Problem: To deliver the care patients want and need without the alarming number of failures in the nation’s increasingly complex health care systems, today’s nurses need to know how to provide individual patient care—but they also need to know how to contribute effectively to creating and improving the systems of care in which they work. Nursing schools excel at teaching students to provide safe, high quality patient care to individuals. But until recently, the education of new nurses has included only minimal learning related to competencies that prepare them for their roles in creating safe, reliable, patient-centered and evidence-based systems of care.
Background: Until the Quality Chasm series of Institute of Medicine (IOM) reports were published 5-10 years ago, nurses and other professionals often knew what constituted good care. But they rarely knew what outcomes were achieved in their local practices or what activities could be initiated, if necessary, to close gaps between their system’s performance and known best practices.
Even when they knew, for instance, that catheter-associated urinary tract infections should be prevented, they usually had no idea how many occurred in their practices or that other practices had made system changes that effectively eliminated these infections. Nurses might remember, with fear or guilt, the health care errors they had made (or almost made), but they wouldn’t know how many others had made the same errors, what the root causes of those errors were, and what processes could be used to help prevent the same errors from happening in the future.
Changing this is a mission that Linda Cronenwett, Ph.D., R.N., F.A.A.N.—director of the Robert Wood Johnson Foundation (RWJF) Quality and Safety Education for Nurses (QSEN) initiative and the new co-director of the RWJF Executive Nurse Fellows program—has dedicated much of her long and productive career to, first as a practicing nurse, then as an administrator in practice and academic settings, and now as a leader of two national initiatives.
“Nurses are educated to deliver safe care, but they are not educated about how to create safety cultures, how to build high reliability processes, how to learn from error, and how to improve system quality,” Cronenwett says. “They are educated to practice as individuals instead of members of teams, units or care systems.”
Indeed, the lack of training in patient safety and quality improvement, she says, has created a gap between what nurses learn as individual care providers and what they need to know as future members of interprofessional teams who practice within massive health care organizations.
It’s a gap Cronenwett knows a lot about after spending decades on the campuses of both schools and hospitals. After graduating from the University of Michigan with a bachelor’s degree in nursing, Cronenwett spent her early professional days in hospital pediatrics and maternity wards. She then went on to earn her master’s and doctoral degrees in nursing while also serving as a clinical nurse specialist and faculty member.
In 1984, Cronenwett became director of nursing research at Dartmouth Hitchcock Medical Center in New Hampshire, charged with facilitating the use of research in practice. Over the next 14 years, she worked with others who were experts in quality improvement processes and methods, and came to appreciate the power of working with every person who was involved with patients instead of with nurses alone. In 1998 she joined the nursing school faculty at the University of North Carolina at Chapel Hill, where she served as dean for a decade. She is now a distinguished professor there.
Cronenwett began serious exploration of how to bridge the gap between academia and practice in understanding quality, safety and health care improvement back in 1997 as part of the Dartmouth Summer Symposium learning community, led by Paul Batalden, M.D., and attended by nurse, physician and hospital administrator educators. A key theme of the sessions was changing medical education to better prepare physicians for working in teams to improve the quality, safety and reliability of health care. Cronenwett and her nurse colleagues agreed that similar changes were needed in nursing education, so she and others began a protracted search for funding for a faculty development initiative to better train nurses in quality and safety.
During that time, Cronenwett sharpened her expertise in the subject as a faculty liaison leader of, and later a National Advisory Committee member for, the Transforming Care at the Bedside (TCAB) initiative, a partnership between RWJF and the Institute for Healthcare Improvement. She also served as co-chair of an Institute of Medicine committee that produced the report Preventing Medication Errors (2006) and as a member of the Board of Directors of the Institute for Healthcare Improvement.
Solution: Cronenwett’s long search for funding finally paid off in 2005, when RWJF began its support for the QSEN initiative. QSEN aims to address the challenge of preparing future nurses with the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems in which they work.
In the first phase of the project, Cronenwett and other nurse leaders outlined the core knowledge, skills and attitudes needed to be competent in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety and informatics. During this phase, the panel developed strategies to support learning, surveyed associate degree and baccalaureate program leaders about curricula, and developed a Web site to share information and materials.
In 2007, QSEN began work with 15 nursing schools that committed to overhaul their curricula to incorporate QSEN competencies. QSEN staff also partnered with representatives of organizations that represent advanced practice nurses to draft proposed knowledge, skills and attitude targets for graduate education.
Now in its third phase, QSEN leaders at the University of North Carolina at Chapel Hill are partnering with QSEN leaders at the American Association of Colleges of Nursing and other universities in a variety of faculty development initiatives: self-paced website offerings, train-the-trainer conferences, and QSEN National Forums.
The goal is far from met but the QSEN initiative continues, and change is underway, Cronenwett says. Faculty members around the country are coming up with new ways to teach QSEN competencies and are revising curricula to better incorporate these competencies from the very beginning of a nurse’s education. Meanwhile, the QSEN Web site is a resource for almost 1,000 users per day; authors are incorporating QSEN content into nursing textbooks; accreditation standards now require nursing education programs to include quality and safety education; and the National Council of State Boards of Nursing is piloting a Transition to Practice model that requires QSEN competency development to continue in the first year of practice.
At the recent 2011 QSEN Forum, curricular and pedagogical innovations were shared in more than 100 oral and poster presentations. Nursing faculty members are embracing the invitation to make a difference in the education of students and in patient care quality and safety. For example, a nursing school in Ontario began to track and learn from student errors, and discovered a common error involving student interpretations of the medication administration record at a partner hospital. Students and faculty shared that information with hospital personnel, and the hospital changed its medication administration record in response.
It’s the kind of change that could put a stop to future medication errors—and the kind of change in nursing education that can help the next generation of nurses see that learning from error and making system improvements is a part of their daily work.
RWJF Perspective: The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing the country. A key challenge is reducing and preventing medical errors, a leading cause of death in the United States. To prevent unexpected hospital deaths, the Foundation supports Transforming Care at the Bedside, an initiative designed to create, test and implement changes to dramatically improve care on medical/surgical units and improve staff satisfaction. The Foundation also supports the QSEN initiative, which aims to prepare future nurses to improve the quality and safety of the health care systems in which they work.
Read more about the Robert Wood Johnson Foundation’s Quality and Safety Education for Nurses project.