Generalizable science X Particular patient → Measured improvement.
Second edition
Edited by
Gwen Sherwood, PhD, RN, FAAN, ANEF
Professor and Associate Dean for Practice and Global Initiatives
School of Nursing
University of North Carolina at Chapel Hill
Chapel Hill, NC
Jane Barnsteiner, PhD, RN, FAAN
Professor Emerita
School of Nursing
University of Pennsylvania
Philadelphia, PA
Editor, Translational Research and QI, American Journal of Nursing
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To faculty, students, and clinicians who are successfully pioneering the work of QSEN. On a daily basis their work demonstrates their commitment that the highest quality, safest care can only be achieved when all clinicians are delivering person‐and‐family‐centered care as members of an interprofessional team, emphasizing evidence‐based practice, safety, quality improvement approaches, and informatics.
Gwen Sherwood, PhD, RN, FAAN, ANEF
Professor and Associate Dean for Practice and
Global Initiatives
School of Nursing
University of North Carolina at Chapel Hill
Chapel Hill, NC
Jane Barnsteiner, PhD, RN, FAAN
Professor Emerita
School of Nursing
University of Pennsylvania
Philadelphia, PA
Editor, Translational Research and QI,
American Journal of Nursing
Kathryn R. Alden, EdD, MSN, RN, IBCLC
Associate Professor
School of Nursing
University of North Carolina at Chapel Hill
Chapel Hill, NC
Elizabeth Cerbie Brown, MSN, RN
Director of Nursing Education
Indiana University Health
Indianapolis, IN
Thomas R. Clancy, MBA, PhD, RN, FAAN
Clinical Professor and Associate Dean
Faculty Practice, Partnerships and Professional Development
School of Nursing
The University of Minnesota
Minneapolis, MN
Linda R. Cronenwett, PhD, RN, FAAN
Dean Emerita and Professor
UNC‐Chapel Hill, School of Nursing
Chapel Hill, NC
and
Co‐Director, RWJF Executive Nurse Fellows Program
Lisa Day, PhD, RN, CNE
Associate Professor
Josiah Macy Jr Foundation Faculty Scholar
Duke University School of Nursing
Chapel Hill, NC
Joanne Disch, PhD, RN, FAAN
Professor ad Honorem
University of Minnesota School of Nursing
Minneapolis, MN
Mary A. Dolansky, PhD, RN, FAAN
Associate Professor
Director, QSEN Institute
Frances Payne Bolton School of Nursing
Case Western Reserve University
Cleveland, OH
Carol F. Durham, EdD, RN, ANEF, FAAN
Professor
School of Nursing
University of North Carolina at Chapel Hill
Chapel Hill, NC
Pamela M. Ironside, PhD, RN, FAAN, ANEF
Prairie du Sac, WI
Jean Johnson, PhD, RN, FAAN
Professor, Founding Dean (retired) and Executive Coach
School of Nursing
George Washington University
Washington, DC
Ellen Luebbers, MD
VA Quality Scholars Fellow
Louis Stokes Cleveland VA Medical Center
Case Western Reserve University School of Medicine
Cleveland, OH
Shirley M. Moore, PhD, RN, FAAN
Edward J. and Louise Mellen Professor of Nursing
Frances Payne Bolton School of Nursing
Case Western Reserve University
Cleveland, OH
Mary Jean Schumann, DNP, MBA, RN, CPNP, FAAN
Associate Professor of Nursing and
Senior Associate Dean for Academic Affairs
George Washington University School of Nursing
Washington, DC
Mamta K. Singh, MD, MS
Associate Professor of Medicine
Case Western Reserve University School of Medicine
Louis Stokes Cleveland Veterans Affairs Medical Center
Cleveland, OH
Nancy Spector, PhD, RN, FAAN
Director of Regulatory Innovations
National Council of State Boards of Nursing
Chicago, IL
Mary Fran Tracy, PhD, RN, APRN, CNS, FAAN
Associate Professor/Nurse Scientist
University of Minnesota School of Nursing
University of Minnesota Medical Center
Minneapolis, MN
Beth T. Ulrich, EdD, RN, FACHE, FAAN
Professor, University of Texas Health Science
Center at Houston School of Nursing
Editor, Nephrology Nursing Journal
Pearland, TX
Mary K. Walton, MSN, MBE, RN
Director, Patient and Family Centered Care; Nurse Ethicist
Hospital of the University of Pennsylvania
Adjunct Assistant Professor of Medical Ethics and Health Policy
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA
Judith J. Warren, PhD, RN, BC, FAAN, FACMI
Consultant, Warren Associates, LLC
Plattsmouth, NE
Amy Hagedorn Wonder, PhD, RN
Assistant Professor
Indiana University School of Nursing
Bloomington, IN
The Carnegie Foundation for the Advancement of Teaching’s Preparation for the Professions Program called out important changes needed in the preparation for professional work in medicine, nursing, law, engineering, and the clergy. Professor Patricia Benner led the team for nursing (Benner et al., 2010). They began by noting that profound changes were occurring in the practice of the nursing professional that were arising from science, technology, patient activism, market‐driven financing of health care service, and in the settings where these forces come together and where nurses now practice. They noted a practice‐to‐education gap characterized by the need to match learning with the realities of the work that nursing professionals face. This book begins to address that gap by opening the knowledge and skills needed to understand and improve these new practice settings of nursing.
All professions earn societal recognition as a “profession” by the ongoing improvement of their own work (Houle, 1980). But as Benner and colleagues (2010) note, improving health care service now isn’t easy or simple. Health care service for patients and populations today occurs in complex, interdependent systems (Batalden, Ogrinc, and Batalden, 2006). Designing and testing changes for improvement in those systems requires new knowledge and skill. This book is about developing those competencies essential for a sense of professional mastery.
“Doing quality improvement” is not necessarily the same as “improving the quality of what we do”–the profession‐enabling work. This is not the work of a small department of zealots who staff offices to meet regulations; it is part of the work of every person who claims designation today as a health care professional.
Improving the quality, safety, and value of health care service invites the use of multiple knowledge disciplines (Batalden et al., 2011). Diverse knowledge‐building traditions from biological, social, and physical sciences and the humanities come together to contribute to the development of the knowledge and science of improvement. This book is about those knowledge domains and invites attention to the scholarly and applied work of educators and researchers who develop and foster critical thinking about improving health care.
At the core of professional work in service of improving health for a patient is a series of interactions that can be represented by the simple logic formula:
Generalizable science X Particular patient → Measured improvement.
Each element of this logic comes together millions of times every day as clinical health professionals do their work.
We can use a similar logic representation for improving health care service:
(Individual, population goal + Generalizable science) X Particular context → Measured performance improvement.
Each phrase or symbol of this simple logic formula is informed by knowledge that is developed and tested in customized ways. Because all health care service is co‐produced by two parties, the person we know as a “patient” and the person we know as a “health care professional,” the process begins by creating a shared aim (Batalden et al. 2015). The shared aim comes from knowledge of the goal sought by the patient and identification of the contribution that the professional’s generalizable knowledge can offer. They work together. Good professional knowledge about “generalizable science” is developed by carefully controlling and minimizing “context” as a variable. In contrast, particular context knowledge comes from obsessing about context, that is, the systems, processes, traditions, patterns, and so forth, that characterize and give “particular” identity to contexts. Measuring performance improvement means measuring over time–not just at two points in time–and it means using balanced measures to understand the multidimensional aspects of quality, safety, and value of process and outcome of health care service. Even the symbols represent knowledge domains. The “+” sign signifies knowing how to match the contribution that the professional’s science can make to the realization of the patient’s goal. The “X” signifies the important role that context plays in the results of the shared work. The “→” represents the knowledge of actually executing change–making it happen. Each part and symbol of the formula invites a different way of knowing, and they must all come together to make change for the improvement of health care service. (Batalden and Davidoff, 2007).
Benner and her colleagues (2010) also note that nurses have very diverse entries, pathways, curricula, and time frames to become a nurse. This book invites attention to that diversity by focusing on the content of what must be mastered–the competencies themselves. As health professions engage in competency‐based learning, it will be important to avoid reducing all the content that is signaled by the competencies into mechanical packages that fail to invite the whole person to the learning and its application in relationship to another person in need.
What is important in health care service is reducing the burden of illness for individuals and populations. The people, and what they are struggling to do together, is what is real in health care. Together they form some relationship and engage in some activity. This relationship and activity are connected by knowledge, skill, and habit. The intervention for improving health care service quality, safety, and value is a social change that is learned experientially (Batalden et al., 2011). Improvement theories, methods, tools, and techniques are all potentially helpful, but we must never confuse them with the work of improving health care service, lest we make an error similar to the one of confusing a map for the territory it represents.
Creating work environments that sustain the generative, refreshing work of improving health care service involves the inextricable linkage of three aims and invites the work of everyone, illustrated in Figure F.1 (Batalden and Foster, 2012). Health care professionals have an opportunity to help design and weave these together.
Figure F.1 Creating work environments for improving health care service.
It is often noted by practicing nurses and other clinicians that their job is to protect the patient from the system of health care service in which the patient and clinician meet. This frames responsibility for the design of the system and its ongoing improvement as external to the working professional on the front lines of health care service. I prefer a different view of professional work, one that accepts the professional responsibility for health care service system quality, safety, and value. This book can help nurses and other clinicians who are not content to work in alien systems.
A nurse who was a member of a class I was teaching many years ago said it very succinctly: “We actually have two jobs–to do our work and to improve it.”
This book invites the work of improving health care, the work that helps make health care workers professionals. Enjoy it.
The synergy inspired by the Quality and Safety Education for Nursing (QSEN) project over the past decade is leading the transformation of nursing education and practice to improve quality and safety of health care (Cronenwett et al., 2007; Cronenwett et al., 2009). Through a series of grants from the Robert Wood Johnson Foundation between 2005 and 2012, the QSEN project was led by a steering team, a national expert panel, and an advisory board who identified the knowledge, skills, and attitudes (KSA) for the six competencies first identified by the Institute of Medicine (IOM) think tank (2003): patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement, safety, and informatics. With the second edition of this seminal text, we celebrate the continuing journey to improve our health care systems launched 11 years ago by a group of pioneers who helped identify and lead early adopters through four phases of QSEN.
The original two dozen pioneers who launched QSEN expanded to 40 champions who became QSEN facilitators (www.qsen.org) and then to hundreds of educators, clinicians, and administrators who led the Pilot Schools Learning Collaborative, the American Association of Colleges of Nursing (AACN)/QSEN Faculty Development Institutes, and countless projects. Although transformation has been swift and pervasive in many settings, many gaps remain. The six quality and safety competencies from the QSEN project are firmly embedded in nursing education essential competencies in both the National League for Nurses and the AACN documents and are spreading globally across education and clinical settings. A train‐the‐trainer approach helped spread educational approaches, preparing thousands of nursing faculty to integrate the new KSAs for the six core competencies. The passion to improve health care has transformed into new education models and teaching strategies, clinical initiatives and applications, evidence‐based practices, and safety cultures.
Faculty and clinicians are embracing a new way of thinking about quality and safety; new partnerships are evolving across professions and among academic and service agencies creating a bold new vision for health professions, education, and practice. Consumers and health care professionals both recognize that health care in America remains far from ideal, but believing joint efforts among educators and clinicians across multiple professions can together make it better.
Quality and safety are universal values in health care; nurses in both education and practice settings have the will through a common value system if they are helped to develop the ideas for leading change, and are provided the tools to execute the change needed and in fact are inspired by the opportunity to work in systems focused on safe quality care.
Education is indeed the bridge to quality (IOM, 2003), and progress comes with each generation of nurses prepared with the competencies to work in and lead health care systems focused on safety: patient‐centered care, teamwork and collaboration, quality improvement, safety, evidence‐based practice, and informatics. Have we reached a tipping point? Nurse leaders have long recognized the imperative to improve patient care outcomes and have been a part of early quality improvement work within nursing. Safety and patient‐centered care have been recognized as cornerstones of effective nursing practice, but with new evidence, a science of safety and quality improvement provide a sharper focus to quality and safety initiatives.
The expanded version of this book seeks to address the needs of faculty, practicing nurses, administrators, and nursing students at all educational levels. Each chapter tells a part of the story and collectively offers a roadmap to improve quality and safety. Updated information in each chapter provides a current view of application of quality and safety; consumer efforts driving change are found in Chapter 2; and Chapter 3 presents the first person account from Dr. Cronenwett of how QSEN began as well as the continuing story of this award‐winning project to become the QSEN Institute at Case Western Reserve University School of Nursing. Section 2 includes an in‐depth current view of each of the six competencies. The chapters provide a resource for faculty, graduate students, practicing nurses, and other leaders including teaching strategies, resources, and current references. Section 3 has redesigned chapters on implementing quality and safety across settings. A revised chapter is provided on the mirror of education and practice to better understand teaching approaches for redesigning teaching approaches. Other instructional approaches include narrative pedagogy, integrating the competencies in simulation, a new chapter to explore application in clinical learning, the critical nature of interprofessional teamwork to improve quality and safety, and developing personal leadership to lead change in organizations focused on improving quality and safety. The last chapter examines global applications of quality and safety, and outlines the need for sharing strategies related to education, research, and practice changes around the world. Three appendices provide additional resources with the knowledge, skills, and attitudes tables for each of the prelicensure and graduate competencies, the results of a Delphi study to assist educators with placing the 162 KSAs for beginner, middle, and advanced placement in nursing programs and staff development, and an extensive glossary.
Each contributor is a leader in quality and safety and offers his or her work to stimulate all nurses and health care professionals to share and disseminate their work around the globe. Together, we hope to rebuild health care as a high‐reliability system focused on safety and quality. It is our hope that the shared and expanding story of QSEN provides motivation and will, that the expansive tool kit within these pages stimulates ideas, and that the continuing efforts for faculty and leader development translate to execution as we move toward new generations of nurses fully prepared to lead and work in health care systems based on cultures of quality and safety.