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• Int J Nurs Sci
• v.8(3); 2021 Jul 10

Quality and Safety Education for Nurses: Making progress in patient safety, learning from COVID-19

The past year of global COVID-19 pandemic renewed the attention on the inherent quality and safety risks in healthcare. Fragmentation in delivery services, poor coordination across transitions in care, and ineffective communication among providers and patients were magnified as healthcare delivery underwent sudden pivots to address unprecedented healthcare demands. The scope of unknown vulnerabilities to system safety and quality, the demands of processing the explosion of new information, and the complexity of managing safety risks to patients and workers were only some of the sudden threats as the virus spread across boundaries.

COVID-19 illuminated both progress and lingering gaps in patient safety and quality over the past twenty years since the deep gaps in patient care quality and safety became public knowledge. In the United States (US), the publication of the Institute of Medicine’s initial report of the startling statistics of preventable patient harm, To Err is Human , was met with alarm by both clinicians and consumers [ 1 ]. Still, two decades later, we do not know the full extent of the burden of preventable patient harm because preventable harm remains a difficult concept to categorize definitively, healthcare staff are often reluctant to report concerns and incidents for fear of retribution, and there is no aggregate reporting of preventable patient harm.

Even before COVID-19, the WHO called preventable harm a global crisis [ 2 ]. Few countries have a national plan to transform healthcare to accurately identify, report, redesign, and mitigate preventable patient harm, briefly defined as harm to the patient unrelated to the patient’s reason for seeking medical care. Data from the most comprehensive global quality report, Crossing the Global Quality Chasm [ 3 ] confirm patient safety is far from reaching zero, the goal for many safety organizations. Primary recommendations for transforming healthcare education and delivery systems include implementing new educational strategies to focus on quality and safety competencies, fostering systems thinking, reimaging leadership development, and creating learning organizations. A brief review of recent literature traces progress, but questions remain. Where are we globally in assuring all nurses have the opportunity to achieve the competencies essential for nurses in developing a mindset for quality and safety in their practice? What educational approaches best prepare nurses for the transition to safe quality practice environments? How do healthcare delivery organizations hardwire quality and safety into organizational culture? What have we learned from the global pandemic to improve safe quality patient care?

1. Quality and Safety Education for Nurses (QSEN): an evidenced based Competency Approach

Transforming healthcare to eliminate preventable harm begins with a competent workforce. The Quality and Safety Education for Nurses (QSEN, www.QSEN.org ) project developed a robust framework used in many countries. It launched at the University of North Carolina at Chapel Hill and became the US national plan for nurses to improve quality and safety in patient care [ 4 ]. QSEN defined six competencies nurses must achieve to be able to lead and transform practice to improve patient care quality and safety.

• (1) Patient-Centered Care: Treats patients and their family with respect, engaging them in decisions about their care, and honoring their culture, values and beliefs.
• (2) Teamwork and Collaboration: Skillfully connecting, coordinating, and communicating across all disciplines and care team members including the patient and family to assure accurate, timely and effective information sharing, informed decision-making and smooth transitions between providers.
• (3) Evidence Based Practice: Assuring latest evidence guides practice interventions that also support patient values and preferences.
• (4) Quality Improvement: Applying a spirit of inquiry to question processes for best practices, measuring actual practice to compare with desired benchmarks, and implementing appropriate system improvements.
• (5) Safety: Identifying and alleviating conditions and processes in the healthcare environment that contribute to preventable harm.
• (6) Informatics: Participating in design and application of informatics and technology to support decision-making, data management, and information sharing and retrieval.

Consistent with competency development, evidence based objectives for knowledge, skills, and attitudes (KSAs) were first developed to guide pre-licensure development of each competency for integrating into nursing curricula [4]. In 2009, higher-level objectives for the KSAs were adopted to guide graduate nursing academic programs and nursing professional practice standards [ 5 ]. This work is translated into Swedish, Korean, Italian, and Chinese through the Quality and Safety in Nursing: A Competency Approach to Improving Outcomes [ 6 ].

To assure nurses are prepared for the transition to practice, these six competencies are embedded in the standards for nursing schools in the US. Globally, several studies demonstrate patient safety and quality are unevenly applied in nursing education and practice. Kirwan et al. [ 7 ] reported patient safety is incorporated in nursing education in 27 countries with less integration in European Union countries. Furthermore, unlike the US, most countries lack regulatory guidelines on how patient safety and quality are integrated. Steven et al. [ 8 ] demonstrated cross-country collaboration could speed change through sharing patient safety student learning events.

HOW we teach is as critical as WHAT we teach for learners to develop a practice based safety mindset. Educator development for effective educational redesign is an imperative [ 9 , 10 ], and is compounded by the emphasis in online learning due to COVID-19. Interactive classrooms [ 11 ] built around unfolding case studies [ 12 , 13 ] encourage learners to apply safety competencies in the security of the learning environment [ 14 ]. Faculty serve as facilitator and coach with students working in small groups or in online virtual breakout rooms.

Learning from case studies and other forms of narrative pedagogy derives from reflecting on the unfolding case to apply knowledge, recall previous experience, and examine the impact of decisions on the patient [ 15 ]. Educators foster clinical judgment by using instructional strategies that help develop reflection among nurses to examine, reconsider, and learn from critical situations [ 16 ]. Reflective Practice ( Fig. 1 ), systematically examining experiences to learn better ways to respond, guides how we learn from experience. Self-awareness developed through reflective practice develops the mental model to ask questions about safety of high-risk procedures, monitor processes that don’t work reliably, and become aware that all actions have consequences. A basic process for reflection in Fig. 1 begins with mindfulness to recognize critical experiences with potential for improvement:

Basic model of reflection.

2. Learning organizations: a systems approach to safety and quality

The first US national patient safety plan [ 17 ] cites areas of organizational progress. These include working interprofessionally for improved collaboration in patient care [ 18 ], more transparent reporting systems to capture near misses and adverse events [ 19 ], more integration of quality and safety competencies across health professions education, and strategic efforts to actively enlist patients in their care [ 20 ]. Yet, preventable harm remains pervasive. The report, like the 2018 global report [ 3 ], reveals system change is the most critical area of improvement to promote learning organizations focused on inquiry as the basis for improvement. Leaders at all levels of the system hardwire safety as a basic value in creating safety culture and supporting their workers. While individual competency development is essential, safety outcomes ultimately depend on how each worker lives patient safety and quality with every patient, every interaction and procedure, every day.

New concepts form the science guiding safety cultures in healthcare organizations [ 21 ]. Because nurses are continuously present with patients and their families, they are key to establishing an organizational safety culture. Developing a mindset for safety begins with inquiry, the presence of mind with a willingness to ask questions about practice, that is, whether practice is based on best evidence with openness to constructive feedback.

Systems thinking is the framework for implementing quality and safety competencies. Systems are a set of interdependent components that interact to achieve a common goal [ 22 ]. Creating a safety culture that embraces transparency enables the organization, whether, in-patient or out-patient primary care, to learn from, not hide, near misses and preventable harm. Just Culture encourages learning from near misses and adverse events through a reporting system with systematic analysis, emphasizing accountability not individual blame [ 19 , 20 ].

Safety cannot rely on a piecemeal set of activities. Improving safety requires a system culture and mindset that guides a proactive system wide plan to provide care that is safe, reliable and free from harm. Total system safety is interdependent, collaborative and coordinated. High reliability organizations simplify and standardize processes to achieve reliable results. For example, following an evidence-based protocol exactly when inserting and managing central lines has resulted in sharp reductions in infection.

Healthcare workers take pride in working in organizations focused on quality and safety. Workers experience satisfaction in doing work well and are supported or restrained by their work environment. New evidence from research on human factors and the value of psychological safety for workers—feeling free from bullying and incivility—is clarifying the need to feel supported in speaking up about unsafe care [ 23 ]. New studies examine the impact of human factors on how workers complete their work, including fatigue, interruptions, distractions, broken processes, unreliable equipment, and other human workplace interfaces [ 24 ].

3. 2020 and beyond: safety lessons from the global pandemic

COVID-19 highlighted the critical inclusion of the QSEN competencies in daily practice and challenged the overall safety for workers and patients. The cessation of family visiting hours put nurses and other healthcare providers as the caring connection between isolated patients with COVID-19 and family members relegated to virtual healthcare visits. Nurses were recognized for their innovative approaches to patient-centered care, a core QSEN competency. Nurses applied competency in evidence-based practice for quick assessment and implementation of rapidly emerging new evidence on treatment and prevention, often relying on skills in informatics. Quality improvement projects evaluated various treatments and monitored infection management. Teamwork and collaboration of all healthcare workers in all settings established a pattern for sharing knowledge, resources, and skills to assure safe quality care delivery [ 25 ]. Daily safety briefings assessed bed availability, coordinated emergency responses, allocated equipment shortages and monitored worker safety. Research continues to examine changes in healthcare that will extend beyond the pandemic, such as improvements in telehealth, increasing healthcare access for all [ 26 ]. Still, safety ultimately relies on shared accountability between the system and each worker in the healthcare delivery organization to engage in and build a culture of safety with high reliability, human factors and transparent reporting.

Ricciardi [ 27 ] issues a call to action for all healthcare workers to commit to the goals of patient safety and quality across the continuum of care, from ambulatory primary care and health promotion to the highest acuity level. Patient safety is a team activity requiring all of us to work together, locally and globally, to build safer systems, eliminate patient harm, and ensure worker safety. Let’s reflect on the experiences of the pandemic for lessons learned to achieve equitable safe quality healthcare every patient, every time.

Peer review under responsibility of Chinese Nursing Association.

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The QSEN Competency Legacy Threaded Through the Entry-Level AACN Essentials

Shaping the future.

Dolansky, Mary A. PhD, RN, FAAN; Dick, Tracey PhD, RN, CNE, COI; Byrd, Elizabeth PhD, RN; Miltner, Rebecca S. PhD, RN, NEA-BC, FAAN; Layton, Shannon S. DNP, RN, LICSW, NEA-BC, CNE, CNL, CWCN

Author Affiliations: Associate Professor (Dr Dolansky), Frances Payne Bolton School of Nursing and School of Medicine, Case Western Reserve University, Cleveland, Ohio; and Assistant Professor (Dr Dick), Assistant Professor (Dr Byrd), Professor (Dr Miltner), and Assistant Professor (Dr Layton), University of Alabama at Birmingham School of Nursing, Birmingham.

Correspondence: Dr Dolansky, Frances Payne Bolton School of Nursing, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106 ( [email protected] ).

The work was completed by a special committee from members of the QSEN Institute.

The authors declare no conflicts of interest.

Cite this article as: Dolansky MA, Dick T, Byrd E, Miltner RS, Layton SS. The QSEN competency legacy threaded through the entry-level AACN Essentials: shaping the future. Nurse Educ . 2024;49(2):73-79. doi:10.1097/NNE.0000000000001511

Accepted for publication: August 6, 2023

Early Access: September 1, 2023

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background: 

For the last 17 years, the Quality and Safety Education for Nurses (QSEN) prelicensure competencies and knowledge, skill, and attitude (KSA) statements were integrated into nursing curricula.

Problem: 

With the publication of the competency-based American Association of Colleges of Nursing (AACN) Essentials , it is important to determine the overlap of the QSEN competencies.

Approach: 

We developed a QSEN-AACN prelicensure crosswalk to help faculty map and integrate the 2021 AACN Essentials into their curriculum.

Outcomes: 

The 6 QSEN competencies match to the 10 AACN Essentials domains except for evidence-based practice, which is listed as a concept. Fifty graduate-level QSEN KSAs were found to better align with prelicensure education and therefore important to integrate into the crosswalk. All but 1 of the original prelicensure QSEN KSA statements and all but 2 of the 50 transferred graduate-level QSEN KSAs were found in the AACN Essentials .

Conclusion: 

Faculty implementing the QSEN framework can use the QSEN-AACN competency crosswalk and QSEN teaching strategies to guide their AACN Essentials journey.

The Quality and Safety Education for Nurses (QSEN) project began in 2005 in response to the Institute of Medicine's report, To Err Is Human , which raised awareness of errors and hazards in acute care in the United States and the need to improve quality. 1 The leaders of the QSEN movement developed and published 6 quality and safety competencies along with knowledge, skill, and attitude (KSA) statements for prelicensure nursing programs. 2 Two years later the graduate-level competencies were published to facilitate curriculum development and assessment of student performance. 3 As the QSEN movement spread, faculty across the United States and internationally integrated the competencies into their curriculum through curricular mapping, incorporating QSEN-inspired teaching strategies, 4 and clinical rubrics for evaluation. 5 The QSEN competencies laid the foundation for enhancing prelicensure and graduate nursing education to deliver safe and high-quality care.

In 2021, the American Association of Colleges of Nursing (AACN) published the Essentials: Core Competencies for Nursing Education , emphasizing competency-based education for entry-level and advanced-level nursing students. 6 Competency-based education is a process whereby students are held accountable to the mastery of competencies deemed critical for an area of study. 7 Competency-based education is inherently anchored to the outputs of an educational experience versus the inputs of the educational environment and system. Students are the “center of the learning experience, and performance expectations are clearly delineated along all pathways of education and practice.” 6(p5)

The AACN Essentials include 10 domains, which are broad areas and considered in the aggregate a framework for the practice of nursing. 6 Built into these domains and associated competencies and subcompetencies are 8 key concepts and 4 spheres of care (disease prevention/promotion of health and well-being, chronic disease care, regenerative or restorative care, and hospice/palliative/supportive care). Each of these key concepts, such as clinical judgment, communication, and evidence-based practice, is represented in most domains. A competency-based education framework might be thought of as a new guiding standard for nursing, but many schools already have experience with this approach. Quality and Safety Education for Nurses was built on a competency-based framework, and the QSEN competencies have been integrated into curricula across prelicensure and graduate nursing programs for over a decade both nationally and internationally. How can faculty use the integration of QSEN competencies to transform their curricula to meet the 2021 Essentials ? We developed a crosswalk of the prelicensure QSEN competencies with the entry level 2021 AACN Essentials and propose that the QSEN-AACN Essentials Crosswalk be used by faculty at schools of nursing to understand how their current QSEN-informed curriculum can facilitate their journey to integrate the 2021 AACN Essentials .

Background of QSEN Competencies

The QSEN initiative was funded by the Robert Wood Johnson Foundation (2005-2012, total funding of $6.1 million) with the mission to address the Institute of Medicine's call for the improved instruction in health professions education related to safety science and quality improvement. 2 , 8 The 6 QSEN competencies developed were patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. The spread and impact of the QSEN competencies is evident by the adoption within schools of nursing, 9-11 the use of the QSEN content in the National State Boards of Nursing Residency programs, 12 , 13 the Future of Nursing Model, 14 nursing textbooks, 15-18 statewide initiatives, 19 and by several professional organizations that incorporated the QSEN competencies, such as the Association of periOperative Registered Nurses. 20 Because of the widespread integration of the QSEN competencies in both associate and baccalaureate programs, it is important to understand the overlap between the QSEN competencies and the AACN Essentials.

A prelicensure crosswalk team from the QSEN Institute was formed and consisted of 5 faculty members each with a variety of experience within nursing education and clinical practice. At the same time, a similar QSEN Institute graduate crosswalk team was formed to compare the QSEN graduate competencies and AACN Advanced-Level Essentials . The 2 groups met initially and throughout the analyses to ensure that the approaches to the crosswalk development were consistent. The prelicensure and graduate crosswalk teams agreed on the following to guide the analyses: ( a ) not all QSEN KSA statements may match Essentials domains, competencies, or subcompetencies, and ( b ) QSEN KSA statements could match multiple subcompetencies in more than one Essentials domain.

There were 2 initial findings related to the prelicensure and graduate QSEN KSA statements that needed to be addressed before the crosswalk work began. First, the 2 teams identified that there were 76 QSEN graduate KSA statements that were duplicates of the QSEN prelicensure statements. Both teams agreed that these 76 KSA statements be left in the prelicensure analysis. Second, the graduate crosswalk team reported that 50 of the graduate-level KSA statements were no longer appropriate at the graduate level and therefore were transferred for consideration in the prelicensure analysis.

For the analysis, the prelicensure crosswalk team reviewed the 162 QSEN KSAs published and decided for the Patient-Centered domain, that the knowledge statement “integrate understanding of multiple dimensions of patient centered care” be considered as 1 knowledge statement and not 6 separate statements. 2 Therefore, the total original QSEN KSA statements used for this analysis totaled 157 and not 162 as listed in a prior QSEN publication. 2 By adding the 50 graduate-level KSA statements, the total number of KSAs for the prelicensure analysis became 207 for our analysis ( Table 1 ).

Four of the prelicensure team members were assigned into dyads, and the fifth member served in a neutral position to review the work of the dyads and verify decisions. The dyads were assigned Essentials domains, competencies, and subcompetencies to crosswalk or connect with the QSEN competencies and KSA statements. Each member of the dyad first individually examined the prelicensure QSEN competency and KSA statements and identified the primary Essentials domain and competencies and subcompetencies that were the best fit for the QSEN KSA statements. The dyad work was intended to support interrater reliability.

Early in the process, it was identified that the QSEN KSAs did not cleanly match to the associated Essentials domains. For example, all the QSEN patient-centered care KSAs were not all found in the persons-centered Essentials domain; some of the KSAs were found in the Essentials Professionalism domain. The team agreed to consider the QSEN competency KSAs in all the Essentials domains, competencies, and subcompetencies.

Individual team members kept a current worksheet of field notes and documentation to provide dialogue on why decisions were made. Dyad groups met after each individual review to discuss their individual results and to reconcile any differences noted in the individual review. The reconciliation process consisted of the dyad groups discussing the rationale leading to resolution of the difference. Any items left unresolved by the dyad group were sent to the fifth neutral team member. If resolution was not achieved with this second review, the item or items were sent to be considered by the full prelicensure team. This process was outlined before work began, and all dyads were able to reconcile any difference in individually crosswalked items.

Five QSEN competencies aligned with a similarly named 2021 Essentials domain. Those QSEN-AACN Essentials domain alignments included Quality and Safety (Quality Improvement and QSEN Safety), Informatics and Healthcare Technologies (Informatics), Person-Centered Care (Patient-Centered Care), and Interprofessional Partnerships (Teamwork and Collaboration). The sixth QSEN competency, Evidence-Based Practice, was introduced within the Essentials as a core concept.

The 157 original QSEN KSAs were merged with the 50 transferred KSAs for a total of 207 prelicensure KSAs to consider. The result of the crosswalk for each of the 6 QSEN competencies is listed in Table 2 and described in the following section of the article.

QSEN Patient-Centered Care

At least 1 of the 47 QSEN Patient-Centered Care competency KSA statements (41 original QSEN and 6 transferred graduate) was found in 9 of the AACN Essentials domains. No QSEN Patient-Centered Care KSAs were crosswalked to the Essentials domain of Scholarship for Nursing Discipline. QSEN Patient-Centered Care KSA statements most closely align with the Essentials Person-Centered Care domain ( Table 2 ). The 47 QSEN KSA statements from 1 competency (Patient-Centered Care) crosswalked with the AACN Essentials Person-Centered Care domain alone a total of 144 times. The 12 knowledge, 17 skills, and 18 attitude statements in the QSEN Patient-Centered Care competency were crosswalked with entry-level subcompetencies of the Essentials Person-Centered Care domain a total of 34, 57, and 53 times, respectively. In other words, there were many instances when 1 QSEN KSA statement paired to more than 1 AACN subcompetency. For example, the QSEN knowledge statement, “Describe strategies to empower patients or families in all aspects of the health care process,” was crosswalked to 8 different entry-level subcompetencies within the Essentials 2 Person-Centered Care domain.

Additionally, QSEN Patient-Centered Care KSA statements also crosswalked extensively with the AACN Essentials Professionalism domain subcompetencies. In the Professionalism domain, QSEN KSA Patient-Centered Care statements crosswalked 15, 31, and 36 times, respectively, for a total of 82 times ( Table 2 ).

QSEN Teamwork and Collaboration

At least 1 of the 39 QSEN Teamwork and Collaboration competency KSA statements (37 original QSEN prelicensure and 2 transferred graduate) was found in 8 of the AACN Essentials domains. No QSEN Teamwork and Collaboration KSAs were crosswalked to the Essentials domains of Population Health and Scholarship for Nursing Discipline ( Table 2 ). QSEN Teamwork and Collaboration KSA statements most closely align with the Essentials Interprofessional Partnerships domain. The 11 knowledge, 17 skills, and 11 attitude statements in the QSEN Teamwork and Collaboration competency were consistent with entry-level subcompetencies of the Essentials Interprofessional Partnerships domain a total of 34, 55, and 29 times, respectively, for a total of 118 times. QSEN Teamwork and Collaboration KSA statements also crosswalked frequently with the AACN Essentials Person-Centered Care domain subcompetencies. In the Person-Centered Care domain, QSEN Teamwork and Collaboration KSA statements crosswalked 7, 19, and 9 times, respectively, for a total of 35 times ( Table 2 ).

QSEN Evidence-Based Practice

At least 1 of the 29 QSEN Evidence-Based Practice competency KSA statements (21 original QSEN prelicensure and 8 transferred graduate) was found in 9 of the AACN Essentials domains. No QSEN Evidence-Based Practice KSAs were crosswalked to the Essentials domain of Interprofessional Partnerships ( Table 2 ). QSEN Evidence-Based Practice KSA statements most closely align with the Essentials Scholarship for Nursing Discipline domain. The 10 knowledge, 10 skills, and 9 attitude statements in the QSEN Evidence-Based Practice competency were consistent with entry-level subcompetencies of the Essentials Scholarship for Nursing Practice domain a total of 16, 18, and 20 times, respectively, for a total of 54 times. QSEN Evidence-Based Practice KSA statements also crosswalked frequently with the AACN Essentials Person-Centered Care domain subcompetencies. In the Person-Centered Care domain, QSEN KSA statements crosswalked 9, 15, and 7 times, respectively, for a total of 31 times ( Table 2 ).

QSEN Quality Improvement

Thirty of the 33 QSEN Quality Improvement competency KSA statements (21 original QSEN prelicensure and 12 transferred graduate) crosswalked to an Essentials domain. At least 1 of those 30 Quality Improvement KSAs was found in 7 of the AACN Essentials domains. No QSEN Quality Improvement KSAs were crosswalked to the Essentials domains of Knowledge for Nursing Practice, Informatics and Healthcare Technologies, or Personal, Professional, and Leadership Development. QSEN Quality Improvement KSA statements most closely aligned with the Essentials Quality and Safety domain. Nine knowledge, 14 skills, and 7 attitude statements in the QSEN Quality Improvement competency were consistent with entry-level subcompetencies of the Essentials Quality and Safety domain a total of 14, 23, and 12 times, respectively, for a total of 49 times ( Table 2 ). One original prelicensure QSEN Quality Improvement knowledge statement, “Give examples of the tension between professional autonomy and system functioning,” 2 (p29) could not be crosswalked. Additionally, 2 of the Quality Improvement attitude statements that were previously considered graduate-level statements did not demonstrate a clear link to the Essentials Quality and Safety entry-level subcompetencies. Those statements were: ( a ) “Value local systems improvement (in individual practice, team practice on a unit, or in the macrosystem) and its role in professional job satisfaction” and ( b ) “Appreciate that all improvement is change but not all change is improvement.” 3 (p345)

QSEN Safety

At least 1 of the 31 QSEN Safety competency KSA statements (20 original QSEN prelicensure and 11 transferred graduate) was found in 7 of the Essentials domains. No QSEN Safety KSAs were crosswalked to the Essentials domains of Person-Centered Care, Scholarship for Nursing Discipline, or Personal, Professional, and Leadership Development. QSEN Safety KSA statements most closely align with the Essentials Quality and Safety domain. The 9 knowledge, 14 skills, and 8 attitude statements in the QSEN Safety competency were consistent with the entry-level subcompetencies of the Essentials Quality and Safety domain a total of 14, 23, and 17 times, respectively, for a total of 54 times ( Table 2 ).

QSEN Informatics

At least 1 of the 28 QSEN Informatics competency KSA statements (17 original QSEN Prelicensure and 11 transferred graduate) was found in 5 of the Essentials domains. No QSEN Informatics KSAs were crosswalked to the Essentials domains of Knowledge for Nursing Practice, Person-Centered Care, Population Health, Scholarship for Nursing Discipline, or Quality and Safety. QSEN Informatics KSA statements most closely align with the Essentials Informatics and Healthcare Technologies domain. The 6 knowledge, 14 skills, and 8 attitude statements in the QSEN Informatics competency could be crosswalked with the entry-level subcompetencies of the Essentials Informatics and Healthcare Technologies domain a total of 11, 18, and 13 times, respectively, for a total of 42 times ( Table 2 ).

QSEN-AACN Essentials Crosswalk Tool

The results of the above analysis were entered into an excel file to serve as an interactive QSEN-AACN Essentials Crosswalk Tool, which is accessible at https://qsen.org/qsen-aacn-crosswalks/ . Multiple spreadsheet tabs are available including a master tab that includes all 10 of the AACN Essentials domains viewed at once and tabs for narrow focus on each individual AACN domain. The master and AACN domain tabs are positioned horizontally and can be found on the bottom of the spreadsheet. All Essentials domains are listed horizontally across the top of the crosswalk tool in column format on all spreadsheets, and the QSEN competencies with KSA statements are listed vertically by row creating a search grid pattern. This grid orientation creates flexibility, allowing users to conversely start with a QSEN competency or Essentials domain when searching for alignments. For example, starting from the selected Essentials domain, a user would scan down the column to identify all possible QSEN competencies matched to the domain. Or, they may start with a single QSEN Competency and follow it along the grid to see all Essentials with possibility of alignment. The QSEN graduate KSAs that were transferred to the prelicensure crosswalk are color coded for ease of identification.

All 6 prelicensure QSEN competencies and 98.6% of the 207 (157 prelicensure and 50 graduate) KSA statements continue to be represented within the entry-level AACN Essentials domains. The Essentials domain names align with the 5 QSEN competencies (Patient-Centered Care, Teamwork and Collaboration, Quality Improvement, Safety, and Informatics) and Evidence-Based Practice continues as a concept. All but 3 prelicensure QSEN KSA statements were crosswalked to the entry-level Essentials competencies and subcompetencies. The ability to crosswalk 98.6% of the QSEN KSA statements to the entry-level subcompetencies of the Essentials, even after absorbing and considering an additional 50 KSAs from the QSEN graduate-level KSAs, demonstrates the continuing contribution of the QSEN work and its impact on nursing education. Our findings point to the wide applicability of the QSEN competency KSA statements developed in 2007 to nursing professional development. Due to the wide applicability of the QSEN competency KSA statements, schools of nursing may choose to continue to use the QSEN competencies.

Since their inception, the QSEN competencies and their associated KSA statements have been used to guide curricula development at multiple levels of nursing education and practice. Our crosswalk considered the alignment of QSEN competencies to the AACN Essentials , which serve to guide curricula of baccalaureate and graduate nursing programs. However, the impact of QSEN is much broader. For example, published articles report on the integration of QSEN competencies into diploma nursing curricula, 21 associate degree nursing curricula, 22 an RN to BSN curriculum, 23 and as part of a statewide initiative to support academic-practice partnerships. 19 In Alabama, the ADN program plans of instruction have incorporated QSEN competencies as expected graduate and program outcomes since 2016 and will continue to use the QSEN framework. 24

Fifty of the graduate-level QSEN KSAs did not match with the advanced subcompetencies of the advanced AACN Essentials . These graduate-level KSAs that were transferred to the prelicensure QSEN KSA crosswalk represents additional content that must be added to the prelicensure curriculum. These 50 graduate KSAs are indicated in a colored font in the QSEN-AACN Crosswalk Tool file. This finding supports our recommendation that schools review these additional KSAs and consider addressing these newer KSAs as they reflect the current status of nursing practice and need to be considered in the prelicensure program. The finding that we were able to crosswalk these graduate QSEN KSAs in the entry-level Essentials subdomains indicates that the QSEN movement has contributed significant impact on educating faculty and therefore student competence in the delivery of high-quality and safe care and has resulted in a shift of some competencies from graduate to the prelicensure level.

The AACN Essentials domain 5, Quality and Safety, was the likely place that the QSEN KSAs would be found; however, the QSEN competency KSAs were found in all 10 of the AACN Essentials domains. This highlights both the essential nature of quality and safety competencies in nursing practice, but also the vision that the QSEN competency developers had on transforming nursing education and the resulting impact on patient outcomes.

Although the QSEN KSAs were found in all 10 of the AACN Essentials domains, the Informatics QSEN competency was the least integrated across all AACN Essentials domains. This may be an area for future expansion as it raises a question about why the informatics competencies are less integrated into the other domains. The informatics competencies as written reflect many documentation tasks and may need to be viewed in a broader framework that expands our thinking on the benefits of data and the importance of the electronic health record in the work of a nurse. For example, some hospitals are providing performance data to nurses so that improvements can be made in real time in the form of dashboards. As data analytics and artificial intelligence mature, the future for nursing competencies will need to keep pace. These new expanded uses of informatics may interface with the other domains in the future updates of the Essentials , for example, skills and knowledge that are needed to use informatics to enhance person-centered care or teamwork and collaboration.

One important caveat to this crosswalk discussion is that the measurement of a student's or nurse's competence has not been addressed. Although the AACN states that the subcompetencies provide “understandable, observable, and measurable,” 6(p15) statements reflective of desired student outcomes, standardized approaches to assessment are not clear. The QSEN leaders also did not provide guidance in assessment or measurement. The AACN is advising schools of nursing to wait for future recommendations on measurement before proceeding in this area. Our colleagues in medicine and dentistry have provided an approach to competency assessment or measurement through the use of Entrustable Professional Activities (EPAs). 25 Entrustable Professional Activities are units of professional practice (ie, tasks or responsibilities) that students are entrusted to perform unsupervised once they have attained sufficient specific competence. Standardization of the measurement of competence will be an important next step in the nursing profession's competency-based education journey. 25

The limitations of this crosswalk were that it was performed by a limited number of QSEN experts and validation occurred only once. The purpose of this work was to provide a tool to inform the integration of the AACN Essentials . A strength of our process was the collaborative team, which included 2 senior QSEN leaders and 3 faculty with current experience in prelicensure education as well as involvement in regional QSEN collaborative activities.

Implications

The QSEN-AACN Essentials Crosswalk Tool that was developed from these results serves as a tool for faculty to use to highlight where their curriculum and teaching activities are in current alignment with the Essentials. The QSEN-AACN Crosswalk Tool is public access and can be used by schools of nursing faculty in their curriculum mapping process. We propose that by using the QSEN-AACN Essentials Crosswalk, faculty will have an added advantage as the evidence of the Essentials integration will be supported by the prior work of the QSEN initiative. A short description of the overview of the crosswalk can be found on the home page of the QSEN.org website.

The QSEN Teaching Strategies, based on the QSEN competencies, will also continue to be of value to faculty in the AACN Essentials journey ( https://www.QSEN.org/strategies ). Some of the QSEN Teaching Strategies have been moved over to the AACN Teaching Resource Database ( https://www.aacnnursing.org/Essentials/Database ). Faculty are encouraged to continue to use the 250 QSEN Teaching Strategies to support their AACN Essentials implementation that are found at the QSEN and the AACN websites.

It is estimated that implementation of the AACN Essentials competency-based model will take 3 to 5 years or more. To accelerate this timeline and avoid starting with a blank curricular map, the QSEN-AACN Essentials Crosswalk provides a tool that can be used to harness existing QSEN-based curricula to build on for the Essentials integration. The work done at most schools of nursing around the QSEN competencies integration, use of QSEN teaching strategies, and QSEN competency evaluation offers a good starting point for the implementation of the AACN Essentials in schools of nursing nationally.

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• Volume 18 - 2013
• Number 3: September 2013
• Quality and Safety Education for Nurses

Quality and Safety Education for Nurses (QSEN): The Key is Systems Thinking

Mary A. Dolansky is an Associate Professor at the Frances Payne Bolton School of Nursing, Case Western Reserve University in Cleveland, OH. Dr. Dolansky is Director of the QSEN Institute (Quality and Safety Education for Nurses) and Senior Fellow in the VA Quality Scholars program, mentoring pre- and post-doctoral students in quality and safety science. She has co-published two books on quality improvement, co-authored several book chapters and articles, and was guest editor on a special quality improvement education issue in the Journal of Quality Management in Health Care . She has taught the interdisciplinary course, “Continual Improvement in Health Care,” at CWRU for the past 8 years and was chair of the quality and safety task force at the School of Nursing that integrated quality and safety into the undergraduate and graduate curriculum.

Shirley M. Moore is the Edward J. and Louise Mellon Professor of Nursing and Associate Dean for Research, Case Western Reserve University in Cleveland, OH. She is a past President of the Academy for Healthcare Improvement and is on the leadership team of the national Quality and Safety Education for Nurses (QSEN) project. She is currently leading the integration of nurse scholars in the VA Quality Scholars Program. She also is conducting NIH-funded studies testing a process improvement approach to health behavior change with patients.

Over a decade has passed since the Institute of Medicine’s reports on the need to improve the American healthcare system, and yet only slight improvement in quality and safety has been reported. The Quality and Safety Education for Nurses (QSEN) initiative was developed to integrate quality and safety competencies into nursing education. The current challenge is for nurses to move beyond the application of QSEN competencies to individual patients and families and incorporate systems thinking in quality and safety education and healthcare delivery. This article provides a history of QSEN and proposes a framework in which systems thinking is a critical aspect in the application of the QSEN competencies. We provide examples of how using this framework expands nursing focus from individual care to care of the system and propose ways to teach and measure systems thinking. The conclusion calls for movement from personal effort and individual care to a focus on care of the system that will accelerate improvement of healthcare quality and safety.

Key words: QSEN, quality, safety, systems, QSEN competencies, education, measurement

...national healthcare quality organizations, such as the Leapfrog Group, report that the majority of hospitals have demonstrated little progress in improving quality and safety. Over a decade has passed since the Institute of Medicine (IOM) report, To Err Is Human : Building a Safer Health System, and the follow-up report, Crossing the Quality Chasm, which turned healthcare professionals’ attention to the importance of improving healthcare outcomes ( IOM, 2000 ; Committee on the Quality, 2001 ). These reports highlighted the need to redesign systems of care to better serve patients in the complex healthcare environment. During the last decade, national initiatives to improve quality and safety have been implemented, such as the Institute for Healthcare Improvement’s (IHI) Transforming Care at the Bedside, 5 Million Lives Campaign , and the Triple Aim ( IHI, 2013a ; IHI, 2013b ; IHI, 2013c ). To accelerate change, regulatory agencies have implemented National Patient Safety Goals, Core Measures, ( Joint Commission, 2013a ; 2013b ; 2013c ), and Hospital Acquired Conditions (HAC) Never Events ( Kuhn, 2008 ). Yet national healthcare quality organizations, such as the Leapfrog Group, report that the majority of hospitals have demonstrated little progress in improving quality and safety. For example, although we know that zero central line infections should be a reality in hospitals, thousands of infections are still reported each year ( Clark, 2013 ).

QSEN is a national movement that guides nurses to redesign the ‘what and how’ they deliver nursing care so that they can ensure high-quality, safe care.  In 2005, nursing leaders responded to the IOM call to improve the quality of healthcare by forming the Quality and Safety Education for Nurses (QSEN) initiative funded by the Robert Wood Johnson Foundation. The QSEN initiative consisted of the development of quality and safety competencies that serve as a resource for nursing faculty to integrate contemporary quality and safety content into nursing education ( QSEN Institute, 2013 ). The focus of QSEN, now the QSEN Institute, has expanded from undergraduate nursing students’ education to include quality and safety education for all nurses. The mission of QSEN is to address the challenge of assuring that nurses have the knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the healthcare systems in which they work. QSEN is a national movement that guides nurses to redesign the ‘what and how’ they deliver nursing care so that they can ensure high-quality, safe care. Linda Cronenwett, PhD, RN, FAAN, the founder of QSEN, often states that QSEN helps nurses to identify and bridge the gaps between what is and what should be and helps nurses focus their work from the lens of quality and safety (Personal Communication, 2013).

Viewing nurses’ work through the lens of quality and safety requires a contemporary approach that incorporates systems thinking. A crucial skill, systems thinking helps nurses to meet the challenge of improving healthcare as they move beyond the application of the QSEN competencies from individual patients and families to accelerate the overall improvement of healthcare quality and safety. In this article, we review the history of QSEN and propose a framework that expands nursing focus from individual care based on personal effort and care of the individual to systems thinking and care of the system. Examples are provided to demonstrate how to integrate systems thinking in the application of QSEN competencies and how systems thinking can be taught and measured.

QSEN History

Although QSEN competencies have spurred quality and safety in nursing education, it is now time to accelerate their use and impact.  In response to calls for improved quality and safety, leaders from schools of nursing across the country joined forces to create the Quality and Safety Education for Nurses (QSEN) initiative. The Robert Wood Johnson Foundation in 2005 funded QSEN Phase 1 and three subsequent phases followed ( Table 1 ). The major QSEN contribution to healthcare education was the creation of six QSEN competencies (modeled after the IOM reports) and the pre-licensure and graduate-level knowledge, skills, and attitude (KSA) statements for each competency ( Cronenwett et al., 2007 ). The competency statements provide a tool for faculty and staff development educators to identify gaps in curriculum so that changes to incorporate quality and safety education can be made ( Barnsteiner et al., 2013 ). The QSEN website serves as a national educational resource and a repository for nurses to publish contemporary teaching strategies focused on the six competencies: patient-centered care, teamwork and collaboration, evidenced-based practice, quality improvement, and informatics. Currently, there are over 100 teaching strategies posted.

QSEN competencies have been used by national nursing organizations and are the central focus of the National Council of State Boards of Nursing (n.d.) Nurse Residency program, the foundational concepts in the Massachusetts Future of Nursing Framework ( Massachusetts Department of Higher Education, 2010 ), and the Ohio Hospital Association ( Ohio Organization of Nurse Executives, 2013 ). The QSEN competencies also have been incorporated into nursing textbooks such as the medical-surgical text by Ignatavicious and Workman ( 2013 ), and other books, such as Quality and Safety in Nursing: A Competency Approach to Improving Outcomes ( Sherwood & Barnsteiner, 2012 ), Second Generation QSEN , a special issue of the Nursing Clinics of North America ( Barnsteiner & Disch, 2012 ) and Quality and Safety for Transformational Leadership ( Amer, 2012 ).

Systems Thinking

Although QSEN competencies have spurred quality and safety in nursing education, it is now time to accelerate their use and impact. The full effect of the QSEN competencies to improve the quality and safety of care can only be realized when nurses apply them at both the individual and system levels of care.  Many nurse educators report that the QSEN competencies are already integrated into their curriculum, but in our practice, we have noted that often this integration is at the individual level of care, rather than at the level of the system of care. The full effect of the QSEN competencies to improve the quality and safety of care can only be realized when nurses apply them at both the individual and system levels of care. Figure 1 provides a display of how the six QSEN domains are linked to optimal patient care through both vigilant individual care and vigilant systems of care . Traditionally, nurses have focused primarily on vigilant individual care ; less attention has been given to assisting nurses to provide vigilant systems of care . We propose that in addition to the emphasis on teaching critical thinking skills ( Simpson & Courtney, 2002 ), nurses also need to be taught the knowledge and skills associated with systems thinking. In their day-to-day work, nurses’ abilities to engage in better problem-solving, priority setting, delegation, interactions and collaborations, decision making, and action-taking are greatly influenced by their ability to view how any one component of their work system is related to other components and to the whole.

Systems thinking is the ability to recognize, understand, and synthesize the interactions and interdependencies in a set of components designed for a specific purpose. This strategy includes the ability to recognize patterns and repetitions in interactions and an understanding of how actions and components can reinforce or counteract each other. These relationships and patterns occur at different dimensions: temporal, spatial, social, technical or cultural ( Oshry, 2007 ). Systems thinking links a person’s environment to his/her behavior. In the delivery of nursing care, this involves the nurse’s understanding and valuing how components of a complex healthcare system influence care of an individual patient. Systems thinking can be viewed as a continuum, ranging from the individual to the larger internal and external environmental components. Figure 2 shows examples of care approaches that represent increasing levels of systems thinking.

Systems thinking links a person’s environment to his/her behavior.  How nurses view both themselves as nurses, and their work, is shaped by the structures and processes of the systems in which they work. Most nurses provide care in healthcare organizations that are characterized as complex, multilevel, and multifunctional. Greater knowledge and application of systems thinking skills by nurses have the potential to mitigate errors in practice, improve nurse priority setting and delegation, enhance problem solving and decision-making, improve timing and quality of interactions with other professionals and patients, and enhance workplace quality improvement initiatives. The ability to engage in systems thinking has been viewed as a key component in the successful delivery of safe and high quality care ( Bataldan & Mohr, 1997 ; Bataldan & Leach, 2009 ; Batalden & Stoltz, 1993 ; Senge, 2006 ). Systems thinking is required to redesign healthcare to improve the quality and safety of care.

The importance of systems thinking in quality improvement (QI) initiatives was identified in early literature on application of QI techniques to healthcare ( Batalden & Stoltz, 1993 ; Deeming & Appleby, 2000 ) and, more recently, was highlighted in reports from the Institute of Medicine ( IOM, 2003 ), the Accreditation Council for Graduate Medical Education ( Varkey, Karlapudi, Rose, Nelson, & Warner, 2009 ), and the article, “Quality and Safety Education for Nurses” ( Cronenwett, Sherwood & Barnsteiner, 2007 ). Given the hypothesized importance of systems thinking in the success of quality and safety in healthcare, it is probable that if nurses engage in better systems thinking, greater improvements in outcomes will be achieved. Knowledge and skills associated with systems thinking, however, are seldom addressed in basic or continuing nursing education. The next sections describe strategies for teaching and learning systems thinking, especially as related to QSEN competencies, and a newly developed tool for measurement of systems thinking.

Teaching and Learning Systems Thinking

Systems thinking is an essential skill for nurses. Yet, there has been little knowledge disseminated about how to assist nurses to better engage in this type of thought process, despite their key roles in planning, delivering, and improving patient care in complex organizations. To teach systems thinking it is important to enhance the learner’s awareness of the interdependencies in people, processes, and services and to view problems as occurring as part of a chain of events of a larger system, rather than as independent events.

The clinical environment is an ideal place to teach systems thinking in undergraduate, graduate, and staff development education. During the clinical experience, the faculty preceptor can broaden the learner’s problem identification from a focus on personal effort in a single situation to a focus on sequences of events with possible multiple causes for both individuals and populations. Table 2 provides examples of this continuum of systems thinking using the QSEN competencies. An example of a teaching technique for systems thinking is to have learners create grids such as those presented in Table 2 to expand their scope of thinking from the individual to the system level of care. Students might obtain outcome data from their unit and identify reasons for variation across time. Enhancing systems thinking skills also can be done by having learners complete an assessment of their unit or microsystem.

Assessment tools are available from the Clinical Microsystem ( 2013 ) Green Books for inpatient, emergency room, long-term care, and outpatient groups. These free workbooks from the Dartmouth Institute have been developed to help individuals assess the complexity of the system in which they work. Another approach to expand learners’ scope of thinking to a systems level is to have them connect nursing skills and clinical issues to national quality and safety initiatives ( Armstrong & Barton, 2013 ). For example, urinary care is connected to the National Quality Forum ( 2012 ) Catheter Associated Urinary Tract Infection (CAUTI) prevention and the Joint Commission’s ( 2013c ) National Patient Safety Goal Number 7.

Nurses can also learn systems thinking by creating flowcharts or process diagrams that elicit the steps of a care process and the multitude of healthcare workers involved in that process. This mapping technique is one of the first steps of a quality improvement project. For example, to improve the care coordination of preparing hospitalized patients for discharge, teams of healthcare professionals could map steps in the course of a patient’s stay leading to discharge. This exercise has been shown to increase knowledge about system factors and enhance awareness of the importance of interprofessional collaboration ( Brennen, Olds, Dolansky, Estrada, & Patrician, in press ).

Another approach to teach systems thinking is to have learners conduct a root cause analysis ( Lambton & Mahlmeister, 2010 ; Tschannen & Aebersold, 2010 ). Root cause analysis (RCA) is a widely used technique to assist people to move beyond blame of an individual for errors made in the workplace to understanding the system factors that may have contributed to errors. Healthcare organizations routinely perform RCA after an event so that appropriate changes can be made in the system to prevent future errors. This technique could be used to understand system factors even when events “almost happen.” Having nursing students participate in RCAs during their undergraduate education has been shown to be beneficial ( Dolansky, Druschel, Helba, & Courtney, 2013 ). For example, having students conduct an RCA for addressing a medication error may lend a new perspective to how system level factors interact with individual level factors in the creation of that error.

In the classroom setting, systems thinking also can be enhanced by using case studies. The book  Set Phasers to Stun ( Casey, 1998 ) includes stories of design, technology, and human error that can be discussed in class. These stories identify the close connection between technology and humans. Another book, Systems Concepts in Action ( Williams & Hummelbrunner, 2011 ), is a practitioner’s toolkit to teach the principles of systems thinking, such as system dynamics, outcome mapping, and social network analysis. Highly effective and very interactive, the game Friday Night in the ER ( 2009 ) guarantees learning and fun. The game is played by four people and simulates the challenge of managing a hospital during a 24-hour period. Each player is in charge of a unit. The demands of the game demonstrate that systems thinking is the key to success.

Lastly, teaching systems thinking requires guided reflection. Faculty need to assist learners to look for and recognize patterns in systems of care by standing back, reflecting on data, and considering the system as a whole. Too often in healthcare we make quick judgments that are based on limited information and preconceived ideas. Teaching nurses to step back and consider the dependencies and interconnectedness of system components will lead to a broader understanding of the healthcare system and the quality of care that results from that system.

Measurement of Systems Thinking

To improve systems thinking, we need to be able to measure it. A valid and reliable measure of systems thinking is now available. The Systems Thinking Scale (STS) is an instrument that measures healthcare professionals’ systems thinking specifically related to system interdependencies. The 20-item STS has good reliability as demonstrated by a test-retest reliability assessment (N=36; correlation of .74) and internal consistency testing (N=342) using Cronbach’s alpha (.89) ( Case Western Reserve University, 2013b ).

...systems thinking can be taught and learned and an individual’s level of systems thinking can be changed.  Data from recent studies indicated that systems thinking can be taught and learned and an individual’s level of systems thinking can be changed ( Abourmatar et al., 2012 ; Moore, Dolansky, Palmieri, Singh, & Alemi, 2010 ). Moore and colleagues tested three groups of healthcare professions students (n= 102) who received high, low, or no dose levels of systems thinking education. There were no differences in STS mean scores at pretest. At posttest, the high-dose systems thinking education group scored significantly higher on the STS than both the low and no-dose groups (p=.05 and .01, respectively). The STS is now publicly available for use and a website has been established to provide information on its use ( Case Western Reserve University, 2013a ).

Almost 10 years have passed since the QSEN competencies were developed, and the field of quality and safety is rapidly advancing. The time has come to consider what new competencies should be added. We propose that the current QSEN competencies and knowledge, skills, and attitudes (KSAs) be reviewed and evaluated. Do the KSAs need to be updated, reclassified, or expanded? Should a systems perspective be made more prominent in the QSEN model? The QSEN competencies were developed to be a tool to promote better education for nurses in healthcare quality and safety. We need to update the QSEN competencies to be as useful as possible to prepare all nurses to ensure the highest level of care possible.

... a safe and high quality system of care requires that all healthcare professionals take responsibility to learn and apply skills associated with improving the wider  system of care .  Throughout QSEN history, reports from nurses and nurse faculty are that they already integrate the QSEN competencies into education and practice. However, we have observed that, despite the fact that contemporary approaches to quality and safety emphasize a systems view, much of the nursing education approach to teaching quality and safety (including application of the QSEN competencies) emphasizes personal effort at the individual level of care. Although we believe that personal expertise of the nurse with individual patients is necessary, a safe and high quality system of care requires that all healthcare professionals take responsibility to learn and apply skills associated with improving the wider system of care . We argue, therefore, that the QSEN competencies should be integrated into nursing curriculum and practice with a strong systems-perspective emphasis. Nurse faculty and staff development educators must critically evaluate the extent to which they apply QSEN competencies and at what levels.

Mary A. Dolansky, PhD, RN Email: [email protected]

Shirley M. Moore, PhD, RN, FAAN Email: [email protected]

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September 30, 2013

DOI : 10.3912/OJIN.Vol18No03Man01

https://doi.org/10.3912/OJIN.Vol18No03Man01

Citation: Dolansky, M.A., Moore, S.M., (September 30, 2013) "Quality and Safety Education for Nurses (QSEN): The Key is Systems Thinking" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 3, Manuscript 1.

• Article September 30, 2013 The Influence of Quality Improvement Efforts on Patient Outcomes And Nursing Work: A Perspective from Chief Nursing Officers at Three Large Health Systems Marla Weston, PhD, RN, FAAN; Darryl W. Roberts, PhD, MS, RN
• Article September 30, 2013 Building Linkages between Nursing Care and Improved Patient Outcomes: The Role of Health Information Technology Patricia C. Dykes, PhD, RN, FAAN, FACMI; Sarah A. Collins, PhD, RN
• Article September 30, 2013 An Overview of the National Quality Strategy: Where Do Nurses Fit? Rosemary Kennedy, PhD, RN, MBA, FAAN; Judy Murphy, RN, FACMI, FAAN; Darryl W. Roberts, PhD, MS, RN
• Article September 30, 2013 An Academic Practice Partnership: Helping New Registered Nurses to Advance Quality and Patient Safety Deborah Flores, EdD, RN; Gale Hickenlooper, RN, MPH; Rebecca Saxton, PhD, RN

QSEN Learning Modules

These cutting edge, interactive learning modules are available to all nurse faculty and students in entry-level and graduate-level registered nursing programs and can be accessed through AACN’s collaboration community. Faculty will have the opportunity to earn American Nurses Credentialing Center contact hours for each QSEN competency learning module.

Background: Between 2010 and 2014, AACN led a faculty development effort linked to the national QSEN initiative funded by the Robert Wood Johnson Foundation. To build on AACN’s commitment to further disseminate the QSEN teaching strategies, AACN is launching thirteen web-based learning modules focused on six core competencies: 

Undergraduate QSEN Learning Modules

• Patient-centered care
• Teamwork and collaboration
• Evidence-based practice (EBP)
• Quality improvement (QI)
• Informatics

Graduate QSEN Learning Modules

Access the QSEN modules below with the following credentials:

Login: AACNQSEN Password: AACNQSEN

Please note that you will be asked to create a new password after you login in for the first time.

For questions regarding Continuing Education Certificates, please contact Sean Holloway, Online Learning Coordinator, at [email protected] .

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10.7 QSEN: Advocating for Patient Safety and Quality Care in Nursing Education

The Quality and Safety Education for Nurses (QSEN) project began advocating for safe, quality client care in 2005 by defining six competencies for nursing graduates. This initiative was created after a decade of review and investigation into the high number and high cost of medical errors in the United States. The goal of the QSEN initiative was to prepare future nurses with the knowledge, skills, and attitudes needed to improve the quality and safety of the health care system. Historically, nursing education focused on knowledge and skill acquisition, but did not address the attitudes and values of the nurse. The QSEN competencies are designed to train nursing students in prelicensure nursing programs. The six QSEN competencies, as shown in Figure 10.6, [1] are Patient-Centered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, Safety, and Informatics. [2]

Read the QSEN Prelicensure Table of Competencies .

Patient-Centered Care

The Patient-Centered Care QSEN competency advocates for the client as “the source of control and full partner in providing compassionate and coordinated care based on respect for client’s preferences, values, and needs.” [3] This competency encourages nurses to consider clients’ cultural traditions and personal beliefs while providing compassionate care. Client-centered care also includes the family in the care team. The goal of client-centered care is to improve the individual’s health outcomes. Integration of this competency has led to improved client satisfaction scores, reduced expenses, and a positive care environment. [4]

Teamwork and Collaboration

The Teamwork and Collaboration QSEN competency focuses on functioning effectively within nursing and interprofessional teams and fostering open communication, mutual respect, and shared decision-making to achieve quality client care. [5] Effective communication has been proven to reduce errors and improve client safety. [6]  The Joint Commission also includes improved communication as one of the National Patient Safety Goals, aligning with this QSEN competency. Collaboration requires information sharing across disciplines with respect for the knowledge, skills, and experience of each team member. Two examples of tools used to promote effective teamwork and collaboration are ISBARR and TeamSTEPPS®. Additionally, “principles of collaboration” have been established by the ANA.

Several communication tools have been developed to improve communication in various health care settings. ISBARR is an example of a well-established communication tool. As previously discussed in the “ Collaboration Within the Interprofessional Team ” chapter, ISBARR is a mnemonic for the components to include when communicating with other health care team members: I ntroduction, S ituation, B ackground, A ssessment, R equest/ R ecommendations, and R epeat back. [7]

TeamSTEPPS®

As previously discussed in the “ Collaboration Within the Interprofessional Team ” chapter, TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) is a well-established framework to improve client safety through effective communication in health care environments. It consists of four core competencies: communication, leadership, situation monitoring, and mutual support.

Principles of Collaboration

The American Nurses Association (ANA) and the American Organization of Nurse Executives (AONE) jointly created the “Principles of Collaboration” to guide nurses in creating, enhancing, and sustaining collaborative relationships. These principles include effective communication, authentic relationships, and a learning environment and culture. The principle of authentic relationships includes the following guidelines [8] :

• Be true to yourself – be sure your actions match your words and those around you are confident that what they see is what they get.
• Empower others to have ideas, to share those ideas, and to participate in projects that leverage or enact those ideas.
• Recognize and leverage each other’s strengths.
• Be honest 100% of the time – with yourself and with others.
• Respect others’ personalities, needs, and wants.
• Ask for what you want but stay open to negotiating the difference.
• Assume good intent from others’ words and actions, and assume they are doing their best.

Read more about the “ Principles of Collaboration ” by the ANA and AONE.

Evidence-Based Practice

The Evidence-Based Practice QSEN competency focuses on integrating scientific evidence with clinical expertise and client/family preferences and values for delivery of optimal health care. [9] See Figure 10.7 [10] for an illustration of Evidence-Based Practices (EBP). Read more about EPB in the “ Quality and Evidence-Based Practice ” chapter. Read examples of evidence-based improvements in the following box.

Read these examples of evidence-based practice improvements:

Intravenous catheter sizes PDF

Oxygen administration for COPD patients

Recognizing alarm fatigue

Quality Improvement

The Quality Improvement  QSEN competency focuses on using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems. [11] The goal of this competency is to improve processes, policies, and clinical decisions to improve client outcomes and system performance. As the pool of nursing literature grows and nursing practices have been updated to reflect current evidence, health care organizations have seen improvements in quality, safety, and experienced cost savings. [12]

Read more about the quality improvement processes in the “ Quality and Evidence-Based Practice ” chapter.

The Safety  QSEN competency focuses on minimizing “risk of harm to patients and providers through both system effectiveness and individual performance.” [13] Although safety is embedded in all of the QSEN competencies, this competency specifically advocates for preventing client harm. Despite the health care industry’s continued focus on process improvement and improving client outcomes, errors continue to occur, and nurses are often involved in these events as frontline caregivers. Safe nursing practice starts with an awareness of the potential risks for client harm in every situation.

Several initiatives have been adopted to reduce risk for client harm, such as double-checking high-risk medications and verifying a client’s name and date of birth prior to every intervention. However, client safety is compromised when there are gaps in quality measures such as inadequate staff training, broken equipment, or an organizational culture that doesn’t support best practices.

The “Safety” competency is best addressed by organizations establishing a safety culture where every worker commits to keeping client safety at the center of decision-making. An organization that has a culture of safety encourages reporting of unusual incidents, process failures, or other issues that could cause client harm, allowing the organization to investigate the event and take action to prevent the event from occurring in the future. Improvements are made as a result of a culture that questions attitudes, actions, and decisions in client care and recognizes threats to safety. Read more about safety culture in the “ Legal Implications ” chapter.

Informatics

The Informatics  QSEN competency focuses on using information and technology to communicate, manage knowledge, mitigate error, and support decision-making. [14] Health care is filled with various technologies used to promote a safe care environment, such as electronic medical records (EMRs), bedside medication administration devices, smart IV pumps, and medication distribution systems. These technologies provide safeguards and reminders to help prevent client harm, but the nurse must be knowledgeable in using technology, as well as understand how information obtained from technologies is used to improve client outcomes. As information related to technology continues to evolve, it is the responsibility of every nurse to participate in continued professional development related to informatics.

• “QSEN Competencies.png” by Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
• QSEN. (n.d.). About. https://qsen.org/about-qsen/ ↵
• Roseman, D., Osborne-Stafsnes, J., Amy, C. H., Boslaugh, S., & Slate-Miller, K. (2013). Early lessons from four 'aligning forces for quality' communities bolster the case for patient-centered care. Health Aff (Millwood), 32 (2), 232-241. https://doi.org/10.1377/hlthaff.2012.1085 ↵
• Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager, 39 (3), 128-132. https://doi.org/10.1097/hcm.0000000000000298 ↵
• Enlow, M., Shanks, L., Guhde, J., & Perkins, M. (2010). Incorporating interprofessional communication skills (ISBARR) into an undergraduate nursing curriculum. Nurse Educator, 35 (4), 176-180. https://doi.org/10.1097/nne.0b013e3181e339ac ↵
• American Nurses Association & American Organization of Nurses Executives. (n.d.). ANA/AONE principles for collaborative relationships between clinical nurses and nurse managers. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-collaborative-relationships.pdf ↵
• “Evidence-Based Practice.jpg” by Kim Ernstmeyer for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
• Cullen, L., Titler, M. G., & Rempel, G. (2011). An advanced educational program promoting evidence-based practice. Western Journal of Nursing Research, 33 (3), 345-364. https://doi.org/10.1177/0193945910379218 ↵

The patient is the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.

A mnemonic for the components to include when communicating with another health care team member: Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.

A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and patient, family, group, community, and population preferences and values.

Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.

Minimizing risk of harm to patients and providers through both system effectiveness and individual performance.

Using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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The Quality and Safety Education for Nurses (QSEN)

More than two decades ago, the Institute of Medicine (IOM) grabbed the attention of healthcare workers and the general public with the release of reports highlighting the tens of thousands of preventable deaths caused by medical errors each year. (IOM Reports - To Err Is Human: Building a Safer Health System, and the follow-up report, Crossing the Quality Chasm). Because nurses make up the majority of the healthcare workforce in the United States, nurses and nurse educators knew that a meaningful response was needed. In response, educators from the University of North Carolina Chapel Hill School of Nursing and other colleges across the United States created the Quality and Safety Education for Nurses (QSEN) competencies in 2005.

What Is the Goal of the QSEN?

The overall goal of the QSEN initiative is to meet the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the healthcare systems within which they work. The attainment of this goal begins with integrating contemporary quality and safety content into nursing education. QSEN leaders partnered with the AACN (American Association of Colleges of Nursing) from 2008 to 2012 to ensure the QSEN competencies were integrated into the appropriate references (textbooks, licensing, accreditation , and certification standards) and to develop faculty training.

What Are the Six QSEN Competencies?

QSEN has six competencies with KSA’s for each competency. Listed below are the competencies with a few examples of the knowledge, skills, and attitudes for each competency.

“Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs.”

• Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values
• Explore ethical and legal implications of patient-centered care
• Discuss principles of effective communication
• Engage patients or designated surrogates in active partnerships that promote health, safety, well-being, and self-care management
• Recognize the boundaries of therapeutic relationships
• Facilitate informed patient consent for care
• Value the patient’s expertise with own health and symptoms
• Seek learning opportunities with patients who represent all aspects of human diversity

“Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.”

• Analyze differences in communication style preferences among patients and families, nurses, and other members of the health team
• Describe impact of own communication style on others
• Discuss effective strategies for communicating and resolving conflict
• Communicate with team members, adapting own style of communicating to needs of the team and situation
• Demonstrate commitment to team goals
• Initiate actions to resolve conflict
• Acknowledge own potential to contribute to effective team functioning
• Appreciate importance of intra- and inter-professional collaboration

“Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.”

• Differentiate clinical opinion from research and evidence summaries
• Explain the role of evidence in determining best clinical practice
• Demonstrate knowledge of basic scientific methods and processes
• Base individualized care plan on patient values, clinical expertise, and evidence
• Read original research and evidence reports related to area of practice
• Question rationale for routine approaches to care that result in poor outcomes or adverse events
• Value the concept of EBP as integral to determining best clinical practice
• Appreciate the importance of regularly reading relevant professional journals

“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.”

• Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families
• Describe approaches for changing processes of care
• Use tools (such as flow charts, cause-effect diagrams) to make processes of care explicit
• Participate in a root cause analysis of a sentinel event
• Design a small test of change in daily work (such as implementing Plan-Do-Study-Act)
• Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals
• Value own and others’ contributions to outcomes of care in local care settings
• Appreciate how unwanted variation affects care

“Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.”

• Examine human factors and other basic safety design principles as well as commonly used unsafe practices
• Discuss potential and actual impact of national patient safety resources, initiatives, and regulations
• Demonstrate effective use of strategies to reduce risk of harm to self or others
• Communicate observations or concerns related to hazards and errors to patients, families, and the health care team
• Use organizational error reporting systems for near misses and error reporting
• Appreciate the cognitive and physical limits of human performance
• Value own role in preventing errors
• Value relationship between national safety campaigns and implementation in local practices and practice settings

“Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.”

• Describe examples of how technology and information management are related to the quality and safety of patient care
• Recognize the time, effort, and skill required for computers, databases, and other technologies to become reliable and effective tools for patient care
• Navigate the electronic health record
• Respond appropriately to clinical decision-making supports and alerts
• Use information management tools to monitor outcomes of care processes
• Appreciate the necessity for all health professionals to seek lifelong, continuous learning of information technology skills
• Value technologies that support clinical decision-making, error prevention, and care coordination

The Alignment of the QSEN Competencies to the New AACN Essentials

QSEN remains relevant today because the provision of safe and quality healthcare remains the foundation of all healthcare and healthcare training institutions. QSEN strives to continue the initiatives for safety and quality within nursing education and nursing care. The alignment of QSEN with the new 2021 AACN Essentials validates QSEN’s continued relevance.

AACN essentials topics and concepts

The AACN Essentials were revised to reflect the constant changes in healthcare including in technology and informatics; shifts in the population demographics; updates to health policy; and other generational topics such as health inequality and global pandemics. As society evolves and healthcare changes, nursing academics have an obligation to evolve and change in order to adequately prepare the nursing workforce. The inclusion of the AACN essentials into nursing curricula establishes a reliable foundation for the education of the future nursing workforce and provides an organizational framework that assures that no necessary concepts are omitted.

One key change of the AACN Essentials is that all programs are placed in one of two categories - entry-level and advanced-level nursing. For purposes of this article, we are discussing entry-level, specifically, baccalaureate level nursing. The Essentials provides a competency-based framework for the evaluation of a baccalaureate nursing program. The framework is made up of 10 Domains and Eight Essential Concepts that cover the broad profession of nursing practice. Each of the QSEN competencies has been included in the AACN Domains and Concepts (as indicated with the highlighting below). AACN provides a crosswalk for comparing and contrasting the QSEN AND AACN competencies.

How to Incorporate QSEN and AACN into Nursing Curriculum

Integration into the nursing curriculum is made easy with the KSA’s. The Essential’s competency statements provide the knowledge, skills, and attitudes that should be assessed and evaluated in the learner. The statements can and should be used as objectives for your courses and program. Teaching and learning strategies should align with the competency statements and allow the learner to demonstrate competency over time.

There are many implementation resources provided by AACN. What does this all mean for nursing education in the near future? I think this is the question most of us are asking ourselves. We are probably also thinking about how Next Generation NCLEX plays into this. Here are a few considerations to summarize:

• Because the AACN Essentials are competency-based, they are more aligned with clinical judgment and the Next Generation NCLEX. Incorporating the Essentials means incorporating student-centered pedagogy and formative assessment and providing varied situations and contexts for learning. These elements are critical to the development of clinical judgment.
• QSEN is a widely used framework in nursing curricula and is aligned with the new Essentials. There is no need to revise or delete QSEN if it is being used in your nursing program. You will note, however, that the Essentials is a broader framework than QSEN so if you are using QSEN, you are most likely also using some other frameworks.
• The Essentials, if implemented and utilized appropriately and fully, can provide your nursing curricula with a valid framework for assessment and evaluation of your students and your program. (Visit the AACN website, listed in the references, to read about all the changes to the Essentials.)
• Finally, utilize a product like UWorld Nursing Platform that has robust reporting to demonstrate that you are evaluating the knowledge and skills of the Essentials and/or QSEN. This will make you and your accreditors happy!

Giddens, J., Douglas, J.P. & Conroy, S. (2022). The Revised AACN Essentials : Implications for Nursing Regulation. Journal of Nursing Regulation, 12 (40, 16-22. doi.org/10.1016/S2155-8256(22)00009-6

https://www.aacnnursing.org/AACN-Essentials

https://qsen.org/competencies/pre-licensure-ksas/

Kavanagh, J. & Sharpnack, P. (2021) Crisis in competency: A defining moment in nursing education. OJIN : The Online Journal of Issues in Nursing , 26(1), Manuscript 2. Accessible online at https://www.doi.org/10.3912/OJIN.Vol26No01Man02

Tongyao Wang, T. , Nelson, Y. M., Alexander, F. Dolansky, M. A. (2022) Future Direction of Quality and Safety Competency-Based Education: Quality and Safety Education for Nurses Teaching Strategies. Journal of Nursing Education . Online June, 1, 2022. https://doi.org/10.3928/01484834-20220510-01

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What are QSEN competencies and why are they important for nurses? (24 April 2018)

• PUBLISHED 8 April, 2023
• CONTENT TYPE Pre-existing
• COPYRIGHT STATUS Original author
• PAYWALLED No
• ORIGINAL AUTHOR Brianna Flavin
• ORIGINAL PUBLICATION DATE 24/04/18
• SUGGESTED AUDIENCE Health and care staff, Patient safety leads

This article explains Quality and Safety Education in Nursing (QSEN), a US initiative to align nursing education and nursing best practices in quality and safety standards. The six focus areas of QSEN are:

• Patient-centred care
• Evidence-based practice
• Teamwork and collaboration
• Quality improvement
• Informatics

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Elektrostal , city, Moscow oblast (province), western Russia . It lies 36 miles (58 km) east of Moscow city. The name, meaning “electric steel,” derives from the high-quality-steel industry established there soon after the October Revolution in 1917. During World War II , parts of the heavy-machine-building industry were relocated there from Ukraine, and Elektrostal is now a centre for the production of metallurgical equipment. Pop. (2006 est.) 146,189.

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Quality and Safety Education for Nurses

Publications, publications.

• Oct 25, 2022

Nurse Leadership and Management: Foundations for Effective Administration

• Dec 15, 2021

Book: Quality and Safety in Nursing, 3rd Edition

• Oct 5, 2021

Zero Days in Safety: One Nurse's Journey into Trauma and Recovery

QSEN Journal Articles

• Aug 6, 2018

QSEN at TCNJ Regional Center

• Jun 13, 2018

Nurse Educator Supplement: September/October 2017 - Volume 42

• Dec 18, 2017

Additional Information

Books, Reports, & Toolkits

Books Highlighting QSEN