Quality and Safety Education for Nurses (QSEN) is an initiative that was funded by the Robert Wood Johnson Foundation from 2005 to 2014. The development of QSEN was based on recommendations of the Institute of Medicine’s (now the National Academy of Medicine) 2003 report, Health Professions Education, which advocated that all health profession students be educated in quality and safety competencies.1 Initial QSEN work focused on defining 6 quality and safety competencies; developing knowledge, skill, and attitude (KSA) elements for each competency; and assessing the presence of the 6 competencies and KSAs in nursing curricula. Early findings revealed that although the faculty agreed that they should be teaching these competencies, new graduates indicated that they were not learning these updated competencies.2 What followed was a 10-year effort to support the integration of the QSEN competencies into nursing education and practice.
The purpose of this study was to evaluate the progress of those efforts. The 2017 National QSEN Faculty Survey is the only national survey to assess faculty understanding, implementation, and evaluation of QSEN competencies in nursing education in 12 years. The aim of this national faculty survey was to assess (1) whether QSEN competencies are being taught in US schools of nursing, (2) the degree of faculty development in schools where QSEN competencies are being taught, and (3) the degree of integration into curricula where QSEN competencies are being taught. The results of this national faculty survey indicate progress has been made in the past 11 years in the dissemination and adoption of the QSEN competencies; however, significant needs remain for faculty development and support.
Smith et al3 conducted the first national faculty survey in 2005, to assess the presence of QSEN competencies in nursing curricula as they were being introduced. In this baseline survey, 195 nursing program leaders were surveyed about the presence of the QSEN competencies in their program, pedagogical strategies used, student competency development, and faculty preparedness for teaching the updated competencies. Results indicated that these leaders perceived a relatively high rate of adoption of the QSEN competencies across curricula and high satisfaction with student competency development and faculty preparedness. However, focus groups with nursing faculty and new graduates indicated less impressive adoption of the QSEN competencies in curricula and significant gaps in student competency development and faculty preparedness. Hypotheses about the stark differences in these data centered on program leaders, deans, directors, and chairs being too distant from the actual “curriculum in use” to accurately respond to the survey.1
The early data led the QSEN founders to concentrate the initiative’s focus on faculty development and easy access to faculty development materials. Although the language of the QSEN competencies was familiar to nurse educators (nursing is a profession that has always taught patient-centered care, safety, and collaboration), the KSAs and updated concepts in the competencies were not well understood by nursing faculty. To address this need, phase II of the QSEN initiative (2007-2009) invited 15 pilot schools to integrate the 6 competencies into their nursing programs and create a collaborative for sharing ideas and strategies for implementation and faculty development. The QSEN Web site was launched during phase II, with a heavy emphasis on providing a wide variety of open source resources for faculty. Resources included peer-reviewed teaching strategies, annotated bibliographies for each of the competencies, and the creation of faculty development modules.
Ongoing feedback from nursing programs highlighted the continuous need for faculty development. Phase III (2009-2012) addressed this clearly identified need by offering 8 regional Faculty Development Institutes, which used a train-the-trainer model so participants could facilitate ongoing faculty development at their own schools. More than 1100 nursing faculty attended. These regional institutes served as an effective strategy for engaging large numbers of faculty across the United States in QSEN work and for disseminating vital strategies to improve the teaching of quality and safety content in a variety of nursing programs.4 In addition, the first annual national QSEN Forum conference was offered during this time, which focused on exposing nursing faculty to innovations in curricular design and teaching strategies and research related to quality and safety education.
During this critical period of growth and development for QSEN, The Gordon and Betty Moore Foundation funded a series of faculty development activities in California over a 4-year period (2009-2013) to support the implementation and evaluation of the effect of incorporating the QSEN competencies into 22 nursing programs.5 A longitudinal evaluation of the effect of this work included an in-depth evaluation of a subset of the participating schools during on-site visits. The findings indicated that most participating schools instituted many of the KSAs for the QSEN competencies, significant curricular change occurred, and academic/clinical partnerships were strengthened.5
The authors engaged in a systematic and thorough review of the history of QSEN-focused data collection done with nursing faculty. All of the instruments used in the aforementioned studies were reviewed. The original QSEN principal investigators shared input on effective approaches for an updated national faculty survey. They provided cautionary guidance on effective and ineffective strategies and on lessons learned in studying the integration of QSEN. Core QSEN faculty shared the instruments previously used in QSEN faculty research and specific suggestions in directly and effectively engaging nursing faculty.
A 16-item instrument was developed to survey faculty. Most item formats were “select all that apply,” with 3 items focused on demographic data and the remainder specific to the integration of QSEN competencies in the participant’s nursing program. An additional open text box was provided for 5 questions to allow for expanded explanations. Six doctorally prepared QSEN experts reviewed the instrument before being implemented in a pilot study that assessed nurse educators at a national baccalaureate education conference in November 2015 regarding the needs that they had for the integration of quality and safety education into their curricula. Introductory data collected from a small sample (N = 40) identified survey elements that needed to be clarified or edited, resulting in a 19-item instrument.
These initial data clearly indicated that many educators feel unprepared to teach quality and safety content in a way that reflects current practice. The majority (79%) indicated that they need educational strategies, faculty development, and support. These initial data supported the need for a national survey. The developers of the current survey partnered with the National League for Nursing (NLN), which distributed a letter via e-mail, asking for participation from their faculty members and providing a link to participate in the survey.
The survey was sent via e-mail to 31998 nursing faculty registered with the NLN. After remaining open for 60 days, 2037 surveys were completed, indicating a 6.4% response rate. Three quarters of respondents reported teaching primarily in a prelicensure nursing program with 40% representing associate degree programs and 30% representing baccalaureate programs. Of those completing the survey, 88% were full-time faculty members, with 43% of the respondents reporting their years of teaching experience as 10 years or less and 18% reporting more than 25 years.
Implementation of QSEN
Most respondents (86%) indicated that they are currently using QSEN in some manner in their teaching. In regard to which QSEN competencies are being taught, patient-centered care, evidence-based practice, and safety were the most frequently identified, each selected by 93% of the respondents. Teamwork and collaboration followed closely with 88%, indicating inclusion in their curriculum. The 2 QSEN competencies with the lowest representation in the curriculum were quality improvement (79%) and informatics (67%). What was not captured by the survey was whether faculty members are exposing their students to updated concepts and QSEN KSAs in teaching these competencies or whether traditional ideas and materials are being used.
One third of respondents reported that most courses in their program (more than 80%) included the QSEN competencies. Conversely, 17% reported that less than 20% of the courses in their curriculum teach the QSEN competencies, with the remainder falling somewhere in between. Although fundamental courses and medical-surgical courses were reported to have the greatest integration of QSEN (82% and 83%, respectively), a concerning lack was identified in public health courses, with only 26% integration, and research courses, with only 27% integration reported. Integration of the QSEN competencies in specialty courses of maternity care, pediatrics, and mental health ranged from 54% to 57% (Figure 1).
Knowledge of QSEN
Almost a third (29%) of the respondents estimated that less than 20% of faculty members in their prelicensure program have been educated about the QSEN competencies (see Figure, Supplemental Digital Content 1, http://links.lww.com/NE/A373). In contrast, another third (29%) estimated that more than 80% of faculty members in their program have received education. The remaining 40% indicated that the number of prepared faculty in their program fall in between. Of those not using the QSEN competencies in their teaching, the most frequently cited reasons included “I would need training in how to use it effectively” (40%) and “I am not sure how to integrate it into what I already do” (31%).
Formal methodologies used to learn the QSEN competencies included learning at conferences (42%), through self-study and simulation (39%), and webinars (30%). Other formal educational methods identified were faculty retreats with a partial QSEN focus (17%), live classroom learning (16%), and faculty retreats completely focused on QSEN (10%). Some faculty indicated learning about QSEN in their master’s programs before their current teaching position, whereas 133 participants (6.5%) did not know what QSEN was or were unaware of any formal educational methods provided at their school to learn the QSEN competencies.
The most common informal methods reported by faculty to learn about QSEN were faculty meetings and self-study. Team meetings and group work on clinical evaluations or curriculum revisions served as the training for some. A small percentage identified being given handouts, “looking over the Web site,” or being told to “Please read up on these.”
Three quarters of respondents indicated that they had accessed the QSEN Web site in the past academic year for resources to integrate the QSEN competencies into the curriculum. Other resources used during the past academic year included the NLN resources with 52% of respondents indicating use, the American Association of Colleges of Nursing (AACN) with 37% reporting use, the Agency for Healthcare Research and Quality being used by 31%, and the Institute for Healthcare Improvement used by 21%. Textbooks and national conferences were additional noted resources. Respondents reported a wide variety of teaching strategies to be effective (Figure 2).
An open text question asked respondents, “What would be helpful to successfully implement QSEN competencies into your program?” Text responses (n = 710) were captured. Seventy-five percent (n = 535) indicated a need for faculty education, faculty development, or educational materials to successfully implement QSEN into their curricula. Of those, 24% (n = 127) identified a wide variety of materials that would be helpful (eg, tool kit, more teaching strategies, examples of curricular integration, lesson plans, modules for both faculty and students, clinical assignments, and course specific guides). The most common specific resource requested was case studies. One quarter of respondents (n = 180) identified the need for release time or compensation for QSEN training, increased administrator support, and increased collegial buy-in to learning about the QSEN competencies. Similarly, 3% of respondents asked for increased national focus on the imperative to integrate QSEN into curricula (through accreditation requirements and professional organizational highlights). Twenty-one respondents were specific in asking for a standardized curricular framework based on other schools’ success, which could be easily implemented, with clear guidelines. Ten percent (n = 71) indicated that QSEN is already implemented in their curricula and they do not need further education or materials.
A second open text question surfaced another important, common gap to effective implementation of QSEN competencies—evaluation. The question asked, “How are QSEN competencies measured at your institution?” Of the 898 text responses captured, almost 20% (n = 174) of respondents indicated that QSEN competencies were not being measured or the respondent did not know how the competencies were being measured. Of those indicating that the QSEN competencies are being measured in the program, 28% (n = 248) identified measurement through student learning objectives, course objectives, course evaluations, or program objectives; 21% (n = 188) cited use of clinical evaluation tools (including simulation) as their program’s mechanism for measuring QSEN competencies; 14% indicated use of testing or examinations; and 11% cited assignments (eg, care plans, article analysis, reflective journaling, and case studies) or rubrics as evaluation methods for QSEN competencies. A small percentage (5%) relied on commercial standardized testing for QSEN competency measurement, and 4% identified student self-evaluation for assessing QSEN competency mastery.
The barriers to implementing QSEN were varied with the greatest number of responses indicating a lack of time to learn something new (43%) and the need for ideas and training in how to use it effectively (40%). The challenge of getting colleagues to participate so that it would be integrated throughout the curriculum rather than in just 1 class was identified as a barrier by 36% of participants. Other issues that related directly to faculty included increased turnover, faculty resistance to change, and knowledge deficit. Lack of administrative support was reported as a barrier by 12% along with budget limitations regarding financial support for faculty development and education.
The 2017 National QSEN Faculty Survey reports faculty perceptions of QSEN integration in nursing curricula since the development of the QSEN competencies 12 years ago. At face value, the results reflect that the QSEN competencies are being incorporated into nursing education to some degree by many nurse educators; the degree to which varies greatly among programs, with a large number indicating the integration is segmental and not throughout the curriculum.
Fundamentals and medical-surgical courses are identified as having the greatest amount of integration, which may be reflective of an increased focus on acute care and hospital safety in the literature. There is a clear need for supporting the integration of the QSEN competencies in public health courses. Application of QSEN in community-based care and primary care is appropriate and vital to quality care and patient safety. The low level of integration of QSEN in nursing research courses is concerning and supports the need to link evidence-based practice, quality improvement, and research in nursing education so that it can serve as a bridge into practice where these 3 are intertwined in the work that direct care nurses do when conducting quality improvement and evidence-based practice unit projects.
Faculty members view the competencies of safety, patient-centered care, teamwork and collaboration, and evidence-based practice as prominent themes in their teaching, with quality improvement and informatics less so. These results support the long-held belief that the literature is lacking for the latter 2 competencies and support the need for connecting faculty to resources to aid the teaching and application of informatics and quality improvement, such as the Institute for Healthcare Improvement’s Open School. Although safety, patient centeredness, and teamwork have always been valued by nurses, and educators report that they teach these, it is important to note that the language and associated skills of these competencies have undergone significant change. These updated definitions are reflected in the QSEN competencies and associated KSAs, but it is unclear if updated concepts are being taught in current curricula; we need further understanding of this question.
A high percentage of full-time faculty members completed the survey with a wide range of experience reported. Almost half indicated being in the faculty role for less than 10 years, which may have facilitated knowledge of the QSEN competencies as their advanced education and introduction to teaching coincided with the incorporation of QSEN concepts into accreditation standards. Open text responses indicated a clear need for preparing new faculty in how to effectively teach the QSEN competencies. Exposure to updated quality and safety competencies in one’s graduate education does not ensure successful integration of this content into didactic and clinical pedagogy.
Inconsistency exists among the number of faculty formally trained in the competencies, with some programs having many faculty prepared and others minimal; in some programs, a single person is responsible for QSEN content, which accounts for reports of fragmented rather than widespread integration of the competencies across curricula. Although some learned about QSEN during graduate education, many learned from conferences, webinars, and self-study or from presentations at faculty meetings. The variation addresses the need for formal education because there are faculty members who have not been exposed to QSEN.
Also concerning was the lack of understanding and the lack of time to learn, both of which affect an individual’s ability to implement teaching strategies that support the competencies and the participation of colleagues to do so. The need for ideas to incorporate the QSEN competencies into classroom and clinical activities was evident among participants as was the need for administrative support to do this work and to attend programs that offer opportunities to learn about teaching this content. Faculty workload and time constraints of the nurse educator role are well documented in the literature.6 The demand on faculty to continually update teaching to align with the fast-paced change of practice creates a need for packaging curricula focused on quality and safety and making it available to educators. It is important to note that integration of the QSEN competencies is not accomplished in teaching a specific lesson but is about using the competencies as an underpinning of the entirety of nursing education.
This study demonstrates that the QSEN Web site (www.qsen.org) serves as the single most significant resource used by respondents. The Web site has been in place since the competencies were developed and houses teaching strategies for classroom and clinical teaching as well as resources to support faculty education. Other significant resources include those housed on the Web sites of NLN and the AACN as well as organizations focused on patient safety and quality improvement. Sustaining these resources and providing links and coordination of services between them is a vital step in ongoing support for faculty to create opportunities for learning.
The survey was sent to nurse educators on the NLN membership list. It is unknown if those who responded are particularly interested in QSEN. The response rate of 6.5% does not allow us to conclude that these results are representative of nurse educators throughout the United States. Although we recognize that the results of this survey may not be representative of all, we hope that this survey will invigorate a conversation about expansion of support services for nurse educators and increased connection to resources to better integrate quality and safety competencies in nursing education.
Future understanding of the effective integration of QSEN competencies into nursing curricula will be well served by an analysis of whether truly updated concepts, competencies, and resources are being used in the education of nursing students in teaching quality and safety. Usage of in-depth, “deep-dive” evaluation methodology, as conducted by Disch and colleagues5 in assessing integration of QSEN into San Francisco Bay Area Schools may provide more clear, informative data about future effective integration strategies.
Quality and safety continue to be consistent foci of efforts to improve the health care system. Integration of the QSEN competencies in nursing education remains varied and inconsistent. There are opportunities to improve resources and provide support and education for nursing faculty so that they can better understand and incorporate the QSEN competencies into their students’ learning. There is particular need in courses focused on community-based care and primary care as well as nursing research, where the QSEN competencies have been underrepresented. Faculty members need education, ideas, and strategies as well as the support of colleagues and administrators in doing this work.
This survey was conducted through a partnership with the NLN, and we are grateful to the NLN members who contributed their time and expertise to survey findings.