Despite modest improvements in health care quality over the past 15 years, errors in health care continue to cause more deaths than motor vehicle accidents and plane crashes combined, and patients are still routinely exposed to wide variations in the quality of health care that they receive.1-3 Quality and safety competencies exist for students of undergraduate and graduate programs in nursing and medicine; however, implementation of these competencies has been slow.4 Inconsistent integration of the competencies into standard curricula exists, and there is an absence of methods to effectively evaluate competency achievement. It is not clear if our efforts are preparing health care professionals who place quality and safety at the forefront of their practice.
In 2003, the Institute of Medicine (IOM) described 5 high-level essential competencies for delivery of safe and high-quality care: quality improvement, patient centeredness, informatics, evidence-based practice, and teamwork.5 Based on this work, what followed was the development of competencies in medicine6 and nursing, specifically the Quality and Safety Education for Nurses (QSEN) competencies.7 The QSEN used the 5 IOM competencies and added safety as a final competency for nursing. From these 6 competencies, 186 knowledge, skills, and attitude (KSAs) statements were developed and validated.
The QSEN initiative, now the QSEN Institute, provides resources to facilitate implementation of QSEN competencies into nursing education. Online resources include teaching strategies, evaluation tools, videos, and links to other sites such as the Institute for Healthcare Improvement. Additional education and collaboration opportunities are available through the annual International QSEN Conference. Learning modules exist on the QSEN Web site to support nurse faculty efforts to integrate the competencies. The “Managing Curricular Change for QSEN Integration” (Learning Module 9 http://qsen.org/courses/learning-modules/module-nine/) provides an implementation framework and specific tools for implementation. Despite a growing number of resources to support nursing faculty efforts and claims that they are undertaking steps to implement quality and safety competencies, implementation of QSEN competencies into nursing education is still lacking.4 The purpose of this article is to describe implementation science and to offer pragmatic strategies to further integrate quality and safety competencies into nursing education programs.
Implementation Science Defined
The uptake of new evidence is slow and can take many years to implement.8 During the past 15 years, the fields of dissemination and implementation research have been growing. Both are recognized within the scope of implementation science. Dissemination research is the scientific study of targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to understand how best to spread and sustain knowledge and the associated evidence-based interventions.9Implementation research is the scientific study of the use of strategies to adapt and integrate evidence-based health interventions into clinical and community settings to improve patient outcomes and benefit population health.9
Implementation Science: Historical Roots
Implementation science has its roots in 2 major streams of research: diffusion of innovations research pioneered by Rogers10 and the evidence-based medicine movement often associated with Archie Cochrane and the international Cochrane Collaboration. The work on diffusion of innovations, which is more focused on dissemination than active implementation, emphasizes the social aspects of how new practices are adapted by individuals. The evidence-based medicine (or health care) movement fosters knowledge synthesis and guideline development, dissemination, and implementation. Implementation science is evolving into a science of health care professionals’ behavior change in the provision of health care services.
Although implementation science evolved from a practice context, its methods may compliment competency implementation in education. Increased knowledge about implementation methods by academic and practice educators may accelerate the uptake of quality and safety competencies into nursing education programs.
Implementation Science Models
Why use models when implementing quality and safety competencies into education at the program level or educational activity level? Models depict essential components and provide a systematic method of explaining or predicting phenomena.11 They ensure a planned process whereby important steps are not left out. They also foster a systematic growth of research in a given area. Tabak et al11 provides an overview of 12 implementation models and how to select a model that contains the specific concepts at the level of implementation one wishes to explore. Nilsen12 further categorizes the models. One category defined by Nilsen12 is process models, which offer important information about how to go about engaging in implementation of new practices. Another category includes determinants models, which describe factors that have been observed to affect implementation.
Process Models: Knowledge-to-Action Framework
One particularly useful model for implementing competencies in nursing education is the Knowledge-to-Action (KTA) Framework13 that has been adapted by the Registered Nurses’ Association of Ontario (RNAO)14 and used in their Best Practice Guidelines Implementation strategy. The KTA Process Framework has 6 steps to assist health care facilities to adapt best practice guidelines (Table 1). The KTA Process Framework could also be used to integrate quality and safety competencies into the curriculum. The first step, assess the problem, explores gaps or identifies opportunities in the curriculum where quality and safety competencies can be embedded. This can be done using concept maps to indicate which QSEN competencies can be highlighted in specific courses or by individual faculty assessments of where the competencies are taught in their own courses. Step 2 is 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. The third step is to identify the facilitators and barriers. Facilitators may include the availability of the QSEN teaching tools and strategies located on qsen.org Web site. Barriers might include other competing program priorities or leadership changes. The fourth step is to select implementation strategies such as facilitation, audit and feedback, and engagement of champions. An example of the fifth step in the KTA Process, monitor and evaluate process and outcome, is to select an evaluation strategy from qsen.org to measure student retention of quality and safety content. Finally, to sustain the change (step 6), the faculty should reevaluate 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.
Determinants Model: Consolidated Framework for Implementation Research
The Consolidated Framework for Implementation Research (CFIR) is a typology of constructs from which theory can be developed15 rather than an explanatory theory. Widely used in both the United States and internationally, the CFIR has 5 domains: the intervention, inner setting, outer context, individuals involved in the implementation, and process whereby the intervention is undertaken.15 One advantage of this framework is that its components are flexible and context dependent. A disadvantage is its vagueness. For example, the fifth domain, implementation process, requires additional theories to help explain how to implement. Other useful determinants models include the Theoretical Domains Framework, which focuses principally at the level of the individual provider,16,17 and the Tailored Implementation for Chronic Diseases framework or checklist.18
Implementation strategies refer to formal methods or techniques used to enhance the adaption, implementation, and sustainability of a clinical practice or program.19,20 They have been described as the how to of changing practice and are an essential focus of implementation science.21 Numerous implementation strategies are described in the health care literature, often as components of complex interventions. An example of strategies can be seen in the steps of the KTA Process described earlier.
Because of inadequate detail in describing discrete intervention components and use of inconsistent terminology,22 several groups have called for consolidation of terms to clarify implementation strategies and facilitate implementation processes.21,22 To this end, the Expert Recommendations for Implementation Change (ERIC) project produced a consensus document outlining terms and definitions for 73 discrete implementation strategies that have been described in the health care literature.20 The strategies have been further evaluated based on their importance and feasibility and grouped into 7 categories.23 Categories include (a) evaluative strategies such as audit and feedback, (b) interactive assistance strategies such as facilitation, (c) strategies for adapting and tailoring implementation to the local context such as with tailored strategy selection, (d) strategies for developing stakeholder interrelationships such as with the use of champions and coalition building, (e) training and education strategies, (f) strategies for supporting clinicians/educators, and (g) engagement strategies for consumers/students.
In the following section, we describe 5 strategies that may be useful in facilitating adaption of QSEN competencies within local nursing curricula. Additional ERIC strategies20 are available in Table 2. In addition to the 73 strategies cataloged through the ERIC project, individual-level behavior change techniques, which may be relevant to supporting individual student learning, are also described in recent work by Michie et al16 in the United Kingdom. Many of these behavior change techniques are widely used in nursing education and will be familiar to nurse educators.
Assess for Readiness and Identify Barriers and Facilitators
Consistent with the KTA Process, this strategy is an assessment of various aspects of the academic setting to determine the readiness for implementing QSEN competencies, the barriers that may impede implementation, and the facilitators that can be used in the implementation effort.20 A systematic review of instruments to assess institutional readiness for process/program implementation is available,29 and there is expert consensus for the importance of the following 6 dimensions in determining local implementation readiness: organizational contextual factors, leadership, organizational support, motivation, organizational climate, and change content.30 Qualitative and mixed method approaches to identify barriers and facilitators are common and can be guided successfully by implementation models.31,32
Audit and Feedback
Audit and feedback have perhaps the most evidence to support effectiveness. Audit and feedback interventions have been evaluated in a meta-analysis of 140 randomized trials across clinical settings and lead to a small but significant improvement in compliance with desired practice.33 In the context of nursing curriculum development, audit and feedback describe collection and summarization of data on single courses and academic programs that can be given to nurse educators to monitor, evaluate, and modify content associated with QSEN competencies.20 Best practices for audit and feedback interventions have been published, with design recommendations for each of the following: audit components, feedback components, nature of the behavior change required, and goals and action plans.34,35
Conduct Cyclical Small Tests of Change
The use of cyclical small tests of change before taking changes program wide is a useful strategy for faculty to successfully implement curriculum changes. Systematic measurement is essential to understanding if the desired changes occur, and results of the small tests of change should be studied for insights on how to improve. This process continues serially over time and allows for program refinement with each cycle.20 The Plan-Do-Study-Act (PDSA) method is one small test of change cycle approach that is widely accepted in quality improvement and recommended as an approach to testing adaption of QSEN competencies. An important barrier to distinguishing its effectiveness across settings is incomplete adherence to all 4 primary features of the model. Failure to use iterative small tests of change and to collect quantitative data to guide evaluation of changes are common and thought to influence overall effectiveness of the approach.24 To this end, we recommend consistency in applying PDSA or other rapid cycle approaches to the implementation of QSEN competencies.
Develop a Formal Implementation Blueprint or Plan
A formal blueprint or plan that includes all program goals and implementation strategies includes the aim or purpose of the implementation, the scope of the change, a timeframe, and appropriate progress measures and milestones.20 A free, downloadable blueprint template is available on the RNAO Web site (http://rnao.ca/bpg/guidelines/resources/best-practice-guideline-implementation-project-plan). The use and continual updating of the blueprint facilitate the evaluation and sustainability of the implementation effort over time.
Application of Implementation Strategies for Quality and Safety Competency Integration
Integrating the QSEN competencies into a nursing curriculum is a complex endeavor that can be accelerated by the use of implementation models and strategies. The foundational work of implementation requires strong leadership at both the program and faculty level. Leaders must value and agree on a clear goal to implement the competencies into the curriculum. Using an implementation model will guide the overall process, helping educators prioritize and plan the steps for curriculum development. The use of implementation strategies is also important. Table 2 describes the application of a selection of implementation strategies identified by the ERIC project.20 The table uses the categories identified by the ERIC project and provides specific action steps at both program (organizational) and course (individual) levels. The information in the table provides specific action steps to facilitate the implementation of the QSEN competencies into nursing education.
Implementation scientists are developing models and strategies to accelerate implementation of both evidence and quality enhancements into practice. We propose the use of implementation science methods as a novel way to facilitate implementation of quality and safety competencies into nursing curricula in both academia and practice. There is currently limited evidence to support application of implementation methods to integration of QSEN competencies into curricula. Furthermore, QSEN competencies are open for interpretation and are not in themselves evidence based.
To date, the 6 competencies contain 186 KSAs; full integration of QSEN competencies may not be feasible for all schools of nursing or hospital-based professional education departments. Prioritizing which KSAs to include can be difficult and requires knowledge of local conditions, including strengths and opportunities in existing undergraduate and graduate programs. Despite these limitations, borrowing implementation models and strategies and applying them to QSEN competency integration is a first step to providing a structure to our efforts. Further initiatives to evaluate our efforts are necessary to understand the effectiveness of these methods. By using implementation science methods, models, and strategies, faculty will have practical tools and techniques to increase uptake of the quality and safety competencies in nursing education.
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