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An innovative course to prepare advanced practice registered nurses to spearhead quality and safety initiatives for older adults

Zonsius, Mary C. PhD, RN (Assistant Professor)1; Miller, Joanne M. PhD, APRN, GNP-BC (Associate Professor Emeritus)1; Lamb, Karen V. DNP, CNS (Associate Professor)1

Author Information
Journal of the American Association of Nurse Practitioners: January 2021 - Volume 33 - Issue 1 - p 57-65
doi: 10.1097/JXX.0000000000000314
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Abstract

A college of nursing's (CON) transition of its adult–gerontology master's program to the Doctorate of Nursing Practice (DNP) degree in 2012 led to an innovative online course that enhanced the adult–gerontology advanced practice registered nurse (APRN) curriculum. The “Quality and Safety for the Aging Adult” course merged two important competency foci, adult–gerontology and quality and safety, into one course. The desired course outcomes were to prepare APRNs to lead quality improvement (QI) and safety initiatives and promote positive health outcomes in the aging adult population. Graduate acute and primary care adult–gerontology APRN students applied quality and safety content and processes to the older adult population that is often vulnerable and underserved.

This article describes the integration of the Quality and Safety Education for Nurse (QSEN) competencies (American Association of Colleges of Nursing [AACN], 2012b) in one Midwestern university's CON adult–gerontology DNP programs through the development and evaluation of a quality and safety course specific to older adults. The six-step knowledge-to-action (KTA) framework (Graham et al., 2006) was selected to guide this process because it has been used to integrate quality and safety competencies in curricula (Dolansky, Schexnayder, Patrician, & Sales, 2017). The six steps include: (1) identify and assess the problem, (2) adapt or tailor to the local context, (3) identify potential facilitators and barriers, (4) determine implementation strategies, (5) monitor and evaluate process and outcomes of implementation, and (6) sustain the change (Dolansky et al., 2017; Graham et al., 2006).

Background

Given the shifting health care landscape, aging population, professional trends, and national mandates, APRNs must be competent to address quality and safety issues specific to the care of older adults (Administration on Aging [AoA], 2018; AACN, 2006; Institute of Medicine [IOM], 2008). The Nurse Practitioner Core Competencies (National Organization of Nurse Practitioner Faculties [NONPF], 2012, 2014, 2017) and the Essentials of Master's Education in Nursing (AACN, 2011) and Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) address the need for APRNs to lead QI and safety initiatives. Furthermore, the graduate-level QSEN (AACN, 2012b) competencies validate the importance of APRNs to develop the knowledge, skills, and attitudes to promote safe quality outcomes. Adult–gerontology is listed as a population in the Consensus Model for APRN Regulation (National Council of State Boards of Nursing [NCSBN], 2008), and adult–gerontology and family APRN programs are working to integrate more gerontological content into their curriculums (Murphy et al., 2014).

Course development

The first step of the KTA framework was to identify and assess the problem (Dolansky et al., 2017). In 2011, a Midwestern university's CON made the decision to move the adult–gerontology master's programs to the DNP level, merge the adult and gerontological APRN programs in accordance with the Consensus Model for APRN Regulation (NCSBN, 2008), and transition from quarters to a trimester system. Concurrently, the CON conducted a curricular gap analysis.

The existing adult–gerontology curriculum was compared with the following key competencies: the DNP Essentials (AACN, 2006), adult–gerontology nurse practitioner (AACN, 2010, 2012a), graduate-level QSEN (AACN, 2012b), and the interprofessional education (IPE) (Interprofessional Education Collaborative Expert Panel [IPEC], 2011) competencies. An analytical review of the literature, a national market analysis of trends driving the quality and safety agenda, and the results of the key competency review pointed toward a significant gap in the curriculum regarding content on gerontology, quality and safety, and interprofessional collaborative practice. The review of updated key competencies was an ongoing process to reflect changes in practice and drove course revisions.

The aging population has grown at an unprecedented rate in the United States (AoA, 2018). By 2040, older adults will be 21.7% of the US population (AoA, 2018). Older adults have more complex needs, increased health care system use, and are more at risk of injury from errors and safety risks (Bynum, Meara, Chang, Rhoads, & Bronner, 2016). Findings in Retooling for an Aging America (IOM, 2008) and The Future of Nursing (IOM, 2010) reinforced the need to make older adults a national focus for quality and safety. The Consensus Model for APRN Regulation (NCSBN, 2008) stated that all advanced care providers for adults needed to be competent in the care of older adults, no matter the clinical setting. Therefore, APRN programs were challenged to include the required gerontological content to already full curriculums.

Step 2 of the KTA model was to “…adapt the quality and safety competencies to the specific content area within a course, identify the faculty and student stakeholders, and determine the resources required” (Dolansky et al., 2017, p. S13). Through the gap analysis, faculty members identified a need to increase the QI and safety focus and to efficiently maintain the existing gerontological content in the curriculum. Faculty members resolved to merge gerontology with quality and safety and to develop a new course. The new course titled, NSG 572 “Quality and Safety for the Aging Adult,” was first taught in spring semester 2014. The required resources for successful implementation included the available teaching resources of the CON and the expertise of the identified course faculty.

Course directors for NSG 572 selected 12 knowledge and eight skill QSEN competencies (AACN, 2012b) that aligned with the course objectives (see KTA step #5). Faculty stakeholders included the course faculty with QI and gerontological expertise and program directors. There was a strong commitment to include QSEN competencies and the gerontological content in the course.

This course provided an opportunity to examine the older adult population from a system and an interprofessional perspective to improve health care outcomes for older adults. Using falls as an example, NSG 572 discussed falls across the continuum of care focusing on evidence-based protocols and organizational benchmarks as one strategy to improve outcomes at the system level.

The third step of the KTA process was “…to identify the facilitators and barriers to the change process and devise ways to maximize facilitators and overcome barriers” (Dolansky et al., 2017, p. S13). Facilitators that assisted in the development of the course included: (a) resources from key national institutes, including QSEN, Hartford Institute for Geriatric Nursing, and Institute for Healthcare Improvement (IHI), (b) key QSEN, gerontological nursing, and IPEC competencies, (c) Health Resources and Services Administration (HRSA) advanced nursing education grants, (d) faculty members with expertise in quality and safety and gerontology, (e) transition to the DNP degree, and (f) a long history of ranked adult and gerontology APRN programs. Primary barriers to successful implementation included limited space in existing courses to add new content and a short time span to develop the course.

The need to expand quality and safety content was driven by the QI domain in the DNP competencies (AACN, 2006) and the CON DNP terminal objectives. The merger of the adult and gerontological content into one APRN certification (NCSBN, 2008) provided the mandate to re-evaluate and improve the gerontological content in all adult APRN programs. Merging the two content areas into the new course allowed the CON to maintain the total number of credit hours for the adult–gerontological advanced practice programs.

During this period, the CON had two HRSA grants that focused on expanding the gerontological APRN program and developing an IPE program. The grants' aims aligned with the planned curricular change. Funds from the grants supported consultants to enhance geriatric, quality and safety, and IPE content expertise as well as faculty time for course development. The short time span for the transition to the DNP degree and restructuring of all CON APRN programs accelerated the curricular changes.

The fourth KTA step was to “select implementation strategies such as facilitation, audit and feedback, and engagement of champions” (Dolansky et al., 2017, p. S13). In 2013, work began to develop the new required course. The online course, taught annually since 2014, was also available as an elective for other graduate nursing students.

Course objectives

The course objectives align with key competencies in the AACN DNP Essentials (2006), adult–gerontology primary and acute care nurse practitioner competencies (AACN, 2010, 2012a, 2016), NONPF (2014, 2017), graduate-level QSEN (AACN, 2012b), and the CON DNP terminal objectives. See Table 1 for course description and objectives.

Table 1
Table 1:
Quality and Safety for the Aging Adult course description and objectives

Course content

The course contained five modules with weekly content delivered over a 15-week semester in an online format. Module 1 (weeks 1–3) addressed: (a) national trends and key stakeholders driving the US quality and safety agenda and the impact on the aging adult and (b) the effect of demographics, physical and psychosocial changes, ageism, and care transitions on the health, quality of care, and safety of older adults. In module 2 (weeks 4–6), key quality and patient safety priorities for the aging adult, caregiving, and transitions of care were examined. The students reviewed geriatric syndromes from a system's perspective and used the interactive GeriaSims (https://igec.uiowa.edu/gerialearning). This online experience provided the students an opportunity to practice beginning management of common geriatric syndromes through the virtual simulation.

Module 3 (weeks 7–9) included common QI models and tools. Resources included a mixture of textbook readings, journal articles, and the IHI Open School quality resources (http://www.ihi.org/education/IHIOpenSchool/Courses/Pages/default.aspx). Module 4 (weeks 10–12) focused on patient safety models and tools and the concept and implementation of just culture across various organizations. Module 5 (weeks 13–15) focused on interprofessional collaborative practice. Students examined the interprofessional collaborative practice domains and the role of the APRN in interprofessional teams. The students used Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) (Agency for Health care Research and Quality [AHRQ], 2019) to evaluate the effectiveness of an interprofessional team at their work site. The final week included a course summary and reflection on learning regarding QI, patient safety, and gerontology.

The module template began with a short narrative that included the module learning objectives, rationale and background for content chosen, and the key learning points. Each module contained required and optional readings and key websites. The instructional strategy was to foster a spirit of inquiry and discovery by exposing students to key information sources for specific content to complete course assignments and practice improvement after graduation.

Varied learning assessment strategies

To assess student learning, the course assignments were designed to align with course objectives. The varied learning assessment strategies included discussion groups, case studies, scholarly writing assignments, and reflection. Online group discussions provided students an opportunity to learn and share in small groups of 5–6 students. An example of a discussion question for module 1 was to select a quality or safety issue and discuss how age-related physical changes and psychosocial issues put an older adult at increased risk.

Students completed a case study analysis of a complex older adult with multiple chronic conditions and addressed potential quality and safety issues in the context of demographics and influences of the aging process. The students also determined the level of care needed, provided a rationale for the composition of the interprofessional team, and analyzed available evidence-based practices (EBPs) to address the identified quality and safety care issues.

To promote collaborative learning, students participated in a group QI case study of a clinical unit with a problem of increased falls to identify how to improve patient outcomes. Students were asked to select and complete a QI tool such as the 5 Whys or a fishbone diagram (Seidl & Newhouse, 2012) to identify factors contributing to the increase in patient falls. In addition, the students selected a QI model and described how it could be used to implement needed change.

The students engaged in two writing activities (literature synthesis and application paper) to promote their development as nursing scholars. For the literature synthesis assignment, students reviewed five data-based research or QI studies, published within the previous 5 years, related to the selected practice change focus. The goal of the assignment was to synthesize the current EBPs for the identified quality or safety issue. The final course assignment, the application paper, was designed to integrate the QI knowledge and skills the students gained during the course. Students used the EBP identified in the literature synthesis paper to design a practice change implementation plan. A QI process or safety model was used to drive the change. Students described the steps to implement the model, the appropriate QI tools needed, and strategies to integrate interprofessional disciplines.

Evaluation plan

The fifth step of the KTA process was to “…monitor and evaluate process and outcome…to select an evaluation strategy from qsen.org to measure student retention of quality and safety content.” (Dolansky et al., 2017, p. S13). To evaluate the effectiveness and impact of this online course, two major concept areas, aging and quality and safety, were analyzed using a pre–post design. The evaluation plan was submitted to the institutional review board, reviewed, and waived as a QI project. Data were collected from students during week 1 of the semester (pre) and week 15 of the semester (post). Tools used for the pre-evaluation included the “What's your aging IQ?” quiz (National Institute on Aging [NIA], 2010) and a Quality and Safety Survey (developed for the course) based on the graduate-level QSEN competencies (AACN, 2012b). The postcourse evaluation included the Quality and Safety Survey and a qualitative analysis of students' self-reflection on learning related to the gerontological (Multidisciplinary Competencies in the Care of the Older Adult [American Geriatrics Society (AGS), 2010]) and graduate-level QSEN competencies (AACN, 2012b).

Quality and Safety Survey development

The goal was to develop a survey to evaluate the change in students' perception of their preparedness and confidence regarding the quality and safety knowledge and skills addressed in this course. The course objectives and the graduate-level QSEN competencies (AACN, 2012b) were used as the starting point for the development of the Quality and Safety Survey. At least one knowledge and one skill competency were selected from five of the six graduate-level QSEN (AACN, 2012b) competency domains. To establish content validity, one course faculty member selected specific QSEN competencies that aligned with course objectives, and two course faculty members validated the selection of these competencies.

The 20-item Quality and Safety Survey consisted of two subscales: preparedness and confidence. The 12-item preparedness scale assessed students' perception of how prepared they were to perform 12 specific actions. A four-point Likert-type scale (very or somewhat prepared and somewhat and very unprepared) was used. The 8-item confidence scale assessed how confident students were in their ability to complete eight skills. A four-point Likert-type scale (very or somewhat confident to confident or very confident) was used. The Quality and Safety Survey evaluated the students' perception of how prepared and how confident they felt to use their knowledge related to a specific competency. Cronbach's alpha for the overall Quality and Safety Survey was 0.916, the preparedness subscale was 0.903, and the confidence subscale was 0.831 across the five classes.

Aging: knowledge and attitudes

To evaluate students' baseline knowledge level and attitudes toward older adults, students completed the online, interactive quiz “What's your aging IQ?” (NIA, 2010) during week 1 of the semester. Upon completion, the students reviewed the rationale for the correct responses. During week 15 of the semester, students reviewed the Multidisciplinary Competencies in the Care of Older Adults (AGS, 2010) to identify two competencies the course helped them develop.

Quality and safety: knowledge and skills

The Quality and Safety Survey was used to evaluate the students' perception of how prepared and how confident they were to use their knowledge and skills related to a specific competency during weeks 1 and 15 of the semester. The students' final application papers from the most current class were reviewed to validate successful use of QI methods and tools. Furthermore, to assess quality and safety knowledge and skills using a qualitative approach, students reviewed the graduate-level QSEN competencies (AACN, 2012b) and selected the most significant knowledge, skill, or attitude they learned.

Results

Aging: knowledge and attitudes

Some ceiling effect was noted in the “What's your aging IQ?” quiz (NIA, 2010) with an average prescore of 26/28 points (range 20–28). The most frequent inaccurate perceptions were:

  1. “Most older adults live alone.” (Answer: False)
  2. “Americans are living longer. But are older Americans also healthier or sicker and disabled?” (Answer: Healthier)
  3. “The estimated number of centenarians in the United States in the year 2050 could be: 111,000, 238,000, or 600,000?” (Answer: 600,000)

The Multidisciplinary Competencies in the Care of Older Adults (AGS, 2010) competency results were aggregated according to the six domains. The most frequently selected domains were Health Promotion and Safety (63.5%), Interdisciplinary and Team Care (50.4%), and Care Planning and Coordination across the Care Spectrum (44.5%) (Table 2).

Table 2
Table 2:
Most common student selected multidisciplinary domains for the care of older adults

Quality and safety: knowledge and skills

The mean pretest preparedness subscale score across the 3 years was 2.66 (range 2.54–2.76). The mean posttest preparedness subscale score was 3.62 (range 3.46–3.74). The mean change between the pre and post preparedness score was 0.92. The mean pretest confidence subscale score across the 3 years was 2.43 (range 2.37–2.66). The mean posttest confidence subscale score was 3.46 (range 3.32–3.54). The mean change between the pre and post confidence score was 1.066.

A two-way ANOVA was conducted to test differences among the five classes. There were statistically significant improvements (p < .000) between pre and post scores across all 5 years. Students felt more prepared and more confident on completion of the course. However, no significant differences were found between the pretest means and the posttest means for the five classes across the 5 years (p < .223) (Table 3).

Table 3
Table 3:
Quality and safety survey—comparison of pre and post means across 5 years

The three preparedness subscale items with the greatest mean change (across 5 years) were:

  • Describe nationally accepted quality measures and benchmarks in the practice setting (mean change = 1.154);
  • Analyze potential and actual impact of national patient safety resources, initiatives, and regulations on systems and practice (mean change = 1.154);
  • Analyze factors that create a culture of safety and a “just culture” (mean change = 1.106).

The three confidence subscale items with the greatest mean change improvement (across 5 years) were:

  • Select and use QI tools (e.g., run charts, root cause analysis, flow diagrams, and Gantt charts) to achieve best possible outcomes (mean change = 1.599);
  • Use quality indicators and benchmarks for improving system processes and outcomes (mean change = 1.217);
  • Use existing resources to design and implement improvements in practice (e.g., National Patient Safety Goals) (mean change = 1.207).

Students' final application papers were reviewed using the assignment rubric for successful use of QI processes and tools. Ninety percent of the students met or exceeded expectations for (a) describing the QI process/model with appropriate rationale and (b) applying the steps of the QI process/model including the use of a quality tool. To evaluate the graduate-level QSEN competencies (AACN, 2012b), the students reviewed the competencies and identified the most significant knowledge, skill, or attitude they learned during the course (Table 4).

Table 4
Table 4:
Graduate-level QSEN competencies selected by students over 5 years

Faculty followed students' DNP project development. Students' QI projects and topics were tracked across the five classes. Notably, nearly 60% of the adult–gerontology primary care students and nearly 35% of the adult–gerontology acute care students completed projects specific to improving care of older adults (Table 5).

Table 5
Table 5:
Students implementing a DNP project related to improving care of older adults

Discussion

The sixth step of the KTA process was to “…to sustain the change … faculty should re-evaluate courses on a set timetable to monitor drift away from the quality and safety competencies and ensure that patient safety content remains in the curriculum” (Dolansky et al., 2017, p. S13–S14). The integration of the gerontological content with a quality and safety lens helped students develop key competencies to prepare them as future adult–gerontological APRNs.

The “What's your aging IQ?” quiz (NIA, 2010) was useful as a premeasure of knowledge and attitudes. The quiz results allowed students to explore the areas where they may have had preconceived perceptions or inaccurate information about older adults. The most frequent misperceptions align with the health care providers' general perception of aging (Kagan & Melendez-Torres, 2015). The top three domains selected by the students (Health Promotion and Safety, Interdisciplinary Team Care, and Evaluation and Assessment) from the Multidisciplinary Competencies in the Care of Older Adults (AGS, 2010) aligned closely with course objectives.

The Quality and Safety Survey was instrumental in demonstrating significant changes before and after across the evaluation of five classes. The changes in both preparedness and confidence for each survey item demonstrated consistent student learning. The students reported that they were prepared and confident to use quality measures, tools, and benchmarks, analyze issues at the system's level, and be champions of ensuring a culture of safety in their workplaces. These skills are essential to creating quality care for older adults. As doctorally prepared scholars in the clinical arena, these students are prepared to lead and evaluate quality initiatives (AACN, 2006; AACN, 2012b; IOM, 2010; Melnyk, 2013).

The qualitative analysis of the QSEN competencies supported EBP and QI as the students' top knowledge or skill they learned. The EBP literature is embedded throughout the course, and students select the EBP literature to support their work in group discussion and scholarly papers. Quality improvement is a strong theme in the course objectives, content, and learning activities.

Limitations

The author-developed Quality and Safety Survey has internal reliability and construct validity; however, it has only been tested in one CON. Further psychometric testing in other settings is needed. Change in confidence and preparedness was evaluated through both student perception and application of QI methods and tools in the final comprehensive paper. Outcome evaluation could be strengthened with additional objective measures of knowledge and competency.

Lessons learned

Student and faculty feedback were incorporated in the QI process to enhance the course over the past 5 years. An early lesson learned was the optimal placement of the course in the adult–gerontology APRN programs of the study. Initially, the course was taught concurrently during the semester students were working on their DNP proposal development. Faculty identified that students needed the QI content earlier in the project planning process; therefore, the course was moved before the DNP project planning courses.

Faculty prioritized the volume of required reading assignments and provided the students with recommended readings to develop a beginning bibliography of resources. Also, the number of graded assignments was evaluated and reduced to align with online teaching recommendations.

Students appreciated the varied learning methodologies that were added to the course. The GeriaSims (https://igec.uiowa.edu/gerialearning) were an effective strategy as noted in the student course evaluations. Course additions included regular Collaborate webinars, a team evaluation tool from TeamSTEPPS (AHRQ, 2019), and a group QI assignment. The optional Collaborate webinars offered opportunity for student and faculty engagement to enhance the online learning experience. The Collaborate sessions were recorded for students who were unable to attend the live session. Students applied interprofessional concepts and evaluated interprofessional clinical teamwork in their respective workplaces through the use of the TeamSTEPPS tool (AHRQ, 2019). The group QI assignment promoted team skills and provided an opportunity to use a QI tool to address a system-wide quality issue related to older adults.

Course faculty recognized that students struggled with synthesizing the key concepts in the literature for the scholarly writing assignments. Strategies to address this issue were to (a) provide detailed feedback on the first assignment, (b) add examples of concise synthesis of the literature to course materials, and (c) reduce the page limit of the writing assignments to force the students to synthesize rather than summarize individual articles.

In the course evaluations, students commented on how the course helped them to immerse themselves in the literature and critically evaluate the evidence related to their selected quality/safety issue. However, students required additional guidance on how to extract QI and benchmarking information from national database and government databases. Although developing literature search skills was not a course objective, it does align with the informatics QSEN competency.

Implications for advanced practice registered nurse practice

The course faculty emphasized the importance of lifelong learning through building a community of nursing scholars and leaders. Course content and assignments were designed to cultivate a spirit of intellectual curiosity and inquiry (Von Stumm, Hell, & Chamorro-Premuzic, 2011). Students explored their role as both members and leaders of interprofessional teams.

Doctorate of Nursing Practice graduates need to have the skill set to address identified gaps between quality and practice to improve patient care outcomes. This skill set aligns with the DNP Essentials and the Future of Nursing report (AACN, 2006; IOM, 2010). This course prepares adult–gerontological APRN students as scholars to improve quality of care for older adults as evidenced by the number of DNP projects with a focus on older adults. Furthermore, students focus on learning to identify the impact of APRNs in improving outcomes/quality of care in clinical practice (Kleinpell, 2017).

Nursing faculty who are prepared at the PhD level are typically not content experts in QI, as this has not been the focus of their education versus DNP-prepared faculty (Dols, Hernandex, & Miles, 2017; Melnyk, 2013). Given the focus of QI in the DNP Essentials and health care arena content, experts in QI are needed to fulfill this gap (Johnson, Drenkard, Emard, & McGuinn, 2015).

Nationally, there are decreasing numbers of experienced gerontological faculty because of anticipated retirements. Another factor for the decrease in gerontological experts is the APRN consensus model (NCSBN, 2008), which no longer recognizes gerontology as a unique population for certification. As gerontology is now integrated into adult–gerontology APRN programs, the quality and amount of the gerontological content may vary.

Conclusion

This innovative course addresses DNP, gerontology, graduate-level QSEN, and IPEC competencies and can be used as a model for DNP education of adult–gerontology APRNs. Students report increased preparation and confidence in using the QSEN competencies for their future clinical practice. Gerontological and QI content is now successfully embedded in this CON's highly ranked adult–gerontology APRN programs.

The “Quality and Safety for the Aging Adult” curriculum positively influenced the preparation of five classes of adult–gerontology nurse practitioner DNP students. Based on the success of this course and positive student outcomes, integrating quality and safety with the gerontology content is an effective teaching strategy to prepare adult–gerontology nurse practitioners to lead quality initiatives that promote positive health care outcomes in the aging adult population. This innovative online course offers a successful model for innovative DNP education of adult–gerontology APRNs.

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      Keywords:

      APRN-DNP; gerontological nursing; older adults; quality; safety

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