Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 15
A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses’ Roles in Practice
I mproving the quality and safety of our healthcare system is the most pressing issue of our time. Since the Institute of Medicine (IOM) reveal –
ed the magnitude of quality and safe- ty outcomes in its report, To Err Is Human: Building a Safer Health System (IOM, 2000), there has been a grow- ing series of efforts for improvements, including changes to health profes- sions education. In 2003, the IOM called for a new framework that would prepare all health professionals with six core competencies to be able to deliver patient-centered care through teamwork and collaboration, with evidence-based care from continuous quality improvement, with a mindset for safety and employing informatics. These competencies are the founda- tion to develop and work in cultures of quality and safety, and change the mindset from a focus on individual provider to a system perspective to improve outcomes. While the compe- tencies are familiar terms, they were redefined for nurses in 2007 by the Quality and Safety Education for Nurses (QSEN) project with a new set of knowledge, skills, and attitudes that change how nurses work (Cronenwett et al., 2007).
Gwen Sherwood Meg Zomorodi
Continuing Nursing Education
Gwen Sherwood, PhD, RN, FAAN, is Professor and Associate Dean for Academic Affairs, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC, and Co- Investigator, Quality and Safety Education for Nursing (QSEN). She may be contacted directly via email at Gwen.sherwood@unc.edu
Meg Zomorodi, PhD, RN, CNL, is a Clinical Associate Professor, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC.
Statement of Disclosure: The authors reported no actual or potential conflict of interest in rela- tion to this continuing nursing education activity.
Note: Additional statements of disclosure and instructions for CNE evaluation can be found on page 23.
This offering for 1.4 contact hours is provided by the American Nephrology Nurses’ Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu- ing nursing education requirements for certification and recertification.
Copyright 2014 American Nephrology Nurses’ Association
Sherwood, G., & Zomorodi, M. (2014). A new mindset for quality and safety: The QSEN competencies redefine nurses’ roles in practice. Nephrology Nursing Journal, 41(1), 15- 22, 72. Retrieved from http://www.prolibraries.com/anna/?select=session& sessionID=2965
Preventable errors are a major issue in health care. The complexity of health care requires interactions among numerous providers for any patient multiple times a day. Nurses are the constant presence with patients and have an important role in coordi- nating the contributions of the myriad of caregivers. Nurses are also the last line of defense. Increasingly, it is recognized that nurses need to be better prepared with quality and safety competencies to have a leading role in making our healthcare system safer. This article presents evidence related to quality and safety, describes the six core compe- tencies from the Quality and Safety Education for Nurses (QSEN) project for integration in nursing practice, describes a practice based on inquiry and engagement, and presents a toolkit for developing a new mindset based on new quality and safety science.
Key Words: Quality and Safety Education for Nurses (QSEN), quality improve- ment, patient safety.
Goal To provide an overview of the role quality and safety competencies have in making our healthcare system safer via the Quality and Safety Education for Nurses project.
Objectives 1. Identify the evidence driving the imperative to improve healthcare outcomes. 2. Describe applications in practice of the knowledge, skills, and attitudes for the six com-
petencies defined by the Quality and Safety Education for Nurses (QSEN) project. 3. Discuss the changes in roles and responsibilities for nurses when applying the six
QSEN competencies.
This article highlights the evi- dence driving the imperative to im – prove healthcare outcomes; describes applications in practice of the knowl- edge, skills, and attitudes for the six competencies defined by the QSEN project; and discusses the changes in
roles and responsibilities for nurses. The article also includes strategies for developing a new mindset to achieve the competencies, with embedded clinical situations and a case study related to nephrology nursing to illus- trate integration of the competencies.
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A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses’ Roles in Practice
The Imperative to Improve Quality And Safety
Healthcare professionals, includ- ing nurses, are well educated and highly skilled, yet the healthcare sys- tem continues to be plagued by quali- ty and safety issues. Healthcare errors occur at an alarmingly high incidence and are the eighth leading cause of death (IOM, 2000; Landrigan, Parry, Bones, Goldman, & Sharek, 2010). More people die each year from med- ical errors than breast cancer or motor vehicle accidents (Barach & Berwick, 2003). The Institute for Healthcare Improvement (IHI) (2007) has esti- mated there are 40,000 incidents of medical errors every day. At least 1.5 million preventable medication er rors occur each year in the United States; this translates to an average of at least one medication error per day per patient (Aspen, Walcott, Bootman, Cronenwett, & the Committee on Identifying and Preventing Medi – cation Errors, 2007). Preventable errors cost the U.S. approximately $17 billion each year (Landrigan et al., 2010). The latest report card from Wachter (2010) shows little progress in the decade following the 1999 report by the IOM (2000). Nurses, as one of the largest groups of providers, have new roles and responsibilities to improve patient safety and quality. What education and preparation to engage nurses as leaders could improve our systems of care?
Quality and safety are core val- ues in health care based on the com- mitment to uphold ethical principles to do no harm, always safeguard the patient, and act with ethical comport- ment (Egan, 2013). Quality is an in – herent approach to doing good work; nurses come to work wanting to per- form good work, but they sometimes lack the preparation and tools or may work in systems where good work is not recognized or supported. Evi – dence supports that nurses want to work in systems that recognize good work and uphold a work environ- ment that supports quality and safety (IOM, 2004; Manojlovich & DeCicco, 2007; Wong & Cummings, 2007). The
MagnetTM recognition program stan- dards are consistent with a safety cul- ture through the focus on quality improvement, strong leadership, and interdisciplinary collaboration (Di Bennedetto et al., 2011; Pischke-Winn, Stratton, Ferket, & Micek, 2013; Triolo, 2012).
Changing Perspectives On Quality and Safety
The new science of quality and safety shifts from prevailing models focused on individual actions to a focus on system improvements. Quality and safety overlap, and each contributes to the other, but each has its own body of knowledge, skills, and attitudes.
Simply put, quality measures actual performance of a standard pro – cess or event ( Johnson, 2012), such as the number and types of patient falls over a period of time in a particular setting. These data are compared with benchmarks in other departments in the same organization and/or with other similar organizations, or against an ethical standard of zero occur- rences. In the case of falls, ethically, no patient should experience a fall, so quality improvement efforts are aimed at zero occurrences.
Safety, on the other hand, is pre- venting errors and negative outcomes that happen unrelated to the patient condition being treated, and again, the goal is zero occurrences. Safety is constantly scanning the environment to prevent mistakes from happening (Barnsteiner, 2012). The mindset is on prevention; there is constant aware- ness of the potential for a patient to fall, and steps are taken for preven- tion. The individual action is the nurse including a reminder to check on a patient at risk for falls in the day’s task list; a system design is using a mattress alarm to alert staff that a patient at risk for falls has gotten out of bed unattended.
Safety is the watchful eye that prevents errors. Quality measures events and seeks improvements through quality initiatives.
Safety Culture: A System Approach
Safety culture is a subset of orga- nizational culture defined by the val- ues and beliefs about health and safety evident in the way the organization lives (Reason & Hobbs, 2003). Safety culture is the visible evidence of how individuals and the overall organiza- tion manage risks and hazards to avoid damage or losses and achieve their goals. Safety culture reflects the com- mon understanding about safety and emerges from the dynamic reciprocal interaction among people, tasks, and systems (Feng, Bobay, & Weiss, 2008).
Other high performance indus- tries, such as aviation, nuclear power, and railway, have adopted safety as an essential standard and changed the culture that drives their systems to make safety a priority with the focus on where the next error could occur (Roberts, Yu, & van Stralen, 2013). Health care is adopting methods from these industries that have produced dramatic safety improvements. In the past, health care has focused on the individual performance and estab- lished blame for the error, and little information was shared with patients and families (Ashpole, 2013). Today, efforts have been made to shift the focus in the healthcare system to one of quality and safety, where errors (safety) are recognized as a break- down in processes (quality) and reported to a central database. Then the errors are investigated to identify the steps in every related process to determine where different decisions or actions could have prevented the error (Sutcliffe, 2011). The process or system is then redesigned to mitigate future occurrences. The mindset is on preventing errors from happening through awareness and alertness to system breakdowns to interrupt the pathway towards an error (a near miss).
To illustrate a system approach, a nurse administered an adult dose of a high-risk medication to an infant. The mistake was reported and investigat- ed by the risk management team to determine what happened from the
Nephrology Nursing Journal January-February 2014 Vol. 41, No. 1 17
purchasing department, to the phar- macy, to the unit, to the medication administration process. The root cause analysis (RCA) revealed that both the pediatric and the adult unit doses came in similar vials, different only in the small lettering detailing the dosage, and both were stored in adjacent bins. To address this prob- lem, the bins were relocated and labeling clarified to reduce the likeli- hood that the wrong vial would be picked up in a rush. However, the mindset did not stop there. Additional organizations that shared benchmark- ing practices were scanned, revealing that others had reported a similar mis- take. Together, the organizations leveraged the manufacturer to change the packaging to more clearly distin- guish the two dosages. Additionally, there was a search to see if other med- ications were at similar risk of misidentification due to similar pack- aging, thus preventing future errors from occurring. This process of trans- parent communication is a key part of safety culture, so information about what happened and steps taken to prevent future occurrences are shared with patients and families (Sammer, Lykens, Singh, Mains, & Lackan, 2010). In this scenario, the nurse who administered the medication was still accountable, while also updating her/his knowledge on the evidence- based standards for safe medication administration, and system changes were established to help prevent future mistakes when human factors lead to a process breakdown.
A New Mindset to Improve Quality And Safety: Applying the QSEN Competencies
Recognizing the need for changes in how nurses are educated to meet practice demands for quality and safe- ty, the Quality and Safety Education for Nurses (QSEN) (www.qsen.org) project (funded by the Robert Wood Johnson Foundation) established a national expert panel to define the six core competencies established by the 2003 IOM report for integrating a quality and safety framework for
nursing (Cronenwett et al., 2007). The panel identified knowledge, skills, and attitudes essential to achieve each competency stated as objectives for integration into curricula (Cronenwett et al., 2007) and are now part of national nursing education curricula standards. The definition for each com- petency with a summary of expecta- tions for practice are shown in Table 1; all 162 knowledge, skill, and attitude statements are available online (www. qsen.org), in Cronenwett et al. (2007), and in Sherwood and Barnsteiner (2012). Graduate competencies reflect higher order performance expected of graduate nurses (Cronenwett et al., 2009) and are embedded in the American Association for Colleges of Nursing (AACN) essentials for Master’s and DNP education; they were updated in 2012 (AACN, 2012).
Applying the QSEN Competencies in Practice
The competencies defined by the QSEN project apply for all of nursing practice: patient-centered care, team- work and collaboration, evidence- based practice, quality improvement, safety, and informatics (see Table 1). Each competency is described for applications in nursing practice with particular application in nephrology nursing.
Patient-centered care. Patient- centered care is demonstrated through respect, response, and clear commu- nication, and always asking patients their preference for which name they wished to be called (Walton & Barnsteiner, 2012). Patient- and family- centered care was first defined by the Picker Institute as improving health care through the eyes of the patient (Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993). When patients and their families are involved in making decisions about their care, the focus shifts from “doing to” to “doing with.” When patients and families are treat- ed as members of the care team, they can become safety allies, thus pre- venting errors. For example, patients may alert clinicians when care is not according to their usual routine or by noticing a different medication. Care
planning is based on cultural aware- ness and assessments to know patient values, beliefs, and preferences. Evidence continues to raise questions about policies and procedures that separate patients and families, partic- ularly visiting hours.
Patient-centered approaches to pain management is an area of partic- ular concern to nephrology nurses to know patient preferences and goals for managing pain, providing patient- appropriate education, and knowing when to administer pharmacologic agents or use complementary thera- pies. In the hospital, practical applica- tions include communication using white boards in the patient’s room to identify persons caring for the patient, daily care goals, and scheduled treat- ments. Patients and their families like- wise use the boards to record infor- mation or register questions for the care team. Some units have provided long-term patients and their families with small journals to maintain a health history, and keep records of treatments, medications, or other health information.
Teamwork and collaboration. Communication and collaboration are at the root of teamwork, but the education of health professionals is by individual discipline, both formally and in continuing education (Disch, 2012). Thus, there is little interprofes- sional contact until new graduates are thrust into practice settings to work closely together, often under stressful conditions. Between 1995 and 2005, ineffective communication and break- downs in working together was the root cause of 66% of healthcare errors (Hughes, 2008). Adverse drug events most often occur at transition points in care or during handoffs, from one provider to another (Hughes, 2008).
Teamwork and collaboration are essential for coordinating complex care involving several health care dis- ciplines (Simmons & Sherwood, 2010), which is especially important for nephrology patients whose care may involve multiple providers. Knowing the roles and responsibilities of other team members can help nurses navi- gate the complicated web of commu-
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A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses’ Roles in Practice
nication and hierarchy so prevalent in health care (Disch, 2012). Participa – ting in interprofessional rounds that include patients and families helps to coordinate information, set daily care goals, and manage schedules for the various treatments. Nurses need to know how to speak up when care is compromised (see Table 2), and to do this, must have organizational support to back them up (Manojlovich & DeCicco, 2007; Wong & Cummings,
2007). Teamwork requires flexible leadership that shifts to match expert- ise and role of the team members.
TeamSTEPPS® is an evidence- based curriculum for developing teamwork to improve quality and safety (Agency for Healthcare Research & Quality [AHRQ], n.d.). Research shows that the risk of serious adverse events is reduced when team training has been implemented (Hughes, 2008). The knowledge and skills
taught in TeamSTEPPS are often embedded in simulation (Carswell, 2013). Standardized communications (see Table 2) help reduce risks during transitions and handoffs, reduce reliance on memory, assure that criti- cal information is shared, and help team members speak up when they see safety hazards.
Evidence-based practice. Patient care is based on evidence-based prac- tice standards and industry best stan-
Table 1 Quality and Safety Competencies Defined by the QSEN Project with Summary Expectations for Nurses
Derived from the Knowledge, Skills, and Attitudes
Competency Definition Examples of Expectations
Patient-centered care
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
• Provides nursing care based on individual and family needs and preferences.
• Applies cultural awareness in the provision of health care services, including aspects of nutrition, spiritual resources, and patient education.
• Uses effective interpersonal communication skills.
Teamwork and collaboration
Function effectively within nursing and inter- professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
• Recognizes own strengths and limitations as a team member.
• Communicates and collaborates effectively in intranursing and interprofessional teams to achieve best outcomes for the patient.
• Treats patient and family as active team members.
Evidence-based practice
Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
• Uses current evidence based standards in care interventions.
• Evaluates evidence to determine best practices. • Determines deviations from standards to
accommodate patient beliefs and preferences.
Quality improvement
Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
• Identifies processes or issue for improvement. • Assists with measurement of the process or issue
against benchmarks. • Can identify good practice. • Apply process improvement strategies to improve
process or issue.
Safety Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
• Applies new safety science for awareness of breakdowns in processes.
• Recognizes and reports errors and near misses that compromise patient safety.
• Participates in analysis of adverse events and near misses for root cause analysis.
Informatics Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making.
• Applies skills in data and information management to access latest evidence.
• Uses decision support tools appropriately. • Records data and patient information in electronic
health records.
Source: Adapted from Cronenwett et al., 2007.
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dards (Tracey & Barnsteiner, 2012). Nephrology nurses need to know the standards of care that guide their practice and recognize those interven- tions that carry high risk, such as managing all types of catheters, pre- venting infections, and maintaining fluid balance (Gomez, 2011). In patient-centered care, nurses recog- nize when to deviate from standards to consider patient preferences, val- ues, and beliefs within an evidence- based approach. Nurses who practice from a spirit of inquiry with reflection on care delivered will use skills in informatics to seek current evidence to determine best practices and clari- fy care decisions. They monitor their practice, reflecting on when changes are needed, and formulate clinical questions to seek new evidence so practice is constantly developing and improving.
Quality improvement. The spirit of inquiry promotes an attitude of continuously improving care every day with every patient ( Johnson, 2012). Quality improvement first measures variance between ideal and actual care, and then implements strategies to close any gaps. Nurses use quality improvement tools and informatics to seek evidence and measure care outcomes, as well as benchmark data to assess current practice. The American Nephrology Nurses’ Association’s publication, Applying Continuous Quality Improve – ment in Clinical Practice, is a resource for information on quality improve- ment tools and applications in neph – rology nursing (Axley & Robbins, 2009). Nurses benchmark in their local system as well as against nation- al standards. The National Database of Nursing Quality Indica tors from the American Nurses Association (n.d.) is one example of a benchmark- ing source where surgical site infec- tions, pain assessment, pressure ulcer development, and falls can be exam- ined.
Safety. Safety is the effort to min- imize the risk of harm to patients and providers by improving both system effectiveness and individual perform- ance (Barnsteiner, 2012). Every nurse,
and in fact, every employee and patient, is responsible for safety. A safety culture, discussed earlier, en – courages asking how one’s actions affect patient risk, where the next error is likely to occur, and how to prevent near misses, and there is a reporting system for collecting infor- mation on adverse and sentinel events. Many goals on the annual list of National Patient Safety Goals from The Joint Commission (2013) are rel- evant for nephrology nursing, such as medication safety, healthcare-associ- ated infections, central line-associated bloodstream infections, pain manage- ment, responding to changes in patient condition, communication, and handoffs.
Standardized communication, described in Table 2, can assure that essential information is shared with
the correct providers to overcome forgetfulness or lack of attention. Human factors consider the mix of people, tasks, and the environment; conditions in the environment, such as distractions, interruptions, and other environmental conditions, impact error potential. Training can increase skills in situation monitoring, environmental scanning, and shared decision-making. Working together, nurses can develop strategies to better manage task overloads, staff fluctua- tions, and interruptions.
Informatics. Informatics is a crit- ical skill for achieving all the compe- tencies by helping manage care. Technology, such as electronic health records, helps communicate care coordination by recording and shar- ing information about a patient (Warren, 2012). Other applications
Table 2 Standardized Communication Strategies from TeamSTEPPS
(www.AHRQ.gov)
Strategy Application
SBAR: Used to develop and refine communication.
Situation: A statement of what is happening right now that needs attention. Background: Information that puts the situation into context and explains the circumstances that have led to the situation. Assessment: Conveys the communicators’ thoughts about the problem. Recommendation: What should be done to correct the problem, when and by whom.
CUS: Used to raise safety concerns, moves to next statement if no action.
C: I am concerned. U: I am uncomfortable. S: I think this is a safety issue. (If no action, next step is to go up the chain of command for help.)
Check back: Used to clarify communication.
Repeat back an order, a request, or other critical information to be sure there was clear communication.
Briefings: Plan care? What is the most important thing this patient needs? What are safety issues? What are the benchmarks and/or evidence for the care interventions?
Huddles: Problem solve or clarify strategy, get everyone on the same page.
What is priority? What else could it be? What could we do differently? What was done well?
Debriefing: Review and feedback.
What did not go well? What could be done differently next time?
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A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses’ Roles in Practice
Figure 1 Applying the QSEN Competencies: A Case Study
The following unfolding case study provides an exemplar of integrating quality and safety in nephrology nursing and poses a number of provocative questions about the patient’s experience. The case study is most effective when discussed with nurses, physicians, and others on the care team to identify opportunities for safety interventions and for quality improvement.
Mr. Orange is a 45-year-old African-American male who has been on hemodialysis for the past six months using a cen- tral venous catheter access following a failed kidney transplant with chronic allograft nephropathy. His history includes high blood pressure, diabetes, and allergy to penicillin.
Today, he wants his 10-year-old daughter to remain with him during his treatment because his wife could not miss any more days of work. The clinic is crowded, and you are con- cerned about the presence of a child in the treatment area; clin- ic policy prevents children from accompanying patients. Yet, it is obviously very important to Mr. Orange that his daughter remains with him, and she is providing distraction from the dis- comfort of his treatment. You recently read an article that chal- lenged visiting rules, with evidence that patients benefit from having their family member with them, and there is no impact on infection rates or disruption to staff when they are provided space to be with their loved one. As you talk to Mr. Orange about his diet, his daughter becomes engaged in the information you are presenting, and begins a conversation with her father that helps you to better understand his attitudes towards his diet, an important aspect of his care plan. • What stands out in this situation? • What actions are consistent/inconsistent with patient-cen-
tered care? • What practice implications or quality improvement projects
come to mind when examining this scenario? Coordinating Mr. Orange’s care requires collaboration
among several specialty physicians, including the transplant team, physical therapy, social work, and nutritional services. Appointments in the clinic are a careful scheduling balance with each provider to coordinate treatment plans.
Prior to initiation of the hemo dialysis treatment, Mr. Orange mentions there was some blood in the small amount of urine he passed before coming to the dialysis facility today. As part of your pre-treatment assessment, you palpate the area of his transplanted kidney in his iliac fossa, and he squirms as you apply pressure and admits that it is tender to palpation. You recall that his im munosuppression has been tapered, and he is only on a minimal dose of alternate day immunosuppressive therapy.
• What stands out? What are priorities? Why, and what are alternative approaches? Mr. Orange has now been admitted to the hospital for fur-
ther assessment, and it is determined he requires a transplant nephrectomy due to more active rejection superimposed on the chronic allograft nephropathy in the presence of reduced immunosuppression. He has just been admitted to Room 6222 from the recovery room. The nurse, a new graduate, is taking the vital signs as ordered every 15 minutes as per protocol of a new admission. He notices the patient’s blood pressure has fallen slightly (118/70). Concerned, he pages the resident. When the resident calls back, the nurse reports the blood pressure to her. The resident informs the nurse that this is a normal blood pres- sure and says to not worry. An hour later, the nurse notices that Mr. Orange is growing agitated and complaining of belly pain. The nurse checks the blood pressure and notices that it is it is lower (90/68). The nurse pages the resident. • What stands out? • What is the most important action to take? Why? • What are alternatives? • How should the nurse communicate with the resident?
The resident informs the nurse that the patient’s blood pres- sure is lower due to his medication. The nurse, although not con- vinced, does not push the issue further. As a new graduate, he is hesitant to challenge the response. The nurse returns to room 6222 and finds Mr. Orange doubled over in pain and growing increasingly pale. The nurse once again pages the resident and waits for 15 minutes by the phone. While waiting for the resident to call him back, the nurse returns to room 6222 to take the next set of vital signs. The patient is unresponsive. • What stands out? • What stands out in the scenario? • What is the priority? Why? What evidence supports this? • What are alternatives, what else could it be? • What went well in the case and what could have been
improved? Discuss aspects of the case related to each of the compe-
tencies: patient centered care, teamwork and collaboration, evi- dence base practice, quality improvement, safety and informat- ics. • How do nurses and other care givers, especially physicians,
deal with disagreements in patient status? • What are lessons to prevent future occurrences?
include safety alerts for the need for action, decision support tools, litera- ture searches for the latest evidence, and management of quality improve- ment data and strategies. It is impor- tant that nurses participate in design- ing applications, making decisions on purchases, and developing training
materials on using information sys- tems and patient related technology.
Engagement and Inquiry: Developing a Quality Safe Practice
Investment in safety is demon- strated through engagement and in –
quiry. Nurses who bring attention and mindfulness to their work engage and focus on each patient, notice break- downs in care processes and seek solu- tions, employ best practices, and participate in lifelong learning (Sherwood, 2012). Engaged nurses develop a mindset for safety, use situ-
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ation monitoring to scan the environ- ment for contextual factors that influ- ence actions, and watch each other’s backs to provide mutual support when needed. Engaged nurses prac- tice from a spirit of inquiry and ask questions about their actions, if it is evidence-based or best practice (Armstrong & Sherwood, 2012). They recognize safety issues in work- arounds when standard operations break down and act to prevent error, know how to employ continuous quality improvement to call a team meeting to address failures in the sys- tem and together create new process- es, and work with the organization in seeking system-based solutions rather than relying on individual perform- ance and skill. Engaged nurses are more satisfied from doing work well, which leads to higher satisfaction and longer retention, and contributes to a healthy work environment (Armstrong, Laschinger, & Wong, 2009).
A Tool Kit to Develop A Quality and Safety Mindset
How do nurses initiate a practice based on quality and safety? What tools help with the transformation? Engaged nurses plan their work beyond mere memorization of facts or completing a task list; nurses can learn from experiences to synthesize and apply knowledge in advancing their practice. This is the process of inquiry in action: asking questions about their work promotes continu- ous learning from accumulated expe- riences through reflection informed by didactic knowledge. Tanner’s (2006) clinical judgment model helps nurses understand how they make informed decisions in practice. They notice what is happening, interpret the meaning and significance, respond in meaningful evidence based ways, and reflect on what happened to be able to improve decision making in the future.
Analyzing case studies, particu- larly with other disciplines, is an effec- tive strategy to reframe events and encourage a spirit of inquiry to exam- ine what happened, distinguish good care from compromised care, discuss conflicting ethical situations, examine
cultural sensitivity, share knowledge, learn how to provide and accept feed- back, and promote professional development. Cases can be used for both low-fidelity (role play) or high- fidelity (computerized mannequins) simulation to be able to practice teamwork and communication, nego- tiate problem solving, improve skills, apply evidence-based best practices, and increase awareness of the poten- tial for error. Briefings, huddles, and debriefings help manage care, keep everyone on the same page, and learn from experience (see Table 2).
Reflective practice is the founda- tion for analyzing unfolding case stud- ies or simulations. Reflection is a sys- tematic way of thinking about one’s actions and responses to improve future actions and responses (Sherwood & Horton-Deutsch, 2012). It is a change process that incorporates experiential learning by considering what one knows, believes, and values within the context of an event. It is also a personal growth strategy to help nurs- es cope with the emotional labor of nursing to make sense of events. Reflection reframes the situation, leading to feelings of satisfaction with work. Reflection can help nurses cope with confusing workforce issues and the complicated context of health care that depletes energy and motiva- tion. Reflective practice is a habit of the mind that helps develop profes- sional maturity through the continued development of practice knowledge, constant quality improvement and attention to safety, and renewal of the human spirit.
Summary There are always competing pri-
orities that challenge practice. New definitions of the six quality and safe- ty competencies developed by the QSEN project are transforming nurs- ing education and practice. Case story analysis and reflective practice can promote nurse learning to help devel- op a new mindset and achieve behav- ior change (see Figure 1). Nurses have important roles in redesigning health- care delivery to assure that it is
patient-centered, delivered by inter- professional teams, based on evi- dence-based standards with continu- ous quality im provement, in a culture of safety, and using informatics. With a mindset for quality and safety, nurs- es engage in their work with the patient as the focus, encourage inquiry, apply evidence-based stan- dards and interventions, investigate outcomes and critical incidents from a system perspective, and reflect on sit- uations in their work to continuously seek to improve care.
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A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses’ Roles in Practice
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Mindset for Quality continued from page 22
Wachter, R.M. (2010). Patient safety at ten: Unmistakable progress, trou- bling gaps. Health Affairs, 29(1), 165-173.
Walton, M.K., & Barnsteiner, J. (2012). Patient centered care. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A com- petency approach to improving out- comes (pp. 67-90). Hoboken, NJ: Wiley-Blackwell.
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Wong, C., & Cummings, G. (2007). The relationship between nursing lead- ership and patient outcomes: A systematic review. Journal of Nursing Management, 10(2), 285-305.
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