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Quality and Safety Education for Nurses Competencies in Doctor of Nursing Practice Education: Exemplars From Education and Practice

Acton, Cindy DNP, RN, NEA-BC; Farus-Brown, Susan DNP, RN, FNP-BC; Alexander, Catherine DNP, RN; Morrow, Linda DNP, RN, CNOR, CPHQ; Ossege, Julianne PhD, RN, FNP-BC, FNAP; Tovar, Elizabeth PhD, RN, FNP-C

doi: 10.1097/NNE.0000000000000426
Feature Articles

Graduate level Quality and Safety Education for Nurses (QSEN) competencies were created to facilitate preparation of the Doctor of Nursing Practice (DNP) graduate to have an impact on health care system changes, advance nursing practice, and improve the health of populations. Although there is agreement that QSEN competencies are important to DNP education, little is known about implementation of the competencies. This article describes the importance of QSEN competencies in DNP education and provides exemplars of QSEN competencies in DNP education and practice.

Author Affiliations: Associate Professor and Director of MSN Administration Track, School of Nursing, Texas Tech University Health Sciences Center, Lubbock (Dr Acton); Assistant Professor, School of Nursing, Ohio University-Zanesville (Dr Farus-Brown); Adjunct Faculty, MGH Institute of Health Professions, Boston, Massachusetts; VA Quality Scholar; and Chief Executive Officer, Mobile Medical Training, Portsmouth, Rhode Island (Dr Alexander); Clinical Assistant Professor, College of Nursing, Sacred Heart University, Fairfield, Connecticut (Dr Morrow); and Associate Professor, University of Kentucky College of Nursing, Lexington (Drs Ossege and Tovar).

The authors declare no conflicts of interest.

Correspondence: Dr Farus-Brown, Ohio University-Zanesville, 1425 Newark Rd, Zanesville, OH 43701 (

Accepted for publication: June 9, 2017

Patient safety and health care quality have been center stage since the publication of To Err is Human: Building a Safer Health System, which detailed the estimated 100 000 deaths in US hospitals due to preventable errors.1 Factors influencing the errors include fragmentation of the health care system, communication failures, inadequate monitoring, failure to act, diagnostic errors, and failure in performance. Fifteen years later, the National Patient Safety Foundation (NPSF) convened an expert panel that assessed the current state of patient safety. This report concluded that, despite the advancements attained, too much remains unchanged and that “a total systems approach to safety, with a single coordinated agenda,” is required.2

With funding from the Robert Wood Johnson Foundation (RWJF), the Quality and Safety Education for Nurses (QSEN) Initiative began in 2005. The overall goal was to prepare nurses with the knowledge, skills, and attitudes (KSAs) required to improve quality and safety in health care systems. Meanwhile, in 2004, the American Association of Colleges of Nursing (AACN) was implementing a new degree for the doctoral level in nursing. The Doctor of Nursing Practice (DNP) degree was designed to educate nurses who could impact health care systems’ multifaceted quality and safety problems and improve patient care on multiple levels.3

By 2012, the graduate level QSEN competencies were revised to purposefully align with the Essentials of Doctoral Education for Advanced Nursing Practice (DNP Essentials), a foundational document for every DNP program.3 Unfortunately, there are few published examples of QSEN competency integration in DNP curricula. Anecdotal evidence suggests that many DNP programs struggle with how to effectively integrate QSEN competencies in meaningful ways. The purposes of this article are to underscore the importance of graduate level QSEN competencies in DNP education, describe how QSEN competencies are currently integrated in DNP education and practice, and provide exemplars of the integration of QSEN competencies into DNP education.

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Importance of Graduate Level QSEN Competencies in DNP Education

The most significant connection between the QSEN competencies and DNP education is that both are nursing education’s response to the Institute of Medicine’s (IOM) call to action.4 The IOM’s recommendations called for a swift, dramatic change in all health professionals’ education, envisioning that health professionals would be educated to address 6 core competencies (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement [QI], safety, and informatics) and that nurses with advanced degrees should be in key leadership positions, determining executive decisions.3,5 To propel nursing into a leadership position, the DNP Essentials were redesigned in 2006, staging the DNP graduate as the transformational leader of nursing practice.3

Three phases (I-III) of the QSEN Initiative occurred between 2005 and 2012, which defined quality and safety competencies, integrated competencies into the curriculum of 6 pilot undergraduate nursing programs, and focused on faculty development. In 2009, the graduate level QSEN competencies were published.6 At the same time, the National Organization of Nurse Practitioner Faculties (NONPF), which had participated in the development of the competencies, compared the QSEN competencies with the NONPF core competencies, finding incongruences between the two.7 In 2012, new funding from RWJF to the AACN provided resources to revise the competencies,8 and these revised competencies continue to serve as the current graduate level QSEN competencies.9 In addition, the funding goals of this initiative (phase IV) were to align with graduate nursing standards, integrate the competencies in the curricula through faculty education, and create electronic resources to enhance faculty development and engage clinical partners.9 It was during this phase, in 2015, that AACN sponsored 60 graduate level QSEN competency workshops.10 This ongoing work is to ensure that DNP graduates promote, model, and lead quality and safety across all health care settings.

Doctor of Nursing Practice programs are growing in number since the first program began at the University of Kentucky in 2010. Today, there are more than 289 programs throughout the United States that offer the DNP degree, with a current enrolment estimated at 22 000 students.11 The growth of DNP programs comes at a time when nurses are urgently needed to deliver advanced practice care, as well as solve the complex quality and safety problems that continue to exist in US health care systems. Dolansky and Moore12 reported that systems thinking is required to improve the quality and safety of care. Acknowledging and understanding the systems perspective facilitate a more comprehensive assessment of successes and failures and enable a more solid resolution of problems.

The QSEN competencies and the DNP Essentials can work in tandem to address the KSAs needed of the DNP graduate. Integration of the QSEN competencies creates a transparent, measurable means to demonstrate academic nursing’s commitment to reforming education within a culture of safety and quality. Congruent with NPSF’s call for 1 coordinated agenda, the integration of QSEN competencies into the DNP curricula prepares a graduate focused to lead preventions of health care system errors and create sustainable changes intended to improve health care.

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QSEN Competencies in DNP Education and Practice

It has been 5 years since the release of the revised graduate level QSEN competencies, and there is little evidence of their integration into DNP curricula. To determine connections between QSEN and DNP programs, a literature search using the keywords “DNP” and “QSEN” was performed, using multiple databases. Many authors who focused on the practice setting concentrated on the integration or comparison of competencies into existing national standards,13,14 evaluating leaders’ practices or performances,15,16 and staff development.17 Among authors who focused on DNP education, only 1 group targeted faculty development,18 3 groups discussed the use of QSEN competencies within the DNP curriculum,19-21 and the remaining authors used the QSEN competencies as part of a DNP project.

Connors et al18 described the success of using a national conference to develop faculty scholars in informatics. Patrician and colleagues19 found that the Veterans Affairs National Quality Scholars offered an interprofessional learning experience for DNP graduates, which emphasized 2 QSEN’s competencies, quality of care and patient safety. Tovar and Warshawsky20 used problem-based learning to deliver the QI methodology of Lean-8 Step Problem Solving Method. Problem-based learning brought real-world clinical issues to life, providing students a hands-on opportunity to apply QI tools, receive immediate feedback, and develop confidence in their ability to use the Lean method in solving future clinical problems in their practice.

Manning and Frisby,21 the earliest to publish integration of QSEN into the DNP curriculum, outlined an innovative method for students to learn QSEN KSAs by incorporating interpretive thinking from both an analytic and reflective point of view. Students created a 5-minute educational video that included 3 QSEN competencies—teamwork and collaboration, evidence-based practice, and informatics—into an existing course design. Approaching course design using multiple teaching strategies developed knowledge and understanding of QI methods that may be integrated early in a student’s practice.

Noteworthy of this search is that the keywords “QSEN” and “DNP” were used to ensure a clear link between them. When the core competencies of QSEN such as QI or patient safety are paired with DNP, the number of articles expands. These results suggest that DNP faculty are addressing quality and safety competencies but are not referencing QSEN. The search terms of DNP and QSEN provided meager evidence about use of QSEN competencies in DNP programs and how DNP faculty obtain graduate level QSEN competencies training. Further investigations are needed to address how DNP program leaders both integrate and evaluate QSEN competency implementation.

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Exemplars of Graduate Level QSEN Competencies in DNP Education

Examples of how faculty in DNP programs are successfully integrating QSEN competencies may promote adoption, especially for those DNP faculty who are not as familiar with QSEN. The 3 exemplars presented provide a broad spectrum of how the DNP programs are meeting QSEN competencies to develop and ultimately ensure DNP graduate readiness to lead changes urgently needed in our current health care systems.

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Analytic and Reflective Practice

A graduate school of health professions, located in the northeastern region of the United States, was involved in an online leadership course set out to align the QI course objectives with the QSEN competencies for DNP practice. Drawing inspiration from a project design by Manning and Frisby,21 faculty incorporated the QSEN competencies into a semester-long leadership project. Using a case study on sepsis,22 students participated in a synchronized online class early in the semester to review the concepts of QI and examination of the QI themes embedded in the case. Students were divided into teams of 3 with the task of developing a 5-minute video focused on the QI and safety issues emphasized in the case. Students were asked to address issues of QI sustainability from a leadership perspective. After completing an annotated bibliography, students developed a storyboard (a set of PowerPoint slides) that served as an outline for their project. Once the video was completed, students designed an evaluation tool to assess the effectiveness of their message in the video. Each student asked colleagues outside school to watch the video and complete the survey. Each group then pooled their data, created a graph of the results, and posted the results online.

During the last synchronized session of the course, each group presented their videos, discussed the survey results, and identified challenges of project work and their overall understanding of the QSEN competencies from a leadership perspective. During the last week of class, students completed 2 assignments: a final reflection on leadership lessons learned from the project and a peer evaluation that addressed the challenges of teamwork and collaboration. Faculty used Manning and Frisby’s21 KSA evaluation tool to evaluate the videos. The Table lists the projects’ learning outcomes, teaching strategies, and evaluation of strategies and the student learning outcomes.

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Complex Statewide Case Study Resolution and Interprofessional Competition

A large university located in the south-central region of the United States offers DNP hybrid courses using both online and in-person class meetings. These courses use modules with content presented through readings of various text books, articles, Web sites, and video streaming. Learning is reinforced during in-person course meetings through didactics and discussions. The QSEN competencies are threaded throughout the program, scaffolding previous course objectives to increase students’ application and synthesis.

The DNP program offered a semester-long interprofessional activity in collaboration with the schools of medicine and pharmacy. Students were assigned to interprofessional groups and given a complex statewide case study to resolve. Student teams were to provide a 20-minute presentation on how they would address issues in the case study to a simulated boardroom of executives.

Student learning objectives required application of content from multiple sources to best resolve the case and included addressing QSEN competencies. Teams used experts from the field to gain further insight into the resolution of their case. Simulation was offered for teams to practice communication skills for their presentations. During the boardroom presentations, the executives further engaged students in dialogue concerning their team’s resolution to the case. The executives and judges selected 1 team to represent the university at a national case study competition. The complex statewide case study was provided by the Center for Health Interprofessional Programs Student Center at the University of Minnesota,23 which offers an interprofessional national case study competition annually.

This activity provided lived experiences for students and a set of skills translatable to any professional setting. In postclass surveys, students rated this activity as a highly effective teaching strategy. Faculty from all schools and the executives rated the boardroom simulation high, stating that the activity sums up the major skills required of new leaders in today’s health care environment. The Table provides examples of learning outcomes and teaching strategies.

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Collaborative APRN Practice

In fall 2017, in a school of nursing located in the southern region of the United States, BSN-to-DNP students enrolled in the primary care track will have the opportunity to participate in a Health Resources and Services Administration training grant. The grant aims to train primary care providers to lead health care systems transformation by improving the Triple Aims of cost containment, population health, and patient experience.24 The grant will provide the BSN-to-DNP student the opportunity to receive training to become a member of an existing collaborative care practice model. The collaborative care practice model will consist of primary care APRNs, family medicine faculty and residents, and Master of Social Work faculty and students. The BSN-to-DNP students will have the opportunity to address health care disparities in medical and behavioral health, as well as complete a health-related population-based analyses. The Table provides examples of how learning outcomes and teaching strategies will be used in this training program.

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Future Use of QSEN Competencies in DNP Education

Quality and Safety Education for Nurses provides competencies for doctoral nursing education. These competencies provide guidelines for DNP faculty to formulate teaching strategies to develop future nurse leaders who are competent in the implementation and evaluation of quality and safety principles in many different health care settings. Methods for evaluation of the implementation of QSEN competencies are needed. Future research in this area is essential to demonstrate both achievement of the competencies and impact of the QSEN competencies in DNP education and patient care outcomes.

This article presented several exemplars for consideration. Further collaboration is needed to foster dialogue among DNP faculty, practice leaders, and other entities invested in DNP education, such as the AACN, NONPF, and American Organization of Nurse Executives. Sharing of current QSEN competency implementation strategies is needed to develop a DNP graduate well prepared to assume the role of a leader and change agent in a variety of health care settings. Discussions also should include examples of how academia can partner with clinical settings because both have the potential to create resources for the DNP student to practice newly acquired skills and develop as a leader. In addition, the NPSF has emphasized the importance of using the QSEN competencies to create a cohesive curriculum for DNP education and practice.2

Table. Exa

Table. Exa

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Doctor of Nursing Practice program; graduate nursing education; nurse practitioner; Quality and Safety Education for Nurses; quality care

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