Nursing homework

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

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...national

healthcare quality

organizations,

such as the

Leapfrog Group,

report that the

majority of

hospitals have

demonstrated

little progress in

improving quality

and safety.

QSEN is a

national

Abstract

Mary A. Dolansky, PhD, RN

Shirley M. Moore, PhD, RN, FAAN

Over a decade has passed since the Institute of Medicine’s reports on the need to improve the

American healthcare system, and yet only slight improvement in quality and safety has been

reported. The Quality and Safety Education for Nurses (QSEN) initiative was developed to

integrate quality and safety competencies into nursing education. The current challenge is for

nurses to move beyond the application of QSEN competencies to individual patients and families

and incorporate systems thinking in quality and safety education and healthcare delivery. This

article provides a history of QSEN and proposes a framework in which systems thinking is a

critical aspect in the application of the QSEN competencies. We provide examples of how using

this framework expands nursing focus from individual care to care of the system and propose

ways to teach and measure systems thinking. The conclusion calls for movement from personal

effort and individual care to a focus on care of the system that will accelerate improvement of

healthcare quality and safety.

Citation: Dolansky, M.A., Moore, S.M., (September 30, 2013) "Quality and Safety Education for Nurses

(QSEN): The Key is Systems Thinking" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 3, Manuscript

1.

DOI: 10.3912/OJIN.Vol18No03Man01

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

Over a decade has passed since the Institute of Medicine (IOM) report, To Err

Is Human: Building a Safer Health System, and the follow-up report, Crossing

the Quality Chasm, which turned healthcare professionals’ attention to the

importance of improving healthcare outcomes (IOM, 2000; Committee on the

Quality, 2001). These reports highlighted the need to redesign systems of care

to better serve patients in the complex healthcare environment. During the last

decade, national initiatives to improve quality and safety have been

implemented, such as the Institute for Healthcare Improvement’s (IHI)

Transforming Care at the Bedside, 5 Million Lives Campaign, and the Triple Aim

(IHI, 2013a; IHI, 2013b; IHI, 2013c). To accelerate change, regulatory

agencies have implemented National Patient Safety Goals, Core Measures,

(Joint Commission, 2013a; 2013b; 2013c), and Hospital Acquired Conditions

(HAC) Never Events (Kuhn, 2008). Yet national healthcare quality organizations,

such as the Leapfrog Group, report that the majority of hospitals have

demonstrated little progress in improving quality and safety. For example,

although we know that zero central line infections should be a reality in

hospitals, thousands of infections are still reported each year (Clark, 2013).

In 2005, nursing leaders responded to the IOM call to improve the quality of

healthcare by forming the Quality and Safety Education for Nurses (QSEN)

initiative funded by the Robert Wood Johnson Foundation. The QSEN initiative

consisted of the development of quality and safety competencies that serve as

movement that

guides nurses to

redesign the

‘what and how’

they deliver

nursing care so

that they can

ensure high-

quality, safe

care.

Although QSEN

competencies

have spurred

quality and safety

in nursing

education, it is

now time to

accelerate their

use and impact.

QSEN History

a resource for nursing faculty to integrate contemporary quality and safety

content into nursing education (QSEN Institute, 2013). The focus of QSEN, now

the QSEN Institute, has expanded from undergraduate nursing students’

education to include quality and safety education for all nurses. The mission of

QSEN is to address the challenge of assuring that nurses have the knowledge,

skills, and attitudes (KSA) necessary to continuously improve the quality and

safety of the healthcare systems in which they work. QSEN is a national

movement that guides nurses to redesign the ‘what and how’ they deliver

nursing care so that they can ensure high-quality, safe care. Linda Cronenwett,

PhD, RN, FAAN, the founder of QSEN, often states that QSEN helps nurses to

identify and bridge the gaps between what is and what should be and helps

nurses focus their work from the lens of quality and safety (Personal

Communication, 2013).

Viewing nurses’ work through the lens of quality and safety requires a contemporary approach that

incorporates systems thinking. A crucial skill, systems thinking helps nurses to meet the challenge of improving

healthcare as they move beyond the application of the QSEN competencies from individual patients and

families to accelerate the overall improvement of healthcare quality and safety. In this article, we review the

history of QSEN and propose a framework that expands nursing focus from individual care based on personal

effort and care of the individual to systems thinking and care of the system. Examples are provided to

demonstrate how to integrate systems thinking in the application of QSEN competencies and how systems

thinking can be taught and measured.

In response to calls for improved quality and safety, leaders from schools of

nursing across the country joined forces to create the Quality and Safety

Education for Nurses (QSEN) initiative. The Robert Wood Johnson Foundation in

2005 funded QSEN Phase 1 and three subsequent phases followed (Table 1).

The major QSEN contribution to healthcare education was the creation of six

QSEN competencies (modeled after the IOM reports) and the pre-licensure and

graduate-level knowledge, skills, and attitude (KSA) statements for each

competency (Cronenwett et al., 2007). The competency statements provide a

tool for faculty and staff development educators to identify gaps in curriculum

so that changes to incorporate quality and safety education can be made

(Barnsteiner et al., 2013). The QSEN website serves as a national educational

resource and a repository for nurses to publish contemporary teaching

strategies focused on the six competencies: patient-centered care, teamwork

and collaboration, evidenced-based practice, quality improvement, and

informatics. Currently, there are over 100 teaching strategies posted.

Table 1. History of QSEN

Phase Details Websites and References

Phase 1a

October 2005-March

2007

QSEN competencies and their

requisite KSAs

QSEN.org website

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

Cronenwett et al., 2007

Phase 2a

April 2007–October

2008

Funded 15 pilot schools to

use the IHI Learning

Collaborative method to

develop, test, and

disseminate teaching

strategies

Peer reviewed teaching

strategies on the website

qsen.org/about-qsen/pilot-schools-june-2007-

november-2008/

http://qsen.org/teaching-strategies/

Phase 3a National forums to educate http://qsen.org/conferences/

November 2008-

February 2012

nursing faculty

Incorporation of nurses into

the Veterans Affairs (VA)

Quality Scholars program

(VAQS- 2 year pre or post-

doctoral fellowships in quality

and safety)

Faculty modules to the QSEN

website

8 regional Faculty

Development workshops

(train the trainer) were

coordinated by the AACN

VAQS.org

http://qsen.org/faculty-resources/learning-

modules/

Barnsteiner et al., 2013

http://qsen.org/faculty-resources/aacn-workshop-

modules/

Phase 4a

March 2012-March

2014

American Association of

Colleges of Nursing (AACN)

funded to further develop

graduate competencies and

coordinate 5 graduate level

faculty development

conferences

www.aacn.nche.edu/faculty/qsen/competencies.pdf

www.aacn.nche.edu/qsen/faculty-development

San Francisco Bay

Area (SFBA) QSEN

Faculty

Development

Instituteb

2009-2013

AACN implementation and

evaluation of impact of

incorporating the QSEN

content into 22 schools of

nursing in the San Francisco

Bay area. Funding for a

series of workshops for

faculty and clinical leaders

Disch et al., 2013

apps.aacn.nche.edu/qsenec/GBMFoverview.html

Academic/Clinical

Partnership and

collaboration in QSEN

Lourdes University

and ProMedicac

Innovative educational model

for undergraduate education

that includes a clinical

integration partner to assist

with the QSEN-based clinical

education model

Didion, Kozy, Koffel, Oneail, 2013

www.rwjf.org/en/research-publications/find-rwjf-

research/2013/04/academic-clinical-partnership-

and-collaboration-in-quality-and-s.html

QSEN Institute

July 2012 to present

The Frances Payne Bolton

School of Nursing at Case

Western Reserve University

continues to host the website

and the National QSEN forum

QSEN.org

aRobert Wood Johnson Foundation funding

bGordon and Betty Moore Foundation funding

cBureau of Health Professions, Health Resource and Services Administration, Department of Health and

Human Services Nurse Education Practice, Quality and Retention

QSEN competencies have been used by national nursing organizations and are the central focus of the National

Council of State Boards of Nursing (n.d.) Nurse Residency program, the foundational concepts in the

Massachusetts Future of Nursing Framework (Massachusetts Department of Higher Education, 2010), and the

Ohio Hospital Association (Ohio Organization of Nurse Executives, 2013). The QSEN competencies also have

been incorporated into nursing textbooks such as the medical-surgical text by Ignatavicious and Workman

(2013), and other books, such as Quality and Safety in Nursing: A Competency Approach to Improving

Outcomes (Sherwood & Barnsteiner, 2012), Second Generation QSEN, a special issue of the Nursing Clinics of

North America (Barnsteiner & Disch, 2012) and Quality and Safety for Transformational Leadership (Amer,

2012).

The full effect of

the QSEN

competencies to

improve the

quality and safety

of care can only

be realized when

nurses apply

them at both the

individual and

system levels of

care.

Systems Thinking

Although QSEN competencies have spurred quality and safety in nursing education, it is now time to accelerate

their use and impact. Many nurse educators report that the QSEN competencies

are already integrated into their curriculum, but in our practice, we have noted

that often this integration is at the individual level of care, rather than at the

level of the system of care. The full effect of the QSEN competencies to improve

the quality and safety of care can only be realized when nurses apply them at

both the individual and system levels of care. Figure 1 provides a display of how

the six QSEN domains are linked to optimal patient care through both vigilant

individual care and vigilant systems of care. Traditionally, nurses have focused

primarily on vigilant individual care; less attention has been given to assisting

nurses to provide vigilant systems of care. We propose that in addition to the

emphasis on teaching critical thinking skills (Simpson & Courtney, 2002), nurses

also need to be taught the knowledge and skills associated with systems

thinking. In their day-to-day work, nurses’ abilities to engage in better problem-

solving, priority setting, delegation, interactions and collaborations, decision

making, and action-taking are greatly influenced by their ability to view how

any one component of their work system is related to other components and to

the whole.

Figure 1 Source: Authors

Systems thinking is the ability to recognize, understand, and synthesize the interactions and interdependencies

in a set of components designed for a specific purpose. This strategy includes the ability to recognize patterns

and repetitions in interactions and an understanding of how actions and components can reinforce or counteract

each other. These relationships and patterns occur at different dimensions: temporal, spatial, social, technical

or cultural (Oshry, 2007). Systems thinking links a person’s environment to his/her behavior. In the delivery of

nursing care, this involves the nurse’s understanding and valuing how components of a complex healthcare

system influence care of an individual patient. Systems thinking can be viewed as a continuum, ranging from

the individual to the larger internal and external environmental components. Figure 2 shows examples of care

approaches that represent increasing levels of systems thinking.

Systems thinking

links a person’s

environment to

his/her behavior.

Figure 2 Source: Authors

How nurses view both themselves as nurses, and their work, is shaped by the

structures and processes of the systems in which they work. Most nurses

provide care in healthcare organizations that are characterized as complex,

multilevel, and multifunctional. Greater knowledge and application of systems

thinking skills by nurses have the potential to mitigate errors in practice,

improve nurse priority setting and delegation, enhance problem solving and

decision-making, improve timing and quality of interactions with other

professionals and patients, and enhance workplace quality improvement

initiatives. The ability to engage in systems thinking has been viewed as a key

component in the successful delivery of safe and high quality care (Bataldan & Mohr, 1997; Bataldan & Leach,

2009; Batalden & Stoltz, 1993; Senge, 2006). Systems thinking is required to redesign healthcare to improve

the quality and safety of care.

The importance of systems thinking in quality improvement (QI) initiatives was identified in early literature on

application of QI techniques to healthcare (Batalden & Stoltz, 1993; Deeming & Appleby, 2000) and, more

recently, was highlighted in reports from the Institute of Medicine (IOM, 2003), the Accreditation Council for

Graduate Medical Education (Varkey, Karlapudi, Rose, Nelson, & Warner, 2009), and the article, “Quality and

Safety Education for Nurses” (Cronenwett, Sherwood & Barnsteiner, 2007). Given the hypothesized importance

of systems thinking in the success of quality and safety in healthcare, it is probable that if nurses engage in

better systems thinking, greater improvements in outcomes will be achieved. Knowledge and skills associated

with systems thinking, however, are seldom addressed in basic or continuing nursing education. The next

sections describe strategies for teaching and learning systems thinking, especially as related to QSEN

competencies, and a newly developed tool for measurement of systems thinking.

Teaching and Learning Systems Thinking

Systems thinking is an essential skill for nurses. Yet, there has been little knowledge disseminated about how

to assist nurses to better engage in this type of thought process, despite their key roles in planning, delivering,

and improving patient care in complex organizations. To teach systems thinking it is important to enhance the

learner’s awareness of the interdependencies in people, processes, and services and to view problems as

occurring as part of a chain of events of a larger system, rather than as independent events.

The clinical environment is an ideal place to teach systems thinking in undergraduate, graduate, and staff

development education. During the clinical experience, the faculty preceptor can broaden the learner’s problem

identification from a focus on personal effort in a single situation to a focus on sequences of events with

possible multiple causes for both individuals and populations. Table 2 provides examples of this continuum of

systems thinking using the QSEN competencies. An example of a teaching technique for systems thinking is to

have learners create grids such as those presented in Table 2 to expand their scope of thinking from the

individual to the system level of care. Students might obtain outcome data from their unit and identify reasons

for variation across time. Enhancing systems thinking skills also can be done by having learners complete an

assessment of their unit or microsystem.

Assessment tools are available from the Clinical Microsystem (2013) Green Books for inpatient, emergency

room, long-term care, and outpatient groups. These free workbooks from the Dartmouth Institute have been

developed to help individuals assess the complexity of the system in which they work. Another approach to

expand learners’ scope of thinking to a systems level is to have them connect nursing skills and clinical issues

to national quality and safety initiatives (Armstrong & Barton, 2013). For example, urinary care is connected to

the National Quality Forum (2012) Catheter Associated Urinary Tract Infection (CAUTI) prevention and the Joint

Commission’s (2013c) National Patient Safety Goal Number 7.

Table 2. Examples of Continuums of Systems Thinking for QSEN Domains

View Table 2 [pdf]

Nurses can also learn systems thinking by creating flowcharts or process diagrams that elicit the steps of a

care process and the multitude of healthcare workers involved in that process. This mapping technique is one

of the first steps of a quality improvement project. For example, to improve the care coordination of preparing

hospitalized patients for discharge, teams of healthcare professionals could map steps in the course of a

patient’s stay leading to discharge. This exercise has been shown to increase knowledge about system factors

and enhance awareness of the importance of interprofessional collaboration (Brennen, Olds, Dolansky, Estrada,

& Patrician, in press).

Another approach to teach systems thinking is to have learners conduct a root cause analysis (Lambton &

Mahlmeister, 2010; Tschannen & Aebersold, 2010). Root cause analysis (RCA) is a widely used technique to

assist people to move beyond blame of an individual for errors made in the workplace to understanding the

system factors that may have contributed to errors. Healthcare organizations routinely perform RCA after an

event so that appropriate changes can be made in the system to prevent future errors. This technique could be

used to understand system factors even when events “almost happen.” Having nursing students participate in

...systems

thinking can be

taught and

learned and an

individual’s level

of systems

thinking can be

changed.

Conclusion

... a safe and

high quality

system of care

requires that all

healthcare

professionals

take

responsibility to

learn and apply

skills associated

with improving

the wider system

of care.

Authors

RCAs during their undergraduate education has been shown to be beneficial (Dolansky, Druschel, Helba, &

Courtney, 2013). For example, having students conduct an RCA for addressing a medication error may lend a

new perspective to how system level factors interact with individual level factors in the creation of that error.

In the classroom setting, systems thinking also can be enhanced by using case studies. The book Set Phasers

to Stun (Casey, 1998) includes stories of design, technology, and human error that can be discussed in class.

These stories identify the close connection between technology and humans. Another book, Systems Concepts

in Action (Williams & Hummelbrunner, 2011), is a practitioner’s toolkit to teach the principles of systems

thinking, such as system dynamics, outcome mapping, and social network analysis. Highly effective and very

interactive, the game Friday Night in the ER (2009) guarantees learning and fun. The game is played by four

people and simulates the challenge of managing a hospital during a 24-hour period. Each player is in charge of

a unit. The demands of the game demonstrate that systems thinking is the key to success.

Lastly, teaching systems thinking requires guided reflection. Faculty need to assist learners to look for and

recognize patterns in systems of care by standing back, reflecting on data, and considering the system as a

whole. Too often in healthcare we make quick judgments that are based on limited information and

preconceived ideas. Teaching nurses to step back and consider the dependencies and interconnectedness of

system components will lead to a broader understanding of the healthcare system and the quality of care that

results from that system.

Measurement of Systems Thinking

To improve systems thinking, we need to be able to measure it. A valid and reliable measure of systems

thinking is now available. The Systems Thinking Scale (STS) is an instrument that measures healthcare

professionals’ systems thinking specifically related to system interdependencies. The 20-item STS has good

reliability as demonstrated by a test-retest reliability assessment (N=36; correlation of .74) and internal

consistency testing (N=342) using Cronbach’s alpha (.89) (Case Western Reserve University, 2013b).

Data from recent studies indicated that systems thinking can be taught and

learned and an individual’s level of systems thinking can be changed

(Abourmatar et al., 2012; Moore, Dolansky, Palmieri, Singh, & Alemi, 2010).

Moore and colleagues tested three groups of healthcare professions students

(n= 102) who received high, low, or no dose levels of systems thinking

education. There were no differences in STS mean scores at pretest. At

posttest, the high-dose systems thinking education group scored significantly

higher on the STS than both the low and no-dose groups (p=.05 and .01,

respectively). The STS is now publicly available for use and a website has been

established to provide information on its use (Case Western Reserve University,

2013a).

Almost 10 years have passed since the QSEN competencies were developed, and the field of quality and safety

is rapidly advancing. The time has come to consider what new competencies should be added. We propose that

the current QSEN competencies and knowledge, skills, and attitudes (KSAs) be reviewed and evaluated. Do the

KSAs need to be updated, reclassified, or expanded? Should a systems perspective be made more prominent

in the QSEN model? The QSEN competencies were developed to be a tool to promote better education for

nurses in healthcare quality and safety. We need to update the QSEN competencies to be as useful as possible

to prepare all nurses to ensure the highest level of care possible.

Throughout QSEN history, reports from nurses and nurse faculty are that they

already integrate the QSEN competencies into education and practice. However,

we have observed that, despite the fact that contemporary approaches to

quality and safety emphasize a systems view, much of the nursing education

approach to teaching quality and safety (including application of the QSEN

competencies) emphasizes personal effort at the individual level of care.

Although we believe that personal expertise of the nurse with individual patients

is necessary, a safe and high quality system of care requires that all healthcare

professionals take responsibility to learn and apply skills associated with

improving the wider system of care. We argue, therefore, that the QSEN

competencies should be integrated into nursing curriculum and practice with a

strong systems-perspective emphasis. Nurse faculty and staff development

educators must critically evaluate the extent to which they apply QSEN

competencies and at what levels.

References

Mary A. Dolansky, PhD, RN

Email: [email protected]

Mary A. Dolansky is an Associate Professor at the Frances Payne Bolton School of Nursing, Case Western

Reserve University in Cleveland, OH. Dr. Dolansky is Director of the QSEN Institute (Quality and Safety

Education for Nurses) and Senior Fellow in the VA Quality Scholars program, mentoring pre- and post-doctoral

students in quality and safety science. She has co-published two books on quality improvement, co-authored

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Improvement in Health Care,” at CWRU for the past 8 years and was chair of the quality and safety task force

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Shirley M. Moore, PhD, RN, FAAN

Email: [email protected]

Shirley M. Moore is the Edward J. and Louise Mellon Professor of Nursing and Associate Dean for Research,

Case Western Reserve University in Cleveland, OH. She is a past President of the Academy for Healthcare

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