of lowest importance, a finding in conflict with contemporary practice environment expectations. Clinical lab and simulations were underused in quality and safety education and may provide an important site for increased teaching related to QSEN competencies. Although responses indicated relatively high levels of self-reported skill preparedness regarding quality and safety competencies, particularly in the areas of patient-centered care and informatics, there were gaps in graduating students’ skills that can guide continuous improvement efforts in prelicensure nursing programs. Future studies are needed to examine the relationship of student perceptions to objective learning assessments and verifiable performance outcomes.
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The authors gratefully acknowledge the following people for their contributions to this study: Elaine L. Smith, MSN, MBA, RN, CNAA (Mountain States Health Alliance, Johnston City, TN), who collaborated in initial survey content and design; John Carlson, MS (statistician, UNC School of Nursing, Chapel Hill, NC); Elizabeth Flint, PhD (Duke University School of Nursing, Durham, NC); Sharon Latta, RN, MSN (Brunswick Community College, Supply, NC); Ann Hubbard, EdD, ARNP, and Lisa Smith, MSN/ED, RN, CNE (Indian River Community College, Ft. Pierce, FL); and QSEN Learning Collaborative Project Directors.3 Quality and Safety for Nurses (QSEN) is funded by the Robert Wood Johnson Foundation. Principal Investigator, Linda R. Cronenwett, University of North Carolina at Chapel Hill.
REFERENCES 1. Institute of Medicine. Health professions education: A bridge to quality. Washington DC: National Academies Press; 2003. 2. Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P, et al. Quality and safety education for nurses. Nurs Outlook 2007;55:122-31. 3. Cronenwett L, Sherwood G, Gelmon S. Improving quality and safety education: The QSEN Learning Collaborative. Nurs Outlook 2009;57:304-12. 4. VanGeest JB, Cummins DS. Educational needs assessment for improving patient safety: Results of a national study of physicians and nurses. Chicago, IL: National Patient Safety Foundation; 2003. 5. Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety climate: A review of surveys. Qual Saf Health Care 2005;14:364-6. 6. Madigosky WS, Headrick LA, Nelson K, Cox KR, Anderson T. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med 2006;81:94-101. 7. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006;6:44. 8. Smith E, Cronenwett L, Sherwood G. Current assessments of quality and safety education in nursing. Nurs Outlook 2007;55:132-7. 9. McNeil BJ, Elfrink VL, Beyea SC, Pierce ST, Bickford ST. Computer literacy study: Report of qualitative findings. J Prof Nurs 2005;22:52-9. 10. Fetter M. Graduating nurses’ self-evaluation of information technology competencies. J Nurs Educ 2009;48:86-90. 11. Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice. Am J Nurs 2005;105:40-51. 12. Cadmus E, Van Wynen EA, Chamberlain B, Steingall P, Kilgallen ME, Holly C, et al. Nurses’ skill level and access to evidence-based practice. J Nurs Admin 2008;38: 494-503. 13. Schnall R, Stone P, Currie L, Desjardins K, John RM, Bakken S. Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge. J Nurs Sch 2008;40:391-4.
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The Quality and Safety Education for Nurses (QSEN) project is focused on enhancing nursing curricula and fostering faculty development to support student achievement of quality and safety competencies. The purpose of this descriptive study was to assess student perspectives of quality and safety content in their nursing programs along with self-reported levels of preparedness and perceived importance of the 6 QSEN competencies. Graduating students (n ¼ 565) from 17 US schools of nursing completed an electronic student evaluation survey. Students reported exposure to QSEN knowledge areas, more often in classroom and clinical learning settings than in skills lab/simulation settings. Clinical experience outside of formal education was associated with perceptions of a higher level of preparedness for QSEN skills in several competencies. In general, students reported relatively high levels of preparedness in all types of prelicensure nursing programs and endorsed the importance of quality and safety competencies to professional practice.
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ver the last 5 years, increasing focus on the need to better prepare nursing graduates for the realities of the practice environment has centered on patient safety and quality topics. A major national initiative, Quality and Safety Education for Nurses (QSEN), funded by the Robert Wood Johnson Foundation, sought to define competencies for prelicensure nursing students using an adapted version of the Institute of Medicine
Dori Taylor Sullivan, PhD, RN, NE-BC, CNL, CPHQ, is Associate Dean for Academic Affairs and Clinical Professor, Duke University School of Nursing, Durham, NC. Denise Hirst, MSN, RN, is QSEN Project Director and Clinical Assistant Professor, University of North Carolina at Chapel Hill, NC. Linda Cronenwett, PhD, RN, FAAN, is Professor, School of Nursing, University of North Carolina at Chapel Hill, NC. Corresponding author: Dr. Dori Taylor Sullivan, Associate Dean for Academic Affairs, Duke University School of Nursing, 307 Trent Drive, DUMC 3322, Durham, NC 27710. E-mail: [email protected] Nurs Outlook 2009;57:323-331. 0029-6554/09/$–see front matter Copyright ª 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2009.08.004
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competencies.1 QSEN’s primary goal is to ‘‘address the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems in which they work.’’2 The QSEN competencies include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Each QSEN competency is defined and further explicated through statements regarding KSAs that should be developed during prelicensure nursing education programs. After defining the quality and safety competencies and KSAs, QSEN continued its work through identification and sharing of effective teaching tools and related materials via a website (http://www.qsen.org) and through selection of pilot schools willing to participate in the QSEN Learning Collaborative. The QSEN Learning Collaborative called for participating schools to design and implement curricular innovations reflecting quality and safety content that would be disseminated to other schools to promote shared learning. A description of the activities and outcomes of the QSEN Learning Collaborative is included in a companion article in this issue.3 During the first QSEN Learning Collaborative meeting, there was consensus among the QSEN faculty and pilot school representatives that evaluation of student perceptions of quality and safety content and competencies was an important goal. Furthermore, given the paucity of knowledge about how to evaluate quality and safety competency development, it was considered appropriate to begin by assessing student perceptions. This article describes the development, administration, and results of a survey measuring student perceptions of the extent to which they had acquired KSAs essential to the development of quality and safety competencies during their prelicensure programs. Specific aims included (1) determining student perceptions of whether and in what manner they were exposed to knowledge related to quality and safety competencies, (2) assessing student perceptions of how prepared they were to perform quality and safety skills, (3) assessing student attitudes about the importance of learning skills
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The final instrument consisted of 26 items with three subscales: knowledge, skills, and attitudes. As in earlier studies,5–8 students’ patient safety knowledge and skills increased significantly after relevant curricular content was incorporated. In summary, there is budding interest in assessing the KSAs associated with quality and safety competencies among samples of healthcare providers in practice and health professional students. Most of the emphasis has been on the competencies of patient safety, informatics, and evidence-based practice. Some studies uncovered gaps in students and practicing nurses’ knowledge and skills through survey techniques, although response rates were typically low. No instrument was sufficiently developed to accomplish the aims of this study with respect to all 6 QSEN competencies.
fundamental to quality and safety competencies, (4) assessing the impact of clinical experience outside of nursing school on student preparedness ratings, and (5) determining whether student perceptions of quality and safety education vary by type of prelicensure program.
REVIEW OF LITERATURE Early efforts to assess KSAs related to quality and safety competencies focused primarily on patient safety, as exemplified by a national education needs assessment survey of nurses and physicians4 and measurement of cultures of safety among both students and practicing professionals across nursing, medicine, and other health disciplines.5–7 A variety of approaches to educational program content and methods was found to develop increased knowledge of safety and quality, and improved skill levels along with the positive attitudes believed to enhance consistent application of these concepts in practice. During the early phase of the QSEN project, a descriptive study using survey methodology was undertaken to document the current state of prelicensure nursing education, with respect to the 6 QSEN competencies in Bachelor of Science in Nursing (BSN) (n ¼ 195) and Associate Degree in Nursing (ADN) (n ¼ 23) programs.8 More than 95% of respondents indicated that content related to each QSEN competency was threaded through their curricula, with 10–18% reporting that they had dedicated courses. Of the QSEN competencies, quality improvement and informatics content were least often included in curricula, whereas patient-centered care and safety content were most often included. Several investigators focused on specific competencies in nursing populations, with informatics and evidencebased practice most frequently addressed. In studies of information technology skills, including computer usage and information literacy, McNeil et al.9 reported greater focus on computer skills than information literacy skills in 80% of 266 schools, and Fetter10 found that graduating baccalaureate nurses in a pilot sample of 42 students reported their ability as moderate. Recommendations for enhancing curricular integration of informatics suggested by both studies included improving faculty skills and attitudes, and clearer competency expectations for prelicensure nursing education. Two large studies of practicing staff nurses have assessed familiarity of this population with the term ‘‘evidence-based practice.’’ Fewer than half of registered nurses (RNs) surveyed by Pravikoff et al.11 in 2005 reported awareness of evidence-based practice. Cadmus et al.12 in a comparable study 3 years later found that 82% were familiar with this term. Schnall et al.13 developed a 35-item self-report instrument to measure student KSAs concerning patient safety. The instrument was tested with 285 students in year 1 of a BSN-to-MSN advanced practice nursing program. 324
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THE QSEN STUDENT EVALUATION SURVEY (SES) Development of the QSEN Student Evaluation Survey (SES) The QSEN KSAs for each of the 6 competencies represented the domain of interest for the QSEN student evaluation survey (SES). Inclusion of all KSA elements was not feasible, however, because the length of the survey would have created too great a participant burden to achieve acceptable response rates. Therefore, expert reviewers (the QSEN Principal Investigators, Advisory Board, and Faculty) proposed sets of items that would represent each competency. The items comprising the SES were approved for pilot testing and prepared for administration using the Survey Monkey online platform. The SES consists of 3 primary questions related to (1) knowledge: whether and where 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. Student respondents identified their schools for purposes of aggregate reporting. The ‘‘knowledge’’ scale of the survey included 19 knowledge objectives from the QSEN competencies and asked students to indicate the venues in which they had learned content pertaining to each topic using a set of 5 categorical response options (classroom, course assignments/readings, clinical experiences, lab/ simulations, not covered). The 19 items were drawn from each of the 6 QSEN competencies, thus allowing assessment of responses by competency as well as by individual items. Self-reported levels of preparedness to perform skills in all 6 QSEN competencies were assessed in the ‘‘skills’’ scale of the survey with 22 items, each scored on a 4-point Likert-type scale with response options of: ‘‘very unprepared,’’ ‘‘somewhat unprepared,’’ ‘‘somewhat prepared,’’ and ‘‘very prepared.’’ Finally, the ‘‘attitudes’’ scale of the survey asked respondents to rate the importance of the 22 skill items O
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Table 1. SES Items by QSEN Competencies for Knowledge and Skills/ Attitudes Scales QSEN Competency Knowledge scale PC Patient-centered care EB Evidence-based practice TC Teamwork and collaboration QI Quality improvement
Number of Items
Sample Items
4 2 5
Strategies to empower patients or families as partners in care The role of evidence in determining best clinical practice Scopes of practice and roles of other professionals on the healthcare team Approaches to improving processes of care (quality improvement) Role of human factors and basic safety design principles in assuring safety How technology and information management are related to the quality and safety of patient care
3
S Safety
4
I
1
Informatics
TOTAL Skills and attitudes scales PC Patient-centered care EB Evidence-based practice TC Teamwork and collaboration QI Quality improvement S Safety I Informatics TOTAL
19 5
Engage patients or designated surrogates in partnerships to promote health, safety, well-being, and self-care Consult with clinical experts before deciding to deviate from evidence-based protocols Demonstrate awareness of own strengths and limitations as a care team member Use quality improvement tools such as flow charts, cause/effect diagrams Use organizational systems for near miss and error reporting Document and plan patient care in an electronic health record
4 3 3 3 4 22
from the skills scale (regardless of the level of preparation they had reported) using a 4-point Likert-type scale with response options of: ‘‘very unimportant,’’ ‘‘somewhat unimportant,’’ ‘‘somewhat important,’’ and ‘‘very important.’’ Table 1 provides sample items of the SES, with the number of items representing each QSEN competency within the KSA scales.
Pilot Testing of the QSEN SES Sample and Methods. After obtaining appropriate Institutional Review Board approvals for the overall survey project (pilot testing and subsequent survey administration among the QSEN Learning Collaborative Schools), 3 schools of nursing not involved with the QSEN initiative (1 BSN and 1 ADN school in North Carolina, and 1 ADN school in Florida) agreed to participate in a pilot test of the SES. Prelicensure students within 6 months of their graduation dates completed the SES (n ¼ 25) and then participated in focus groups (n ¼ 23) conducted by 2 of the authors using a semistructured question format. Student Responses. Students who completed the pilot survey thought that it reflected topics important to their practice as a professional nurse. Several items were reworded to enhance clarity in response to pilot N
feedback. Most importantly, the potential influence of work experience in a clinical setting (most often as some type of clinical assistant) either before or during nursing school emerged during the focus groups. Therefore, an additional demographic question was added to the SES to capture the amount and type of students’ patient care experience outside of formal nursing school education. An ‘‘other comments’’ section was added to the survey in case survey respondents wished to share additional insights.
Administration of the QSEN SES Sample. The SES was administered to eligible students at the 15 QSEN pilot schools (listed in the table in a companion article in this issue3), and at 2 BSN programs in which professors were QSEN core faculty (see Acknowledgments). Eligible students were defined as those enrolled in prelicensure nursing programs who were within 6 months of graduation. This range was necessary to accommodate varying graduation dates from several programs. The sample included 2 (12%) ADN programs, 14 (82%) BSN programs, and 1 (6%) diploma school of nursing from a total of 14 US states. Methods. For each school, a primary faculty contact agreed to provide information to eligible students about the QSEN project and forward a list of eligible student
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systems for near-miss and error reporting (3.1). Students felt most prepared to perform skills and actions related to a) assess presence and extent of pain and suffering (3.6); b) demonstrate awareness of own strengths and limitations as a care team member (3.5); and c) communicate observations or concerns related to hazards or errors in the care environment (3.5). Table 3 shows mean preparedness scores for the total sample on skill items in each of the 6 QSEN competencies and means by program type: Bachelor of Science with graduate programs (BSG), Bachelor of Science program only (BSN), and Associate degree programs (ADN). Because only one diploma school was included in the sample, those responses are included in the ‘‘All Responses’’ column but are not listed separately. Students across all schools reported that they were somewhat or very prepared in skills representing each of the 6 competencies. Respondents felt most prepared in skills related to patient-centered care and informatics and least prepared in skills related to evidence-based practice and quality improvement. Although mean scores varied across the 17 schools, there was almost no variability in mean ratings by program type. Attitudes: Student Ratings of Importance of Quality and Safety Competencies. Students were asked to rate the importance of the 22 skill items as a proxy for their attitudes regarding quality and safety competencies. Response options ranged from 1 (very unimportant) to 4 (very important). The mean of all responses regarding importance of items was 3.8, with an individual item mean range of 3.4–3.8. The skills students cited as most important for nurses to be able to perform in their first year of practice included: a) assess presence and extent of pain and suffering (3.8); b) communicate care provided and needed at each transition in care (referred to as hand-offs) to minimize risk (3.8); and c) demonstrate effective use of strategies to reduce risk of harm to self or others (3.8). Although mean scores on all items were 3.4 or higher, the items receiving the lowest ratings of importance were: a) use quality improvement tools such as flow charts, cause/effect diagrams (3.4); b) locate evidence reports related to clinical practice topics and guidelines (3.4); and c) evaluate the effect of practice changes using quality improvement methods and measures (3.4). Table 4 shows the mean importance ratings for each of the 6 QSEN competencies by program type. As in the results for self-rated levels of preparedness on skill items, respondents said that the most important skills for new nurses were in the areas of patient-centered care and the least important were in evidence-based practice and quality improvement. However, safety was seen as the second most important competency (vs. informatics in the preparedness section). Again, although mean scores across the 17 schools varied, there was limited variability by program type.
e-mail addresses for electronic delivery of the SES. Surveys were distributed via e-mail using Survey Monkey between April and June of 2008, with 1 school delayed until September 2008. E-mailed reminders using Survey Monkey were sent at 2 and 4 weeks.
Results of the QSEN SES Response Rates. The SES was distributed to 1665 students via e-mail. A total of 575 students completed the SES, for a response rate of 35%. Student response rates among the 17 participating schools varied from 16–56%. Surveys with substantial missing data, defined as those missing responses on more than 25% of items (n ¼ 10, 1.7%), were excluded from the analysis. Other surveys with fewer skipped questions (n ¼ 64, 11%) were retained in the analysis along with the fully completed surveys. In the final sample (n ¼ 565), the frequency of items with missing data was similar across the three scales (knowledge: 11%; skills: 12%; attitudes: 13%). Knowledge: Student Perceptions of Quality and Safety Curriculum Content. Student respondents indicated whether and in what learning venues each of the 19 topics had been included. Table 2 lists the three knowledge content areas that were perceived by students as most frequently and least frequently taught for each of the 4 learning venues. In addition, it lists the 3 items most often identified by students as ‘‘not covered.’’ Also listed is the percentage of respondents who reported having been taught the item. All of the most frequently included items in the curriculum in each of the 4 learning venues (the 12 items listed in Table 2) belonged to 3 of the 6 competencies: patient-centered care, safety, and evidence-based practice. In contrast, 10 of the 12 items least frequently included belonged to the Quality Improvement and Teamwork and Collaboration competencies, as did the 3 items most commonly reported as not covered in any learning venue. As indicated in Figure 1, in all but 1 QSEN competency (patient-centered care), students reported that QSEN knowledge objectives were most frequently learned in the classroom, followed (in order of decreasing frequency) by course assignments/readings, clinical experience, and lab/simulation. Skills: Self-Reported Student Preparedness for Skills Related to Quality and Safety Competencies. Students were asked to self-report their preparedness to perform a list of actions or skills derived from the KSAs from the 6 QSEN competencies, with higher scores indicating perceptions of being better prepared. The mean of all responses to all skill items was 3.3 (3 ¼ somewhat prepared, 4 ¼ very prepared), with means for individual skill items ranging from 3.0–3.6. The lowest scores across the entire sample were for the following skills: a) consult with clinical experts before deciding to deviate from evidence-based protocols (3.0); b) evaluate the effect of practice changes using quality improvement methods and measures (3.0); and c) use organizational 326
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Table 2. Knowledge Topics Most and Least Frequently Reported to be in the Curriculum, with Associated QSEN Competencies* Mean, Total Most Frequent Items
Range by School
Sample
High
Low
95%
100%
87%
Principles of effective communication with patients (PC)
91%
100%
86%
Diverse cultural, ethnic, and social backgrounds as sources of patient, family and community values (PC)
90%
100%
85%
Classroom Concepts of pain and suffering and associated nursing interventions (PC)
Course assignments/ readings Diverse cultural, ethnic, and social backgrounds as sources of patient, family and community values (PC)
83%
85%
68%
Concepts of pain and suffering and associated nursing interventions (PC)
82%
84%
71%
The role of evidence in determining best clinical practice (EB)
81%
86%
70%
87%
92%
81%
86%
87%
83%
79%
92%
68%
40%
49%
13%
Clinical experiences Concepts of pain and suffering and associated nursing interventions (PC)
Principles of effective communication with patients (PC) Benefits and limitations of safety enhancing technologies (eg, bar coding, medication pumps, alarms) (S) Lab/simulations General types of hazards and errors in care (S)
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Mean, Total Least Frequent Items
Sample
High
Low
61%
70%
55%
70%
76%
54%
73%
100%
68%
43%
49%
30%
49%
62%
43%
55%
71%
46%
27%
31%
24%
33%
83%
24%
49%
59%
46%
5%
9%
0%
Classroom Methods for determining how care quality in a local setting compares to national benchmarks (QI) Impact of perceived power differentials among healthcare team roles on teamwork and patient safety (nursing and other disciplines) (TC) Processes used in analyzing causes of errors (e.g., root cause analysis) (QI) Course assignments/ readings Methods for determining how care quality in a local setting compares to national benchmarks (QI) Impact of perceived power differentials among health care team roles on teamwork and patient safety (nursing and other disciplines) (TC) Processes used in analyzing causes of errors (eg, root cause analysis) (QI) Clinical experiences Methods for determining how care quality in a local setting compares to national benchmarks (QI) Processes used in analyzing causes of errors (eg, root cause analysis) (QI) Reliable sources for locating evidence-based reports and clinical practice guidelines (EB) Lab/simulations Methods for determining how care quality in a local setting compares to national benchmarks (QI)
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Table 2. Continued
Most Frequent Items Benefits and limitations of safety enhancing technologies (eg, bar coding, medication pumps, alarms) (S) Role of human factors and basic safety design principles in assuring safety (S)
Range by School
Mean, Total Sample
High
Low
39%
53%
29%
38%
47%
33%
Range by School
Mean, Total Sample
High
Low
Health care organization characteristics that influence effective team functioning (TC)
10%
21%
6%
Diverse cultural, ethnic, and social backgrounds as sources of patient, family, and community values (PC)
10%
13%
10%
11%
23%
5%
15% 24%
19% 35%
11% 13%
Least Frequent Items
Not covered in any learning venue Impact of perceived power differentials among healthcare team roles on teamwork and patient safety (nursing and other disciplines) (TC) Processes used in analyzing causes of errors (eg, root cause analysis) (QI) Methods for determining how care quality in a local setting compares to national benchmarks (QI)
*PC, Patient-centered care; EB, evidence-based practice; TC, teamwork and collaboration; QI, Quality improvement; S, safety; I, informatics.
students from ADN programs had higher ratings than students from BSG programs (by Tukey’s HSD posthoc comparison). No significant differences between type of program or experience were found for skill preparedness related to evidence-based practice, patientcentered care, or quality improvement. Students with patient care experiences outside of nursing school had a higher mean total skill preparedness score (F[1471] ¼ 4.64, p ¼ .03), but there was no significant difference among program types. No effect of program type or interaction of program type with clinical experience was found on the individual competency or total scores for ratings of the importance (attitudes) of the 6 competency domains. As noted previously, the results reported from the student sample as a whole mask variation that was found across individual schools. Referring back to Tables 3 and 4, the range of school means shows substantial variation among schools, with mean differences as high as 1.0 and 1.5 for quality improvement preparedness and importance ratings, respectively. Variation in the extent of student experience outside of the nursing program was one factor in explaining these differences. Thematic Analysis of Respondent Comments. Fortysix (46) respondents posted comments at the end of the SES. Of these, 31 relevant responses were content-analyzed, yielding 4 themes. The most frequent comments related to the quality of the nursing program attended (48% positive quality, 6% negative quality). The 3 remaining themes in descending order of frequency were perceptions of the gap between theoretical classroom
Impact of Clinical Experience and Program Type on Ratings of Preparedness and Importance of QSEN Competencies. Overall, 372 of 565 students (66%) reported having patient care experiences outside of their nursing education programs. More than half of those with experience had been certified nursing assistants, and 37% of these had 1–2 years of experience. There were no significant differences between types of schools, with respect to the proportions of students with experience outside of nursing school, although there was wide variation across individual schools. A two-way analysis of variance (ANOVA) was used to examine the effects of program type, experience outside of nursing school (a dichotomous yes-or-no response), and the interaction of those factors on ratings of the QSEN competencies. Scores were calculated for students’ ratings of their preparedness (skills) and perceptions of importance (attitudes) by QSEN competencies separately and across all competencies in total scores. The interaction of program type and experience did not have a significant effect on any of the ratings of skills preparedness; therefore, the ANOVAs for the scores related to preparedness were re-estimated with only the main effects of program type and experience. Students with patient care experiences outside of nursing school had higher mean scores on Teamwork and Collaboration (F[1463] ¼ 5.27, p ¼ .02], informatics (F[1465] ¼ 5.42, p ¼ .02), and safety (F[1462] ¼ 14.01, p < .01]. The ratings of skills preparedness for the safety domain also differed by type of school (F[2462] ¼ 5.15, p < .01]; 328
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KNOWLEDGE 100
Averaged % Response
80
60
40
20
0
PC
TC
EB
QI
S
I
QSEN Competencies Learning Venues:
Course Assignment
Classroom
Clinical
Lab/Simulation
Figure 1. Learning venues reported by students as sources of knowledge about QSEN competencies. Key to competencies: PC, patient-centered care; TC, teamwork and collaboration; EB, evidence-based practice; QI, quality improvement; S, safety; I, informatics.
retical and the real world application gets lost. It’s taught during lecture, but no clinical instructor has ever taken us aside to show us what an incident report entails – or describes different avenues for implementing quality improvement on a unit. We talk about EBP and questioning the way things are done, but the actual avenues to create a change are a bit of a mystery. I wish there was a way to translate the theory from the classroom into real world clinical skills. We only started looking
content and the realities of clinical practice (26%); comments about aspects of safety and teamwork and collaboration, including understanding the role of health team members and the need for communication and conflict resolution training (26%); and suggestions that programs should have more clinical time (13%). The following partial quote expresses some of the themes described: I think the problem with learning quality and patient safety in school is that it’s presented as theo-
Table 3. Skills: Levels of Perceived Preparedness by QSEN Competency and Program Type* Program Type* Total Sample (n ¼ 503) QSEN Competencies† PC I S TC EB QI
Range of School Means (n ¼ 17 schools)
BSG (n ¼ 327)
BSN (n ¼ 34)
ADN (n ¼ 118)
Mean
SD
High
Low
Mean
Mean
Mean
3.4 3.4 3.3 3.3 3.2 3.1
0.7 0.8 0.7 0.8 0.8 0.8
3.8 3.6 3.7 3.5 3.6 3.5
3.2 2.9 3.0 2.9 3.0 2.5
3.4 3.4 3.3 3.3 3.2 3.0
3.5 3.3 3.5 3.4 3.4 3.2
3.5 3.5 3.5 3.4 3.2 3.2
*Program types are identified as: BSG, BSN in school with graduate program; BSN, BSN in school without graduate program; ADN, Associate Degree in Nursing program. †QSEN competencies are listed in descending order from highest to lowest mean levels of perceived preparedness. PC, Patientcentered care; I, informatics; S, safety; TC, teamwork and collaboration; EB, evidence-based practice; QI, quality improvement.
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Table 4. Attitudes: Perceived Importance of Learning QSEN Skills by QSEN Competency and Program Type* Program Type* Total Sample (n ¼ 497) QSEN Competencies†
Range of School Means (n ¼ 17 schools)
BSG (n ¼ 327)
BSN (n ¼ 31)
ADN (n ¼ 115)
Mean
SD
High
Low
Mean
Mean
Mean
3.8 3.8 3.7 3.7 3.6 3.5
0.6 0.6 0.7 0.7 0.7 0.8
4.0 4.0 3.8 3.9 3.9 3.8
3.0 2.7 2.9 2.6 2.6 2.3
3.8 3.8 3.7 3.7 3.7 3.5
3.7 3.6 3.5 3.6 3.6 3.5
3.8 3.7 3.7 3.7 3.6 3.5
PC S I TC EB QI
*Program types are identified as follows: BSG, BSN in school with graduate program; BSN, BSN in school without graduate program; ADN, Associate Degree in Nursing program. †QSEN competencies are listed in descending order from highest to lowest mean levels of perceived importance. PC, Patient-centered care; S, safety; I, informatics; TC, teamwork and collaboration; EB, evidence-based practice; QI, Quality improvement.
formatics, with half of the most frequently occurring content belonging to the patient-centered care competency domain. Students felt least prepared for skills in the areas of evidence-based practice and quality improvement, especially using quality improvement tools and evaluating effects of practice changes. Graduating students indicated strong support for the importance and value of the QSEN competencies in their professional nursing practice. In many cases, the reported importance ratings exceeded self-reported levels of preparedness. In view of comments regarding gaps between theoretical presentation of quality and safety information, and demonstrated application in practice, further assessment of faculty familiarity with contemporary quality and safety practices might help reduce the gap, along with a redesign of curriculum content and development of new teaching strategies. Particular attention is needed to developing competency in the area of quality improvement. Perhaps it would make a positive difference if the introduction of students to a clinical setting included a presentation by unit staff of information about local quality improvement projects, including data about that unit’s care indicators compared with national benchmarks. With one exception (ADN students scored higher than BSG students in the safety competency domain), there were no significant differences in levels of self-reported preparedness by program type. In contrast, the strong relationship between clinical experience outside of the formal nursing program and student perceptions of skill preparedness was remarkable. Further study of what students actually learned from these external patient care experiences would be valuable, along with attempts to discover whether or how that learning could be shared with other students.
into health care quality as seniors and I feel like it’s too little too late..
DISCUSSION Prelicensure students from BSN, ADN, and diploma programs, in high percentages, reported that quality and safety knowledge and skills were addressed in their curricula. The knowledge topics perceived as present by the highest percentages of students reflected content from 3 of 6 competencies: patient-centered care, safety, and evidence-based practice. In contrast, the topics perceived as being addressed least frequently belonged to the quality improvement and teamwork and collaboration competencies. Faculty members rely on classroom activities to deliver most of the quality and safety content. A minority of students reported that faculty used skills lab and simulation activities to teach the knowledge content, focusing on specific items of safety knowledge (such as safety technologies and general hazards and errors) rather than the full spectrum of quality and safety competencies. Apparently, there is substantial opportunity to enhance learning in this venue. Several quality and safety items were addressed in more than one learning venue. It is not known whether the placement of specific content in various learning venues reflected faculty judgments regarding the most effective teaching-learning strategies, a desire for repetition and enhancement, logistical and convenience factors, or a combination of multiple rationales. Collectively, these results are similar to previous findings from the quality and safety curriculum program survey of prelicensure program leaders.8 Students believed they were most prepared to perform skills in the areas of patient-centered care and in330
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Quality and safety competencies of graduating nursing students
To be prepared for practice, new nurses must develop the full spectrum of quality and safety competencies. The results of this study suggest that efforts to meaningfully and effectively incorporate all of the QSEN KSAs into prelicensure curricula are welcomed by students. Furthermore, students appear to have views consistent with those of their faculties regarding the areas in which they are prepared and the areas where improvements are needed.8
Limitations Low response rates and response rates that differed significantly across participating schools are some limitations of this study. In addition, the sample was comprised of schools already highly motivated to improve quality and safety education and contained an overrepresentation of BSN students. Thus, the results reported here may not be representative of all US schools of nursing. Variation in the timing and focus of Learning Collaborative schools’ curricular projects may also have influenced student responses. Comments indicated that students were generally proud of their schools, and this sentiment may have contributed to a positive response bias. Nonetheless, the pattern of student responses, although more positive than expected, parallels the pattern of faculty responses previously reported by Smith et al.8
SUMMARY Prelicensure nursing students from 17 schools of nursing perceived QSEN quality and safety competencies as very important to their future professional nursing practice. Many aspects of quality and safety content were perceived to be present in curricula, although the level of inclusion varied across the 6 QSEN competencies and the learning venues used. Quality improvement was consistently cited as the competency with the lowest perceived skill level and among the topics of lowest importance, a finding in conflict with contemporary practice environment expectations. Clinical lab and simulations were underused in quality and safety education and may provide an important site for increased teaching related to QSEN competencies. Although responses indicated relatively high levels of self-reported skill preparedness regarding quality and safety competencies, particularly in the areas of patient-centered care and informatics, there were gaps in graduating students’ skills that can guide continuous improvement efforts in prelicensure nursing programs. Future studies are needed to examine the relationship of student perceptions to objective learning assessments and verifiable performance outcomes.
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The authors gratefully acknowledge the following people for their contributions to this study: Elaine L. Smith, MSN, MBA, RN, CNAA (Mountain States Health Alliance, Johnston City, TN), who collaborated in initial survey content and design; John Carlson, MS (statistician, UNC School of Nursing, Chapel Hill, NC); Elizabeth Flint, PhD (Duke University School of Nursing, Durham, NC); Sharon Latta, RN, MSN (Brunswick Community College, Supply, NC); Ann Hubbard, EdD, ARNP, and Lisa Smith, MSN/ED, RN, CNE (Indian River Community College, Ft. Pierce, FL); and QSEN Learning Collaborative Project Directors.3 Quality and Safety for Nurses (QSEN) is funded by the Robert Wood Johnson Foundation. Principal Investigator, Linda R. Cronenwett, University of North Carolina at Chapel Hill.
REFERENCES 1. Institute of Medicine. Health professions education: A bridge to quality. Washington DC: National Academies Press; 2003. 2. Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P, et al. Quality and safety education for nurses. Nurs Outlook 2007;55:122-31. 3. Cronenwett L, Sherwood G, Gelmon S. Improving quality and safety education: The QSEN Learning Collaborative. Nurs Outlook 2009;57:304-12. 4. VanGeest JB, Cummins DS. Educational needs assessment for improving patient safety: Results of a national study of physicians and nurses. Chicago, IL: National Patient Safety Foundation; 2003. 5. Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety climate: A review of surveys. Qual Saf Health Care 2005;14:364-6. 6. Madigosky WS, Headrick LA, Nelson K, Cox KR, Anderson T. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med 2006;81:94-101. 7. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006;6:44. 8. Smith E, Cronenwett L, Sherwood G. Current assessments of quality and safety education in nursing. Nurs Outlook 2007;55:132-7. 9. McNeil BJ, Elfrink VL, Beyea SC, Pierce ST, Bickford ST. Computer literacy study: Report of qualitative findings. J Prof Nurs 2005;22:52-9. 10. Fetter M. Graduating nurses’ self-evaluation of information technology competencies. J Nurs Educ 2009;48:86-90. 11. Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice. Am J Nurs 2005;105:40-51. 12. Cadmus E, Van Wynen EA, Chamberlain B, Steingall P, Kilgallen ME, Holly C, et al. Nurses’ skill level and access to evidence-based practice. J Nurs Admin 2008;38: 494-503. 13. Schnall R, Stone P, Currie L, Desjardins K, John RM, Bakken S. Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge. J Nurs Sch 2008;40:391-4.
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