Instructions ( two pages)

Submit QSEN Assignment after reading and reviewing the Cronenwett et al article. See the Cronenwett et al article and Rubric attached below.

As a nurse leader, you are charged with improving quality and safety in health care systems. Describe a nursing or patient care concern or issue from your clinical practice that needs improvement. If your clinical practice is limited, you may draw from experiences encountered during your clinical rotations in nursing school. Analyze the significance of the concern for nursing practice in relation to the Quality and Safety Education for Nurses (QSEN) competences described in the Cronenwatt article.  This assignment is limited to the Evidence-based Practice (EBP) or Quality Improvement (QI) competencies.  Why is it important to explore this concern or issue? What would be the best or preferred practice for this concern? As a nurse manager or leader, how will you improve practices in your work environment related to this concern?

  

See the Cronenwett et al article and Rubric attached below.  You must review the article and rubric.

Quality and safety education for nurses

Linda Cronenwett, PhD, RN, FAAN
Gwen Sherwood, PhD, RN, FAAN
Jane Barnsteiner, PhD, RN, FAAN
Joanne Disch, PhD, RN, FAAN
Jean Johnson, PhD, RN-C, FAAN
Pamela Mitchell, PhD, CNRN, FAAN
Dori Taylor Sullivan, PhD, RN, CNA, CPHQ

Judith Warren, PhD, RN, BC, FAAN, FACMI

Quality and Safety Education for Nurses (QSEN) ad-
dresses the challenge of preparing nurses with th

e

competencies necessary to continuously improve
the quality and safety of the health care systems in
which they work. The QSEN faculty members
adapted the Institute of Medicine1 competencies for
nursing (patient-centered care, teamwork and col-
laboration, evidence-based practice, quality im-
provement, safety, and informatics), proposing defi-
nitions that could describe essential features of what it
means to be a competent and respected nurse. Using
the competency definitions, the authors propose
statements of the knowledge, skills, and attitudes
(KSAs) for each competency that should be devel-
oped during pre-licensure nursing education. Quality
and Safety Education for Nurses (QSEN) faculty and
advisory board members invite the profession to com-
ment on the competencies and their definitions and

Linda Cronenwett is a Professor and Dean at the School of Nursing,
University of North Carolina at Chapel Hill.
Gwen Sherwood is a Professor and Associate Dean for Academic
Affairs at the School of Nursing, University of North Carolina at Chapel
Hill.
Jane Barnsteiner is a Professor and Director of Translational Research
at the School of Nursing and Hospital of the University of Pennysylvania,
Philadelphia, PA.
Joanne Disch is Kathyrn R. and C. Walton Lillehei Professor and
Director of the Densford International Center for Nursing Leadership at
the School of Nursing, University of Minnesota, Minneapolis, MN.
Jean Johnson is a Professor and Senior Associate Dean for Health
Sciences at The George Washington University, Washington, DC.
Pamela Mitchell is Elizabeth S. Soule Professor and Associate Dean for
Research at the School of Nursing, University of Washington, Seattle,
WA.
Dori Taylor Sullivan is an Associate Professor and Chair, Department
of Nursing at Sacred Heart University, Fairfield, CT.
Judith Warren is an Associate Professor at the University of Kansas
School of Nursing and Director of Nursing Informatics at Kansas
University Center for Healthcare Informatics, Kansas City, KS.
Reprint requests: Linda Cronenwett, PhD, RN, FAAN, Dean and
Professor, School of Nursing, University of North Carolina at Chapel
Hill, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460.
E-mail: lcronenwett@unc.edu

Nurs Outlook 2007;55:122-131.
0029-6554/07/$–see front matter
Copyright © 2007 Mosby, Inc. All rights reserved.

doi:10.1016/j.outlook.2007.02.006

122 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U

on whether the KSAs for pre-licensure education are
appropriate goals for students preparing for basic
practice as a registered nurse.

A
series of national commissions have documented
significant problems related to safety and quality in
the US health care system.1–5 In light of these

problems, reports from multiple national committees con-
cluded that if health care is to improve, providers need to
be prepared with a different set of competencies than are
developed in educational programs today.1,6 Health pro-
fessionals, using scientific evidence, need to be able to
describe what constitutes good care, identify gaps between
good care and the local care provided in their practices,
and know what activities they could initiate, if necessary,
to close any gaps.7 Faculties of medicine, nursing, and
other health professions are challenged by the 2003
Institute of Medicine (IOM) Health Professions Education
report1 to mindfully alter learning experiences that form
the basis for professional identity formation so that grad-
uates are educated to deliver patient-centered care as
members of an interdisciplinary team, emphasizing
evidence-based practice, quality improvement approaches,
and informatics.1

Will, ideas, and execution are required to incorporate
the development of the above competencies in nursing
education. Unlike medicine, where commitment to an
adapted version of the IOM competencies is now in
place for the continuum from medical school to resi-
dency program to certification,8,9 nursing has no con-
sensus on the competencies that could apply to all
nurses—that would define what it means to be a
respected and qualified nurse. At the core of nursing,
however, lies incredible historical will to ensure quality
and safety for patients. Evidence of valuing quality and
safety competencies in nursing is evident in nursing
publications,10 –12 standards of practice,13 and accredi-
tation guidelines.14,15 The American Association of
Colleges of Nursing Task Force on the Essential

Patient Safety Competencies for Professional Nurs-

T L O O K

Quality and safety education for nurses Cronenwett et al

Table 1. Patient-centered Care

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

Knowledge Skil

ls

Attitudes

Integrate understanding of multiple
dimensions of patient-centered
care:

● patient/family/community
preferences, values

● coordination and integration of
care

● information, communication, and
education

● physical comfort and emotional
support

● involvement of family and friends
● transition and continuity

Elicit patient values, preferences
and expressed needs as part
of clinical interview,
implementation of care plan
and

eva

luation of care

Communicate patient values,
preferences and expressed
needs to other members of
health care team

Provide patient-centered care
with sensitivity and respect for
the diversity of human
experien

ce

Value seeing health care
situations “through patients’
eyes”

Respect and encourage
individual expression of patient
values, preferences and
expressed needs

Value the patient’s expertise
with own health and
symptoms

Seek learning opportunities with
patients who represent all
aspects of human diversity

Describe how diverse cultural,
ethnic, and social backgrounds
function as sources of patient,
family, and community values

Recognize personally held
attitudes about working with
patients from different ethnic,
cultural and social
backgrounds

Willingly support patient-
centered care for individuals
and groups whose values differ
from own

Demonstrate comprehensive
understanding of the concepts of
pain and suffering, including
physiologic models of pain and
comfort

Assess presence and extent of
pain and suffering

Assess levels of physical and
emotional comfort

Elicit expectations of patient &
family for relief of pain,
discomfort, or suffering

Initiate effective treatments to
relieve pain and suffering in
light of patient values,
preferences, and expressed
needs

Recognize personally held values
and beliefs about the
management of pain or
suffering

Appreciate the role of the nurse
in relief of all types and sources
of pain or suffering

Recognize that patient
expectations influence
outcomes in management of
pain or suffering

Examine how the safety, quality, and
cost-effectiveness of health care
can be improved through the
active involvement of patients and
fa

milies

Examine common barriers to active
involvement of patients in their
own health care processes

Describe strategies to empower
patients or families in all aspects of
the health care process

Remove barriers to presence of
families and other designated
surrogates based on patient
preferences

Assess level of patient’s
decisional conflict and
provide access to resources

Engage patients or designated
surrogates in active
partnerships that promote
health, safety and well-being,

Value active partnership with
patients or designated
surrogates in planning,
implementation, and
evaluation of care

Respect patient preferences for
degree of active engagement
in care process

Respect patient’s right to access
to personal health records

and self-care management

123M A Y / J U N E N U R S I N G O U T L O O K

in car

Quality and safety education for nurses Cronenwett et al

ing Care recently completed an enhancement to the
Essentials of Baccalaureate Education for Profes-
sional Nursing Practice to include exemplars of qual-
ity and safety competencies.16 But the ideas for what to
teach, how to teach, and how to assess learning of the
competencies are sorely lacking, and there are few, if
any, examples of schools claiming to execute a com-
prehensive quality and safety curriculum.

DEFINING THE COMPETENCIE

S

Quality and Safety Education for Nurses (QSEN),
funded by the Robert Wood Johnson Foundation, was
designed to address these gaps—to build on the will, to
develop the ideas, and to facilitate execution of changes
in nursing education. Before teaching strategies could
be developed, however, the QSEN faculty needed to
identify specifically what was to be achieved. Working
with an Advisory Board of thought leaders in nursing
and medicine (see acknowledgments), the authors re-
viewed the relevant literatures and adapted the IOM1

competencies for nursing. The goal was to describe
competencies that would apply to all registered nurses.

In Tables 1– 6, the definitions are shared with the
profession with the hope that nursing, through its
professional organizations, can benefit from the work.
If nursing constituencies find these competency defini-
tions clear and compelling, over time the competencies
can serve as guides to curricular development for

Table 1. Continued

Definition: Recognize the patient or designee a
compassionate and coordinated care based on

Knowledge

Explore ethical and legal implications
of patient-centered care

Describe the limits and boundaries of
therapeutic patient-centered care

Recognize t
therapeut

Facilitate inf
consent fo

Discuss principles of effective
communication

Describe basic principles of
consensus building and conflict
resolution

Examine nursing roles in assuring
coordination, integration, and
continuity of care

Assess own
communic
encounte
families

Participate i
or resolvin
context o

Communica
and need
transition

formal academic programs, transition to practice, and

124 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U

continuing education programs. In addition, the defini-
tions can provide a framework for regulatory bodies
that set standards for licensure, certification, and ac-
creditation of nursing education programs.

PRE-LICENSURE NURSING
EDUCATION
The competency definitions provided a broad frame-
work for QSEN’s work to define pedagogical strategies
for quality and safety education; however, as is evident
in the accompanying article in this issue, when the
competency names and definitions were used alone, the
vast majority of pre-licensure program leaders stated
that they already included content related to the com-
petencies in their curricula.17 Relying on the respondent
to interpret the general definitions of the QSEN com-
petencies, levels of satisfaction with the extent to which
students developed these competencies were high, and
program leaders believed that faculty possessed the
necessary expertise to teach these competencies.

The QSEN faculty and advisory board members did
not share the view that pre-licensure nursing students
were graduating with these competencies. We knew
that many students graduated without ever communi-
cating a recommendation for a change in patient care to
a physician. Many of us knew that students learned the
“five rights” of medication administration but lacked
the language of common concepts related to safety

source of control and full partner in providing
ct for patient’s preferences, values, and needs.

ls Attitudes

undaries of
tionships

d patient
e

Acknowledge the tension that
may exist between patient
rights and the organizational
responsibility for professional,
ethical care

Appreciate shared decision-
making with empowered
patients and families, even
when conflicts occur

f
skill in
patients and

ding consensus
flict in the
nt care

re provided
each

e

Value continuous improvement
of own communication and
conflict resolution skills

s the
respe

Skil

he bo
ic rela

orme
r car

level o
ation

rs with

n buil
g con
f patie

te ca
ed at

sciences or quality improvement methods. With the

T L O O K

Quality and safety education for nurses Cronenwett et al

Table 2. Teamwork and Collaboration

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

Knowledge

S

kills Attitudes

Describe own strengths,
limitations, and values in
functioning as a member of a
team

Demonstrate awareness of own strengths
and limitations as a team member

Initiate plan for self-development as a
team member

Act with integrity, consistency and
respect for differing views

Acknowledge own potential to
contribute to effective team

functioning

Appreciate importance of
intra- and inter-professional
collaboration

Describe scopes of practice and
roles of health care team
members

Describe strategies for identifying
and managing overlaps in
team member roles and
accountabilities

Recognize contributions of other
individuals and groups in
helping patient/family achieve
health goals

Function competently within own scope
of practice as a member of the health
care team

Assume role of team member or leader
based on the situation

Initiate requests for help when
appropriate to situation

Clarify roles and accountabilities under
conditions of potential overlap in
team-member functioning

Integrate the contributions of others who
play a role in helping patient/family
achieve health goals

Value the perspectives and
expertise of all health team
members

Respect the centrality of the
patient/family as core
members of any health care
team

Respect the unique attributes
that members bring to a
team, including variations in
professional orientations and
accountabilities

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

Solicit input from other team members to
improve individual, as well as team,
performance

Initiate actions to resolve conflict

Value teamwork and the
relationships upon which it is
based

Value different styles of
communication used by
patients, families, and health
care providers

Contribute to resolution of
conflict and disagreement

Describe examples of the
impact of team functioning on
safety and quality of care

Explain how authority gradients
influence teamwork and
patient safety

Follow communication practices that
minimize risks associated with handoffs
among providers and across transitions
in care

Assert own position/perspective in
discussions about patient care

Choose communication styles that
diminish the risks associated with
authority gradients among team
members

Appreciate the risks associated
with handoffs among
providers and across
transitions in care

Identify system barriers and
facilitators of effective team
functioning

Examine strategies for improving
systems to support team

Participate in designing systems that
support effective teamwork

Value the influence of system
solutions in achieving
effective team functioning

functioning

125M A Y / J U N E N U R S I N G O U T L O O K

Quality and safety education for nurses Cronenwett et al

goal of clarifying rather than prescribing current mean-
ings of the competency definitions, we outlined the
knowledge, skills, and attitudes (KSAs) appropriate for
pre-licensure education.

During 2 workshops and multiple email communica-
tions, the authors led the process of KSA development.
We focused on all of pre-licensure education (associate,
diploma, baccalaureate, and master’s entry), because the
ultimate goal is to assure that all patients will be cared for
by nurses who have developed the KSAs for each com-
petency. We tried to answer the question, “What should
nursing promise with regards to its pre-licensure gradu-
ates’ quality and safety education?”

At each step, we sought feedback from nursing faculty.

Table 3. Evidence-based Practice (E

Definition: Integrate best current evidence wit
and values for delive

Knowledge

Demonstrate knowledge of basic
scientific methods and processes

Describe EBP to include the
components of research
evidence, clinical expertise and
patient/family values

Participate
appropri
other res

Adhere to
(IRB) guid

Base individ
patient v
and evid

Differentiate clinical opinion from
research and evidence summaries

Describe reliable sources for
locating evidence reports and
clinical practice guidelines

Read origin
evidence
of practi

Locate evi
clinical p
guideline

Explain the role of evidence in
determining best clinical practice

Describe how the strength and
relevance of available evidence
influences the choice of
interventions in provision of
patient-centered care

Participate
environm
integratio
standard

Question ra
approac
less-than
adverse

Discriminate between valid and
invalid reasons for modifying
evidence-based clinical practice
based on clinical expertise or
patient/family preferences

Consult wit
deciding
evidence

In contrast to the results of the survey, when nursing

126 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U

school faculty from 16 universities in the Institute for
Healthcare Improvement Health Professions Education
Collaborative reviewed the KSA draft, they uniformly
reported that nursing students were not developing these
KSAs. Additional focus groups were held with faculty
who taught pre-licensure students in QSEN faculty mem-
bers’ schools, and the responses were the same. Although
the faculty agreed that they should be teaching these
competencies and, in fact, had thought they were, focus
group participants did not understand fundamental con-
cepts related to the competencies and could not identify
pedagogical strategies in use for teaching the KSAs.

A chief nurse executive serving on the QSEN advi-
sory board led a focus group of new graduates. Not only

ical expertise and patient/family preferences
optimal health care.

Skills Attitudes

tively in
ata collection and

activities

tional Review Board
s

ed care plan on
, clinical expertise

Appreciate strengths and
weaknesses of scientific
bases for practice

Value the need for ethical
conduct of research
and quality
improvement

Value the concept of EBP
as integral to
determining best clinical
practice

search and
rts related to area

e reports related to
e topics and

Appreciate the
importance of regularly
reading relevant
professional journals

ucturing the work
o facilitate
new evidence into
ractice

le for routine
care that result in

ed outcomes or
s

Value the need for
continuous improvement
in clinical practice
based on new
knowledge

ical experts before
viate from
d protocols

Acknowledge own
limitations in knowledge
and clinical expertise
before determining
when to deviate from
evidence-based best
practices

BP

)

h clin
ry of

effec
ate d
earch

Institu
eline

ualiz
alues
ence

al re
repo

ce

denc
ractic
s

in str
ent t
n of
s of p

tiona
hes to
-desir
event

h clin
to de
-base

did these nurses report that they lacked learning expe-

T L O O K

nge

Quality and safety education for nurses Cronenwett et al

riences related to the KSAs, they did not believe their
faculties had the expertise to teach some of the content.

In September 2006, three QSEN faculty leaders
presented the competencies and KSAs in a special
session of the National League for Nursing (NLN)
Educational Summit. Over 100 ADN, diploma, and
BSN faculty members listened to the results of the
survey and contrasted those results with the responses
from faculty focus groups. Once again, this audience
confirmed the focus group feedback. Nurses and nurs-
ing faculty hold commitments to patient-centered care
and safety central to their professional identities. They
consider their teaching approaches to be aimed at the

Table 4. Quality Improvement (QI)

Definition: Use data to monitor the outcomes of ca
and test changes to continuously improve

Knowledge S

Describe strategies for learning
about the outcomes of care in
the setting in which one is
engaged in clinical practice

Seek informatio
of care for po
in care setting

Seek informatio
improvement
care setting

Recognize that nursing and other
health professions students are
parts of systems of care and
care processes that affect
outcomes for patients and
families

Give examples of the tension
between professional
autonomy and system
functioning

Use tools (such
cause-effect
make proces

Participate in a
analysis of a s

Explain the importance of
variation and measurement in
assessing quality of care

Use quality mea
understand p

Use tools (such
and run chart
for understan

Identify gaps be
best practice

Describe approaches for
changing processe

s of care

Design a small t
daily work (us
learning meth
Do-Study-Act

Practice alignin
measures and
involved in im

Use measures to
effect of cha

development of these competencies. Yet when educa-

tors understand the competency definitions by seeing
the KSAs, they acknowledge that the KSAs represent a
new view of what is required.

One additional source of feedback was obtained
through written requests to leaders of advanced practice
organizations that represent nurse practitioner and clin-
ical nurse specialist faculties and accrediting bodies for
nurse anesthesia and nurse-midwifery programs. We
asked whether the competency definitions were appro-
priate for all nurses, including advanced practice
nurses, and were told they were. We received helpful
comments on the KSAs, and respondents supported the
assessment that they were appropriate for pre-licensure

cesses and use improvement methods to design
uality and safety of health care systems.

Attitudes

ut outcomes
ions served

ut quality
cts in the

Appreciate that continuous quality
improvement is an essential part
of the daily work of all health
professionals

w charts,
ams) to
care explicit

cause
el event

Value own and others’
contributions to outcomes of
care in local care settings

to
ance

ntrol charts
t are helpful
ariation

n local and

Appreciate how unwanted
variation affects care

Value measurement and its role in
good patient care

change in
n experiential
ch as Plan-

aims,
nges
ng care

luate the

Value local change (in individual
practice or team practice on a
unit) and its role in creating joy
in work

Appreciate the value of what
individuals and teams can to do
to improve care

re pro
the q

kills

n abo
pulat

n abo
proje

as flo
diagr
ses of

root
entin

sures
erform

as co
s) tha
ding v

twee

est of
ing a
od su

)

g the
cha

provi

eva

graduates.

127M A Y / J U N E N U R S I N G O U T L O O K

Quality and safety education for nurses Cronenwett et al

More presentations to faculty at national meetings
are scheduled, and we expect the profession’s vision for
pre-licensure KSAs to evolve over time. The current
versions of the KSAs are included in Tables 1– 6.
Although it is beyond the scope of this article to
describe and reference every idea presented, we include
in the section below a few comments and references for
each competency.

DISCUSSION OF KSAs
Patient-centered Care

The essential features of this competency were
derived from work by Bezold,18 the Picker Insti-
tute,19 and Lorig.20 Educators have worked hard on

Table 5. Safety

Definition: Minimize risk of harm to patients an
individual

Knowledge

Examine human factors and other
basic safety design principles as
well as commonly used unsafe
practices (such as work-arounds
and dangerous abbreviations)

Describe the benefits and limitations
of selected safety-enhancing
technologies (such as barcodes,
Computer Provider Order Entry,
medication pumps, and
automatic alerts/alarms)

Discuss effective strategies to
reduce reliance on memory

Demonstrate
and standa
support saf

Demonstrate
to reduce r

Use appropria
reliance on
functions, c

Delineate general categories of
errors and hazards in care

Describe factors that create a
culture of safety (such as open
communication strategies and
organizational error reporting
systems)

Communicat
related to h
patients, fa
team

Use organiza
for near-mi

Describe processes used in
understanding causes of error and
allocation of responsibility and
accountability (such as root-
cause analysis and failure mode
effects analysis)

Participate a
errors and
improveme

Engage in ro
than blami
misses occ

Discuss potential and actual impact
of national patient safety
resources, initiatives, and
regulations

Use national
own profes
focus atten
settings

the issues related to diversity during the last years,

128 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U

and curricula generally address principles of commu-
nication, physical comfort, emotional support, and
education. The QSEN faculty and advisory board
members believed greater attention might be needed
to KSAs that are concerned with eliciting and incor-
porating patient preferences and values in the plan of
care, valuing the patient (or surrogates) as partners in
care, appreciating the legal and ethical dilemmas
posed by shared decision-making, and developing
expertise in managing conflict. New graduates who
develop the KSAs would be advocates for removing
barriers to the presence of patient surrogates and
would invite patients or surrogates to partner with
them, for example, in safe medication administration

viders through both system effectiveness and
rmance.

Skills Attitudes

tive use of technology
d practices that
nd quality

tive use of strategies
harm to self or others

rategies to reduce
ory (such as, forcing

lists)

Value the contributions of
standardization/reliability
to safety

Appreciate the cognitive
and physical limits of
human performance

ervations or concerns
s and errors to

, and the health care

error reporting systems
error reporting

Value own role in
preventing errors

riately in analyzing
ing system

use analysis rather
en errors or near-

Value vigilance and
monitoring (even of
own performance of
care activities) by
patients, families, and
other members of the
health care team

t safety resources for
development and to
n safety in care

Value relationship
between national
safety campaigns and
implementation in local
practices and practice
settings

d pro
perfo

effec
rdize

ety a

effec
isk of

te st
mem
heck

e obs
azard

milies

tional
ss and

pprop
design
nts

ot-ca
ng wh
ur

patien
sional
tion o

and safe transitions in care.

T L O O K

Quality and safety education for nurses Cronenwett et al

Teamwork and Collaboration
The essential features of this competency include

sections related to self, team, team communication and
conflict resolution, effect of team on safety and quality,
and the impact of systems on team functioning.21–25

Although educators devote curricular time to fostering
teamwork competence with members of the nursing
team, faculty focus group participants acknowledged
that little is done to foster shared mental models and
communication styles essential to inter-professional
team functioning. A mandate to strengthen teamwork
and collaboration skills is derived from knowledge of
the relationships between quality of team communica-
tions and clinical outcomes.23,24 New graduates who
develop the KSAs would use team communication
practices25 and seek system support for effective team
functioning wherever they worked.

Evidence-based Practice (EBP)
This competency provoked lengthy discussions

about KSAs that would be relevant to all of pre-
licensure nursing education. Many impressive guides to
EBP in nursing26 –28 include approaches that require
competencies not universally developed in undergrad-

Table 6. Informatics

Definition: Use information and technology to co
support de

Knowledge

Explain why information and technology
skills are essential for safe patient care

Seek educ
informat
settings

Apply tech
manage
safe pro

Identify essential information that must
be available in a common database
to support patient care

Contrast benefits and limitations of
different communication technologies
and their impact on safety and
quality

Navigate t
record

Document
in an ele

Employ co
technolo
for patie

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

Respond a
decision
alerts

Use inform
tools to m
care pro

Use high q
of health

uate students. The QSEN faculty and advisory board

desired a set of KSAs that would be achievable in all
pre-licensure programs, recognizing that some bacca-
laureate and graduate-entry programs might choose to
devote additional curricular time to develop additional
KSAs for this competency. Currently, all programs
were perceived to be lacking in sufficient development
of KSAs that go beyond “understanding of basic scien-
tific methods and processes.”29 New graduates who
develop the KSAs would differentiate between clinical
opinion and various levels of scientific evidence30 and
value the need for continuous improvement based on
new knowledge. They would also understand that EBP
is about more than evidence—that it involves patient
preferences and values and the clinical expertise nec-
essary to understand when it is appropriate for clini-
cians to deviate from evidence-based guidelines in
order to deliver high quality, patient-centered care.

Quality Improvement
Although nurses value highly their contributions to

quality care, the KSAs associated with this competency
present unique challenges to most nursing faculty.
Course coordinators who design curricula, by and large,
have not been exposed to improvement methods and

nicate, manage knowledge, mitigate error, and
-making.

kills Attitudes

about how
managed in care

providing care

y and information
tools to support

s of care

Appreciate the necessity for all
health professionals to seek
lifelong, continuous learning
of information technology
skills

ectronic health

plan patient care
ic health record

nication
to coordinate care

Value technologies that
support clinical decision-
making, error prevention,
and care coordination

Protect confidentiality of
protected health information
in electronic health records

priately to clinical
ng supports and

management
or outcomes of
s

electronic sources
information

Value nurses’ involvement in
design, selection,
implementation, and
evaluation of information
technologies to support
patient care

mmu
cision

S

ation
ion is
before

nolog
ment

cesse

he el

and
ctron

mmu
gies
nts

ppro
-maki

ation
onit

cesse

uality
care

tools for understanding variations in care.10 Although

129M A Y / J U N E N U R S I N G O U T L O O K

Quality and safety education for nurses Cronenwett et al

faculty are aware of and concerned about the IOM
Quality Chasm1–5 reports and their implications for
nurses, most are unprepared to teach quality improve-
ment concepts or demonstrate them in practice. Faculty
development and new partnerships with preceptors,
nurse managers, physicians, and other health profes-
sional colleagues in clinical settings will be required if
students are to acquire the skills described in Table 4.31

New graduates who develop the KSAs would learn and
use improvement methods as part of their coursework
and clinical practica, and they would enter the work-
force prepared to participate in improvement work as a
part of their daily work as health professionals.

Safety
Faculties take seriously their role in preparing nurses

to deliver safe care to patients. One could argue that
the entire curricula and supervised hours of clinical
practice are designed with future safety for patients in
mind. The bulk of the focus, however, is on teaching
students the knowledge they need to care for individual
patients, with limited—if any— emphasis on the im-
mense system problems in safety.4,5,32 The QSEN
faculty and advisory board members felt it was crucial,
therefore, to have a separate “safety” competency for
nursing, with KSAs related to system effectiveness and
reliability in addition to the traditional foci on individ-
ual performance. Educational needs assessments have
been published,33 and faculty are beginning to address
safety issues in new ways, such as medication errors
involving students.34,35 New graduates who develop the
KSAs will know about human factors and safety design
principles, understand the importance of error reporting
and safety cultures, and value vigilance and cross-
monitoring among patients, families, and members of
the health care team.

Informatics
In the QSEN survey17 as well as another recent

survey, where the topic was solely about informatics,36

it is clear that nursing faculty are uncertain about what
and how to teach about informatics. Yet health profes-
sionals and patients will rely increasingly on informa-
tion technology to communicate, manage knowledge,
mitigate error, and support decision-making.37,38 The
QSEN faculty and advisory board members argued that
basic informatics KSAs were essential for developing
the other 5 QSEN competencies. New graduates who
develop the KSAs in informatics will be able to
participate in the design, selection, and evaluation of
information technologies used in the support of patient
care. They will learn to navigate an electronic health
record and experiment with communication technolo-
gies to support coordination and safe, effective transi-

tions in care.

130 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U

SUMMARY
At the core of nursing lies incredible historical will to
ensure quality and safety for patients. Many current
endeavors such as the work occurring in the Robert
Wood Johnson Foundation-sponsored project, Trans-
forming Care at the Bedside, demonstrate how quality/
safety/improvement work attracts the hearts of nurses,
resulting in the “joy in work”7 that retains the health
care workforce. Attending to the development of QSEN
competencies may help nurses—who love the basic
work of nursing—love their jobs, too.

To assure new graduate competencies in patient-
centered care, teamwork and collaboration, evidence-
based practice, quality improvement, safety, and informat-
ics, all of nursing education must embrace the need for
change. These competencies cannot be mastered through a
didactic approach nor developed in a single course or
web-based module. Every clinical instructor will have to
engage differently with the inter-professional team on
patient care units where they are teaching. Simulation
cases will include components that address the QSEN
competencies. Reflective papers and case studies will
be used to deepen understanding of the values and
attitudes required for quality and safety work. By the
time this article is published, the www.qsen.org Web-
site will be populated with dozens of beginning ideas
for teaching the development of the QSEN competen-
cies in classrooms, clinical settings, and skills/simula-
tion labs. We invite the profession to use, critique, and
continuously improve the KSAs, submit strategies to
the QSEN Website, and share what is learned as we
attempt, each in our own way, to create a future where
nurses are prepared with the competencies called for in
the IOM Health Professions Education1 report. As the
most trusted profession, we owe ourselves and our
patients nothing less.

The authors gratefully acknowledge the following QSEN faculty and
Advisory Board members for their contributions to the development
of the competency definitions and KSAs: Paul Batalden, MD,
(Dartmouth); Geraldine Bednash, PhD, RN, FAAN, (American Asso-
ciation of Colleges of Nursing); Jean Blackwell, MLS (UNC-Chapel
Hill); Lisa Day, PhD, RN (UC-San Francisco); Karen Drenkard, PhD,
RN, CNAA, (Inova Health System); Carol Durham, EdD(c), MSN, RN,
(UNC-Chapel Hill); Leslie Hall, MD (U Missouri-Columbia); Pamela
Ironside, PhD, RN, FAAN, (Indiana University); Mary (Polly)
Johnson, MSN, RN, FAAN (NC Board of Nursing); Maryjoan
Ladden, PhD, RN, (Harvard); Shirley Moore, PhD, RN, FAAN,
(Case Western Reserve University); Audrey Nelson, PhD, RN,
FAAN (Veterans Administration-Tampa); Elaine Smith EdD(c),
MBA, MSN, RN, CNAA (UNC-Chapel Hill); M. Elaine Tagliareni,
EdD, RN (Community College of Philadelphia).
Quality and Safety Education for Nurses is funded by the Robert
Wood Johnson Foundation. Principal Investigator, Linda R. Cronen-
wett, University of North Carolina at Chapel Hill.

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131M A Y / J U N E N U R S I N G O U T L O O K

http://www.ihi.org/IHI/Topics/HealthProfessionsEducation/EducationGeneral/ImprovementStories/DevelopingHealthProfessionalsCapableofContinuallyImprovingHealthCareQuality.htm

http://www.ihi.org/IHI/Topics/HealthProfessionsEducation/EducationGeneral/ImprovementStories/DevelopingHealthProfessionalsCapableofContinuallyImprovingHealthCareQuality.htm

http://www.ihi.org/IHI/Topics/HealthProfessionsEducation/EducationGeneral/ImprovementStories/DevelopingHealthProfessionalsCapableofContinuallyImprovingHealthCareQuality.htm

http://www.ihi.org/IHI/Topics/HealthProfessionsEducation/EducationGeneral/ImprovementStories/DevelopingHealthProfessionalsCapableofContinuallyImprovingHealthCareQuality.htm

http://www.nursingworld.org/ojin/topic26/tpc26_4.htm

http://www.npsf.org/download/EdNeedsAssess

http://www.npsf.org/download/EdNeedsAssess

Quality and safety education for nurses
DEFINING THE COMPETENCIES
PRE-LICENSURE NURSING EDUCATION
DISCUSSION OF KSAs
Patient-centered Care
Teamwork and Collaboration
Evidence-based Practice (EBP)
Quality Improvement
Safety
Informatics
SUMMARY
Acknowledgement
REFERENCES

QSEN Discussion Board Rubric

Criteria

Exemplary

Accomplished

Developing

Beginning

Total

Describes nursing or patient care concern that needs improvement

18-20 points

16-17 points

14-15 points

13 points

/20

The concern is
comprehensive, clearly stated, and focused.

The concern is clearly stated and somewhat focused.

The concern is unclear and is too broadly or too narrowly focused.

The concern is
weak or absent.

 Describes the Evidence-based Practice and/or Quality Improvement 

QSEN competencies and relates significance of issue to QSEN competencies. Why is it important to explore this concern?

18-20 points

16-17 points

14-15 points

13 points

/20

All
components of discussion prompt thoroughly and completely addressed.

Most
components of discussion prompt are completely addressed.

Limited
components of discussion prompt addressed. Ideas expressed are general in nature and/or occasionally may not be relevant.

Minimal or no
components of discussion prompt addressed. Ideas expressed lack depth, are off-topic and/or confusing to follow.

Describes best or preferred practices for this concern. Supports with at least one current nursing RESEARCH article.

22-25 points

20-21 points

16-19 points

15 points

/25

Thorough, logical, and clear discussion of (1) Preferred Practices and (2) How the literature relates to the practice(s) are described

Adequate and clear discussion of (1) Preferred Practices and (2) How the literature relates to the practice(s) are described

Some discussion but no clear link between (1) Preferred Practices and (2) How the literature relates to the practice(s) described

Minimal discussion and no link made between (1) Preferred Practices and (2) How the literature relates to the practice(s) described.

Describes strategies to improve practices in the health care system. Support with at least one reference. Textbooks or current nursing literature are appropriate.

All
components of discussion prompt addressed. Thorough, logical, and clear discussion of strategies described. Literature clearly supports improved strategies discussed.

Most
components of discussion prompt addressed.
There is adequate discussion of strategies described. Literature supports improved strategies discussed.

Limited
components of discussion prompt addressed. There is some general discussion of strategies described. Literature for supporting improved strategies is weak.

Minimal or no
components of discussion prompt addressed. Minimal discussion of strategies described. Literature for supporting improved strategies is not relevant or missing.

/25

Writing Quality, Grammar & APA

9-10 points

7-9 points

5-6 points

0-4 points

Posts show above average writing style using standard English, basically free from grammar, punctuation, and spelling errors. 0-1 APA errors.

Posts show average writing style using standard English with few grammar, punctuation, and spelling errors.
2-3 APA errors.

Posts show an average and/or casual writing style with some errors in spelling, grammar, punctuation, and usage. 4-5 APA errors.

Posts show a below average/poor writing style in terms of appropriate standard English writing style, clarity, language used, and grammar. >5 APA errors.

/10

TOTAL POINTS (sum of all criteria)

/100