Teaching and Learning in Nursing (2013) 8, 140–146

www.jtln.org

The impact of integrating Quality and Safety Education forNurses' safety competency in first-year associate degreenursing students

Angela D. Jones DNP, RN⁎

Angelina College, Lufkin, TX 75902, USA

⁎ Corresponding author. Tel.: +1 936E-mail address: angelajones@angelina

1557-3087/$ – see front matter © 2013 Nhttp://dx.doi.org/10.1016/j.teln.2013.06.00

KEYWORDS:QSEN;Safety;Culture of safety

Abstract The purpose of this pilot project was to integrate Quality and Safety Education for Nurses(QSEN) safety competency teaching strategies in first-semester associate degree in nursing (ADN)students and evaluate student learning outcomes. A pretest–posttest design measured the students'perception of safety awareness. Results suggest a strong correlation between didactic and clinicalinstruction of QSEN safety competency teaching strategies to enhance students' awareness of safety,

thus fostering quality patient care.© 2013 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

633 5264..edu

ational Organization for Asso1

The Institute of Medicine (IOM) evaluated health care inthe United States, revealing an astounding number ofpreventable medical errors. As a result, new health careinitiatives are continuously being developed, implemented,and evaluated to improve quality and safety in all areas ofpractice within the health care delivery system. In the report,“To err is human: Building a safer health system”, it isestimated that as many as 98,000 people die in hospitalsannually to causes related to preventable medical errors(Kohn, Corrigan, and Donaldson, 2000). These preventablemedical errors are associated with individual errors, as wellas systems errors (Kohn et al., 2000). The findings of thisreport have had a substantial impact on the health caredelivery system of America, and consequently, strategieshave been developed to decrease preventable medical errors.

The focus on quality, safe patient care affects all health caredisciplines because each discipline has a duty to respond to theidentified national patient safety concerns. According to Kohnet al. (2000), the public and private sectors have responded

ciate Deg

quickly to the concerns for public safety. Numerous initiativeshave been identified to target patient safety across all healthcare disciplines. It has been estimated that more than 2.7million registered nurses (RNs) contribute to the health careworkforce, thus making nursing the largest division within thehealth care delivery system (U.S.Department of Labor, Bureauof Labor Statistics, 2012). Because nurses comprise atremendous sector of the health care delivery system, it isimperative that the nursing profession address the nationalconcerns regarding quality and safety in patient care. Becauseof the astounding number of RNs affecting the health caresystem, the nursing profession has the potential to effect thegreatest change concerning patient safety.

To assure the greatest change in nursing, it is essential thatthe manner in which nursing education is developed anddelivered is also changed. Because of the complexity of thecurrent health care system, a paradigm shift to encompass asystems approach to safetymust be included in nursing curriculain addition to the individual focus on safety (Cronenwett et al.,2007). The Quality and Safety Education for Nurses (QSEN)initiative was developed to empower nursing education topromote the essential knowledge, skills, and attitudes necessary

ree Nursing. Published by Elsevier Inc. All rights reserved.

141The impact of integrating QSEN

to improve patient outcomes and reduce preventable medicalerrors (QSEN, 2012). The concept of safety needs to beincorporated throughout the entire nursing curriculum, begin-ning with the students' first nursing course and threadingthroughout the nursing curriculum. The question of inquiry thatguided this project was, in first-semester fundamental nursingstudents, what is the effect of QSEN safety competencyteaching strategies on student learning outcomes?

1. Background

The Robert Wood Johnson Foundation funded the QSENinitiative to address how nursing would respond to thenational health care concerns (Cronenwett et al., 2007). TheQSEN team was made up of faculty experts within the fieldof nursing, an interprofessional advisory council, andpedagogical leaders who collaborated to accomplish theproject goal of addressing the challenge of preparing nursesto deliver safe, quality care (Cronenwett et al., 2007;Sherwood, 2011; Sullivan, 2010). The QSEN team ofexperts defined the fundamental competencies that wouldguide this educational initiative to include patient-centeredcare, teamwork and collaboration, evidence-based practice(EBP), quality improvement, safety, and informatics. Tofoster a greater understanding of the QSEN competenciesand to facilitate program implementation and evaluation,each of the six competencies has numerous objectives withinthe knowledge, skills, and attitudes (KSA) categories. Theobjectives contribute to greater faculty awareness andunderstanding of student learning outcomes in relation toeach of the competencies. Although the objectives are criticalto obtaining competency in each of the defined areas, theseobjectives allow faculty the flexibility necessary to incorpo-rate multiple instructional methodologies to achieve the goal(Sherwood, 2011).

As the nation focuses on health care concerns regardingquality and safety, nursing education must seek to meet thesenational concerns thorough curriculum redesign and teachinginnovation. Of the numerous initiatives created to addressthese concerns, the QSEN Institute (www.qsen.org) offers acomprehensive approach to quality and safety by providingnursing faculty with a compendium of EBP ideas and teachingstrategies to foster QSEN competency achievement. Nursingeducation must respond to effectively create a culture of safetyin the next generation of nursing professionals, therebybridging the gap between education and clinical practice.

2. Student learning outcomes as related to QSENsafety competency

The concept of safety is paramount to successful patientoutcomes; therefore, early introduction to safety is funda-mental to nursing education providing the impetus for thisproject of integrating QSEN safety competency in firstsemester nursing education courses. According to Cronen-

wett et al. (2007), the QSEN faculty believed it was essentialto have a separate safety competency to focus on a systemsapproach to safety in conjunction with individual patientsafety. To effectively and efficiently understand the QSENsafety competency in prelicensure nursing education, theliterature was reviewed, revealing research-based studieswith significant results related to evaluating student learningoutcomes associated with QSEN competencies in prelicen-sure nursing curriculum. Of these research studies, only tworelated to the QSEN safety competency within the actualclinical environment. Measurement of student learningoutcomes is essential to evaluate teaching strategy effective-ness and to ensure the content was learned. According toIronside & Sitterding (2009), development of quality andsafety competencies must occur continuously and infuse intoall learning encounters throughout the nursing program.

There are many reliable studies associated with QSENcompetencies and measurement of student learning out-comes. Many of these studies are conducted in a simulatedclinical environment and evaluate integration of all of theQSEN competencies. For example, Piscotty, Grobbel, &Tzeng (2011), conducted a study of students in both atraditional and an accelerated bachelor of science in nursing(BSN) program to evaluate the effectiveness of a student-ledsimulation project integrating the QSEN competencies. Theauthors sought to evaluate the impact the simulation projecthad on increasing students' KSA in the six competencyareas. The conclusion supported the use of simulated clinicalexperiences to strengthen self-confidence and self-efficacyas related to quality and safety in nursing practice. A study ofthis type offers sound support for the use of the QSENcompetencies in a simulated clinical environment; however,this does not address the impact of QSEN safety competencyteaching/learning tools in actual clinical environments.

The literature revealed two studies that address evaluationof student learning outcomes as related to the safetycompetency in actual clinical environments. Miller &LaFramboise (2009) conducted a pilot study to determinethe effects of integrating classroom and clinical contentrelating to quality and safety health care systems ascompared to only classroom presentation. A mixed-methodquasi-experimental study was conducted with a populationof senior BSN students enrolled in an adult medical–surgicalcourse at a Midwestern university. Miller and LaFramboiseposed three distinct research questions: What are thestudents' perceptions of their KSA related to quality andsafety competencies? What is the effect of integratingclassroom content alone on perceptions of their KSA? andWhat is the difference in the themes identified between thetwo groups? The Student Perceptions of Safety and QualityKnowledge, Skills, and Attitudes Questionnaire was devel-oped and tested. Intervention group 1 received classroomcontent only, Intervention group 2 received both classroomand clinical content, and the control group received nostructured classroom quality and safety content nor did theyparticipate in clinical quality and safety projects. All

142 A.D. Jones

participants were evaluated using the questionnaire in apretest–posttest design, and the intervention groups partic-ipated in a case study to further evaluate the effectiveness ofthe interventions. After interventions and questionnaireswere completed, the statistical analysis reflected a statisti-cally significant finding. Students' perceptions related tosafety were higher in the intervention group. Overall, thestudents' perceptions of their competencies as related toQSEN were positive. Several themes emerged from theanalysis of case study data. The themes from Interventiongroup 1 included blaming, lack of communication, andresource seeking, whereas the themes from Interventiongroup 2 focused on safety, problem solving systems, andlack of communication (Miller and LaFramboise, 2009).This study supports the use of QSEN safety strategies tofoster a culture of safety in nursing students.

Chenot & Daniel (2010) conducted an exploratory,quantitative study with a survey design to examine currentsafety education in prelicensure nursing education andprovide recommendations for improving safety education.The pilot study was conducted for reliability then followedby a larger study. The Healthcare Professionals PatientSafety Assessment Curriculum Survey (HPPSACS) was thetool developed and tested to measure students' perceptions ofsafety awareness. The major focus of the study related toprelicensure nursing education and consisted of studentsenrolled in seven universities and colleges in the southeast-ern United States. Analysis of the question regardingstudents' perceptions of their awareness, skills, and attitudesassociated with patient safety reflected a general sensitivityof the students relating to their personal role in patient safety.A research question was also posed concerning therelationship between the type of collegiate nursing programand the students' perceptions of their patient safety skills,attitudes, and awareness. As a result, the researchers notedthat the associate degree in nursing (ADN) students hadhigher error reporting and comfort scores as compared to theaccelerated and traditional BSN students. The curriculum ofall participating programs was analyzed to determine patientsafety focus and instructional methodologies. Because theentire curriculum was evaluated, didactic and clinicalexperiences would be included, thus impacting the results.All of the schools included in the study implemented at leastthree of the QSEN competencies in their curriculum with oneschool including all of the core QSEN competencies (Chenotand Daniel, 2010). This study further strengthens the use ofQSEN safety competency teaching strategies in developingsafety awareness in nursing students.

3. Method

3.1. Purpose

The purpose of this project was to integrate QSEN safetycompetency in first semester fundamental nursing courses.

The aims included (a) integrating QSEN safety competencyin the fundamentals didactic and clinical courses and (b)evaluating student understanding of safety before the clinicalexperience and again after completion of the clinicalexperience. The goal of improving student learning out-comes as related to creating a culture of safety in beginningnursing students using QSEN's safety competency teachingstrategies has the potential to impact the students and thenursing profession. The most significant outcome associatedwith creating this culture of safety is the potential reductionof preventable medical errors, improving the quality ofpatient care.

3.2. Design

A pretest–posttest design was used to evaluate studentlearning outcomes associated with didactic presentation ofQSEN safety teaching/learning strategies followed byclinical implementation. This project was implemented inan ADN program in east Texas during the fall semester 2012.

3.3. Sample

Upon approval from the Institutional Review Board,recruitment of participants occurred during the first week ofthe fall 2012 semester. First-semester nursing students wereinformed of the project during the first week of thesemester and invited to participate in the project. Therequirements and expectations were reviewed by theinvestigator; students were provided the opportunity toask questions. The students were made aware that agreeingto participate/not participate in the project would not affecttheir grade in the course or progression in the nursingprogram. Study participants were offered no monetary orgrade increase incentives.

The QSEN safety competency teaching strategies wereimplemented in the nursing program for first-semesterfundamental students. As an ethical determinant of informa-tion sharing, the QSEN safety teaching/learning tools areproven beneficial; therefore, all students would receive theinformation as presented. Students choosing not to partici-pate would receive the interventions as planned; however,their data would not be included in the statistical analysis ofthe results. Because no additional labor was required, all ofthe first-semester students agreed to participate. No furtherinclusion criteria were specified, and no qualified studentwas excluded.

A convenience sample consisting of all nursing studentsenrolled in the first-semester nursing courses (N = 84) madeup the study population as all first-semester fundamentalnursing students in the ADN program were invited toparticipate in the project. Study participants were at least 18years of age and had successfully met the requirements forentrance into the associated ADN program.

143The impact of integrating QSEN

3.4. Protection of human subjects

Before beginning the project, the investigator introducedall fundamental nursing students to the project, presenting aclear project overview along with the purpose, goal, andaims. After the verbal introduction, participants were thengiven a student consent form to read, discuss, and sign.Because the QSEN safety teaching strategies were to bethreaded into the planned curriculum, no additional re-quirements were made of the students other than the pretestand posttest evaluation of safety knowledge. Students couldchoose to withdraw from the ADN program and/or theproject at any time. All sensitive materials were stored in alocked filing cabinet in the investigator's secure office.

3.5. Instruments

During the second week of class after the QSEN overviewand safety competency was introduced, all students weregiven the HPPSACS, modified for nurses, as a pretestevaluation of the students' knowledge of patient safety(Chenot and Daniel, 2010). The HPPSACS is a 34-itemquestionnaire evaluating nursing students' self-evaluation ofpatient safety assessments (Chenot and Daniel, 2010). Thefirst 18 items are related to patient safety: prevention,assessment, interventions, and collaboration among healthcare professionals. Items 19–23 relate to the individualstudents' level of comfort when assessing safety concerns,violations, and error reporting. The remaining items wereboth multiple-choice questions regarding essential safetyfacts concerning the health care delivery system andquestions concerning previous experience with patient safetyissues or concerns. The HPPSACS evaluation tool is anadapted version of the Patient Safety/Medical FallibilityAssessment Pre and Post Curriculum Survey created byMadigosky, Headrick, Nelson, Cox, & Anderson (2006) toevaluate safety understanding by medical students.

Demographic data were also collected for each participantincluding: age, ethnicity, previous health care experience,and prerequisite entrance grade point average (GPA) and wasassessed with the pretest. After completion of the clinicalexperiences, all participating students completed theHPPSACS again as a posttest evaluation of safety knowl-edge after completing the biweekly clinical experiences for 6weeks. The results were statistically analyzed via anindependent t test.

3.6. Procedures

The plan for the project was to integrate the QSENsafety competency each week for the first 5 weeks of thefundamentals didactic nursing course before beginning theclinical experiences using the QSEN safety educationclassroom teaching strategies as listed on the QSEN Website (QSEN, 2012). The safety competency was thenintegrated in the corresponding clinical course with each

clinical experience using the QSEN safety clinicalteaching strategies.

Of the numerous classroom and clinical tools available,the plan isolated five tools that were introduced during thedidactic portion of the plan (one per week). The QSENsafety tools included the following: (a) ReformulatingSBAR (Situation–Background–Assessment–Recommenda-tions) to “I-SBAR-R” (Introduction–Situation–Back-ground–Assessment–Recommendations–Read back), (b)Little Room of Errors, (c) Clinical Assessment Tool, (d)the 60 Second Situational Assessment, and (e) StudentOfficer of Patient Safety. The I-SBAR-R communicationcard, the Clinical Assessment Tool, and the 60 SecondSituational Assessment tools were used during eachclinical experience. In addition, each student had theopportunity to function as the Student Officer of PatientSafety at least once during the clinical rotation.

Data collection occurred at three points. Before beginningthe project, all students voluntarily completed the consentform. After consent was obtained, the project began withclassroom instruction that included an overview of QSENand Safety Competency during the first week. Theintroduction to QSEN also included the QSEN safety tool:Little Room of Errors skills lab activity. A simulated patientroom in the skills lab was set up with multiple safetyviolations or potential safety hazards. These safety hazardsincluded medications at the bedside, spilled water on thefloor, unlocked bed, call bell and over bed table out of reachfor the patient, a frayed extension cord, and a pack ofcigarettes and lighter placed on the bedside table withoxygen in use. In all, there were 20 safety hazards present.Students were asked to independently identify all of thesafety hazards, actual or potential, during their assigned time(5 minutes) in the skills lab.

The second data collection point occurred during Week 2when the HPPSACS pretest was administered. Introductionof the remaining QSEN teaching tools occurred in theclassroom as follows:

• Week 2: Introduce QSEN safety tool: Reformulating SBARto “I-SBAR-R”

• Week 3: Introduce QSEN safety tool: Clinical AssessmentTool: Teaching strategy for safety and patient centered care

• Week 4: Introduce QSEN safety tool: The 60 SecondSituational Assessment

• Week 5: Introduce QSEN safety tool: Student Officer ofPatient Safety.

Upon completion of the didactic introduction of each ofthe five QSEN safety tools, clinical implementation occurredduring Weeks 6–12. Clinical integration consisted of usingthe previously introduced QSEN safety tools with eachclinical experience (biweekly for 6 weeks). The final datacollection point occurred after completion of the clinicalexperiences, when all students received the HPPSACS againas a posttest evaluation of safety knowledge.

144 A.D. Jones

4. Data analysis

4.1. Demographics

The demographic data that were collected with theHPPSACS pretest addressed the age of the students,ethnicity, previous health care experience, and the students'GPA for the required prerequisite courses (Table 1). Of thesample population, most of the students were between theages of 18 and 29 (71%). Sixty-two percent were Caucasian,with the remaining 38% representing African American,Hispanic, Middle Eastern, Native American, and biracialethnic backgrounds. Fifty-one percent had previous healthcare experience (nursing assistant, previous nursing educa-tion, emergency medical services, etc.). The requiredprerequisite courses for the ADN program include English,General Psychology, Dosage Calculations, and eight credithours of Human Anatomy and Physiology. The studentslargely reported a prerequisite GPA of 3.0 and higher (80%).Of the students who initially agreed to participate in the

Table 1 Participant demographics

Demographicdata

n (N = 84) %

Age 18–25 years 45 5426–29 years 14 1730–39 years 17 2040–49 years 6 750+ years 2 2

Ethnicity Caucasian 52 62AfricanAmerican

15 18

Hispanic 12 14Asian 0 0East Indian 0 0Other 2 (1 Middle

Eastern and 1Native American)

2

Biracial 3 (races notspecified)

4

Previous experience Nurse assistant 23 27Emergencymedicalservice

4 5

Dentalassistant

2 2

Medicalassistant

4 5

Previousnursingeducation(student)

6 7

Other 4 (phlebotomy) 5Prerequisite entrance GPA

(English Composition,General Psychology,Dosage Calculations, andHuman Anatomy andPhysiology)

4.0 7 83.0–3.9 60 722.5–2.9 12 142.4 or below 1 1No response 4 5

project, eight withdrew from the nursing program prior tocompleting the HPPSACS posttest.

5. Results

The goal of this project was to improve student learningoutcomes as related to creating a culture of safety inbeginning nursing students. As a result of using the identifiedQSEN safety competency teaching strategies, it was notedthat didactic introduction of the selected tools along withrepeated clinical implementation yielded a statisticallysignificant impact. The first question asked in the HPPSACSaddresses the inevitability of making errors in health care.After project implementation, it was noted that the studentsbelieved that errors in health care are not inevitable (α = .01,t test = 2.619, p = .004). To further support this shift increating a culture of safety in beginning nursing students,another question that was statistically significant was relatedto health care professionals' not tolerating uncertainty inpatient care (α = .01, t test = −2.95, p = .001). The conceptof safety was continually addressed during this project,reflecting an appropriate use of time during the nursingcourses (α = .01, t test = −2.714, p = .003).

6. Findings

During the project implementation in the clinical setting, itwas noted by the student investigator during the first clinicalday in which the students were assigned to care for actualpatients, the nursing students noted an actual safety hazardnegatively affecting the patient assigned to their care. Thepaired students were assigned to the care of an elderly patientadmitted for gastrointestinal bleeding, anemia, and progressiveconfusion. The patient was ordered to receive oxygen at 2 L vianasal cannula. After receiving the morning shift report, thestudents entered the patient's room to begin their QSEN 60Second Situational Assessment and obtain vital signs. Thestudents reported to the instructor that the patient was confusedwith an oxygen saturation of 86%. Furthermore, the nasalcannula was correctly placed in the patient's nares and theoxygen tubing appropriately connected to the oxygen source;however, the students assessed that the oxygen flow was notturned on as indicated in report. The situation was immediatelycorrected, reported to the RN, and the patient was reassessed.Within 5 minutes of the intervention, the patient's oxygensaturation remained greater than 96%.

During clinical implementation of the QSEN safety tools,there were numerous occurrences of missing patient namebands, patient beds not in the lowest position, call lights outof reach, and side rails lowered inappropriately. Because ofthe frequent discussions concerning patient safety and therepetitive use of the QSEN safety tools, students werevigilant in safety assessment and intervention. The statisticalresults in addition to the actual clinical experiences

145The impact of integrating QSEN

rigorously support the use of QSEN safety competencyteaching strategies in fundamental nursing students, creatinga culture of safety and reducing preventable medical errors.

Error reporting systems within the health care deliverysystem are often ineffective, as errors are often underreported(Kohn et al., 2000). The IOM report further acknowledgesthat successful error reporting systems are most oftenconfidential and nonpunitive, further facilitating errorreporting. Because of this, the IOM made two recommen-dations for improving error reporting systems to includemandatory and voluntary systems for reporting errors inhealth care. Voluntary reporting typically identifies thoseincidents that result in little to no patient harm, whichultimately aids in early identification of actual or potentialsafety problems (Kohn et al., 2000). After project imple-mentation, it was noted that the nursing students' perceptionof error reporting shifted to support the idea of error reportingbeing confidential and nonpunitive, further reinforcing theadoption of a culture of safety.

6.1. Limitations

This pilot project was implemented in a relatively smallpopulation of ADN students in a single nursing program.Although the key areas on the HPPSACS supporting thepurpose of this project were statistically significant, there wereother safety-related areas that did not reflect a significantincrease in the students' safety awareness or attitude. Tofurther validate the efficacy of the QSEN safety competencytools, additional students representing the various types ofnursing programs should be included. Furthermore, the effectsof these interventions on students' adoption of a culture ofsafety across the nursing curriculum should be evaluated.

7. Indications

Research studies reviewed address prelicensure nursingeducation from the vantage point of nursing education asrelated to preparing the students for the role of the professionalRN. Quality and safety competencies for practical (vocational)nurses need to be developed with the same focus, strength, anddetermination as that of the QSEN initiative to ensure that alllevels of nursing are providing the highest quality patient carewith a foundation of safety. Further empirical studies arewarranted to evaluate the contributions of QSEN to pre-licensure nursing education, postgraduate nursing education,nursing practice, and nursing research.

8. Conclusions

Current literature reflects the importance of integrating thecore QSEN competencies into prelicensure nursing education.Nursing students are the next generation of nursing pro-fessionals and should be immersed in a culture of safety

beginning with the first nursing education didactic course andclinical experience to develop an attitude of quality and safety.The traditional nursing education curriculum has not ade-quately prepared nursing students to transition to the role ofclinician upon graduation due to the complexities associatedwith the health care system of today (Cronenwett et al., 2007).

The QSEN initiative has provided a rich storehouse ofvaluable information that provides nurse educators withinnovative teaching strategies and evaluation tools necessaryto effectively implement and evaluate the six core QSENcompetencies. Nurse educators must accept the challenge ofcurriculum revision and use a varied pedagogical approach toteaching the essential QSEN competencies (Cronenwett,Sherwood, and Gelmon, 2009; Cronenwett et al., 2007;Sullivan, 2010). As student learning outcomes improve, amore effective and efficient professional clinician willemerge, bridging the gap between education and practice.QSEN is a comprehensive resource for promoting the KSAnecessary to enhance safe, patient-centered care, improvepatient outcomes, and reduce preventable medical errors.

Acknowledgments

The author would like to thank Dr. Alicia Culleiton, DNP,RN, CNE, Capstone Chair, Duquesne University, Pittsburgh,PA, for her support, encouragement, and guidance inpreparing and completing this manuscript.

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