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Quality and Safety Education for Nurses Implementation: Is It Sustainable?

Cooper, Elizabeth DNP, RN, CNE, CNL

doi: 10.1097/NNE.0000000000000415
Feature Articles

Is the Quality and Safety Education for Nurses (QSEN) initiative still advancing in prelicensure nursing education? The purpose of this article is to report a 2-part evaluation regarding QSEN within the curricula. The evaluation included an online survey and conference for faculty in the San Francisco Bay Area (SFBA). This article discusses survey results and the ideas and suggestions of SFBA faculty that were made at the conference. The results were positive. Most schools continue to advance QSEN into their curricula. Ten ways to strengthen integration of QSEN in the curriculum and barriers are identified.

Supplemental digital content is available in the text.

Author Affiliation: Associate Professor, School of Nursing & Health Professions, University of San Francisco, California.

The author declares no conflicts of interest.

Correspondence: Dr Cooper, University of San Francisco, 2130 Fulton St, San Francisco, CA 94117 (

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Accepted for publication: May 17, 2017

Health care safety concerns have plagued providers and educators for more than 10 years. The Institute of Medicine (IOM) published groundbreaking reports about poor safety outcomes.1,2 The IOM challenged the health care community to revise its methods to enhance quality and safety for patients. This charge included all areas of health care: service and academia. Nurse educators responded to this charge in multiple ways, including changes to curricula, course work, and focus in clinical education.

One of the goals of the Quality and Safety Education for Nurses (QSEN) initiative was to revise prelicensure nursing education. Taking the IOM’s suggestions and pairing it with support from the Robert Wood Johnson Foundation, QSEN developed with a goal of enhancing nursing education to produce nurses who were prepared to deliver high-quality, safe patient care at all levels and sites.3 Quality and Safety Education for Nurses focused on assisting faculty to include the knowledge, skills, and attitudes of 6 competencies in the curriculum. These competencies included safety, patient-centered care, teamwork and collaboration, evidence-based practice (EBP), informatics, and quality improvement (QI).4

The QSEN creators developed a plan to share QSEN’s message and motivated nursing faculty to make changes in nursing education.5 Four phases of this initiative included (1) forming a thought leader group, defining competency definitions and learning objectives, and introducing QSEN in a major nursing publication; (2) selecting 15 pilot schools to integrate the 6 competencies into their nursing programs; (3) conducting train-the-trainer workshops offered nationally to develop faculty expertise and create sustainability; and (4) developing graduate level competencies.

The San Francisco Bay Area (SFBA) nursing schools entered into the QSEN initiative during the phase 3 Train-the-Trainer faculty development institutes. During the faculty development institutes, SFBA nursing schools learned from the experts. Faculty had opportunities to share thoughts and ideas, gain insight, and receive mentoring from experts in the QSEN field. This train-the-trainer approach provided strategies to weave QSEN into the curricula for more than 1100 nursing faculty nationally, which included the SFBA faculty.3,6

The purpose of this article is to report a 2-part evaluation regarding QSEN within the curricula. The Gordon and Betty Moore Foundation generously provided the University of San Francisco with a convening grant to make this evaluation possible. One of the main goals of this grant was to assess the current state of QSEN in the SFBA curricula years after its implementation and determine future initiatives for QSEN in SFBA nursing schools.

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QSEN Convening Survey

A previous study completed in 2012 by the QSEN leaders concluded that QSEN was integrated in multiple SFBA nursing curricula. The Gordon and Betty Moore Foundation support and activities increased the awareness and knowledge about QSEN, which helped to advance the work into the curricula.3 Has this work continued? Is QSEN still a main focus in the educational process for SFBA nursing students? Do nursing faculty want to continue with the QSEN initiative? The focus of this survey and faculty conference was to evaluate the use and sustainability of QSEN competencies in prelicensure nursing curricula in SFBA nursing schools over time.

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The SFBA consists of 22 schools in 10 counties. All schools were invited to participate in both an online survey plus a faculty conference. Fourteen of the schools participated in the online survey, plus 12 attended the faculty conference (see Table, Supplemental Digital Content 1. Faculty from both ADN and BSN programs were represented.

The QSEN survey results were discussed at the faculty conference held in fall 2016. Of the faculty attending the conference, 81% were full-time, and 19% consisted of adjunct faculty. The number of students in each program ranged from 40 to 1279, and the number of faculty teaching in each program varied from 6 to 200.

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Survey Topics

QSEN Assessment: Faculty Training in QSEN Competencies

The SFBA nursing schools had years of experience with the QSEN initiative in their educational programs. All schools had been involved in some fashion for at least 3 years, including 59% of schools being involved the full 6 years. Educating nursing faculty on the QSEN initiative was now completed at each individual nursing school. Formal methods identified to complete this task included new faculty orientation, self-study, faculty retreats that were completely focused on QSEN, faculty retreats that were partially focused on QSEN, live classroom sessions, Webinars, curriculum meeting topics, and QSEN information available in every syllabus. New faculty orientation was the most common method of educating faculty in the SFBA schools at 69%.

Informal methods of educating faculty were also used. They included discussions at lunch, one-on-one peer discussions, faculty meetings, mentoring with chair of the department, and self-study. Of the SFBA nursing schools, all stated that the informal method used most was discussing QSEN at a faculty meeting.

Of the 14 SFBA schools that responded to the survey, 46% responded that all of their nursing faculty had received QSEN education. In addition, 85% of the nursing schools reported that at least 75% or more of their faculty received QSEN education. All SFBA nursing schools were at or greater than 45% of faculty educated, with the exception of 1 school with only 10% of the faculty being educated about QSEN.

The next question dealt with the last 2 years, 2014 to 2016. The question asked whether the percentage of faculty educated in QSEN remained the same in the last 2 years? Faculty education remained the same for 62% of the schools. Fifteen percent noted that education about QSEN had increased, which was attributed to its inclusion in the nursing school’s new faculty orientation sessions. A decrease in education of faculty occurred in 23% of the schools. Reasons cited were loss of faculty due to retirement or change of status to part-time and the increase of adjunct faculty.

The next question asked what barriers were encountered in educating faculty in the QSEN competencies. The 2 main barriers to QSEN education were lack of interest among faculty and low attendance at meetings. Small faculty turnout at meetings was a concern and believed to be due to a small number of full-time faculty, only full-time faculty being required to attend meetings, limited interest and attendance among adjunct faculty, and inadequate time. Two of the schools did not experience any barriers to learning about QSEN.

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QSEN Assessment: Courses

The total number of didactic/theory courses offered in the prelicensure programs varied from 3 to 14. Most of the faculty (92%) identified that all of their didactic/theory courses included QSEN content in a variety of forms; no school identified less than 80%. Schools reported that the percentage of QSEN content remained the same at 83% or increased its inclusion by 17%, in these last 2 years. One school adopted QSEN as its theoretical framework for the nursing program, which led to an increase in QSEN content in courses. No school decreased QSEN content in didactic/theory courses for the last 2 years.

The total number of clinical courses offered ranged from 5 to 14. All schools included QSEN in their clinical course content; 75% of the faculty participants reported that all of their clinical courses include QSEN content. No school noted a decrease for the last 2 years. The amount of QSEN content remained the same in 92% of the schools, and in the other 8% of the schools, QSEN content increased because their curriculum framework included QSEN competencies.

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QSEN Assessment: Competencies and Students

One section of the survey asked the SFBA faculty whether the 6 QSEN competencies were covered equally in their nursing program and, if not equal, to rank them in order of high to low inclusion. Half of the programs reported that the 6 competencies were integrated equally in the curriculum as a whole. The ranking from high to low inclusion was as follows: safety, patient-centered care, teamwork and collaboration, EBP, informatics, and QI. Most faculty (92%) stated that the ranking of competencies had not changed for the last 2 years.

The creators of QSEN included projects or policies as ways that QSEN could be woven throughout the students’ experience.6,7 The next part of the survey addressed specific student projects or policies. The SFBA faculty responded that 73% of the schools had a student error policy. In half of the schools, students completed a QI project in the clinical setting. An evidence-based project or paper was included in all of the nursing programs. Students participated in interprofessional activities in 92% of the programs. Special assignments addressing the concept of patient-centered care were commonly used (92% of the programs). The electronic health record was used by all of the students, either in the clinical setting and/or simulation.

Sixty-seven percent of the faculty reported that the QSEN activities and involvement had increased for the last 2 years, which expanded student awareness and interest in QSEN. No faculty indicated that the activity and involvement had decreased, despite barriers in educating faculty.

The SFBA faculty participants indicated that QSEN competencies were still a priority in their school’s educational plan for prelicensure students. Weaving QSEN throughout the curriculum, planning work for the student that addressed each competency, and having buy-in from faculty were the reasons provided for the positive responses. The SFBA faculty reported that, for the last 2 years, the educational plan for QSEN had remained the same. Faculty were continuing to integrate QSEN into the curriculum and course work and encourage faculty to remain committed to the work. Multiple ways were identified to keep QSEN as a priority (Table 1).

Table 1

Table 1

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SFBA Faculty Conference

After the survey, SFBA faculty from 12 nursing schools attended a follow-up conference at the University of San Francisco. Robust faculty discussions occurred focused on multiple topics including identifying the surprises that occurred with the inclusion of QSEN, challenges posed, desires for their own schools of nursing, “wish list” for faculty as a whole, and discussions about teaching the 6 competencies.

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SFBA Faculty Discovery: Surprises, Challenges, and Desires

Faculty reflected that there had been many surprises with integrating QSEN in their educational plans. Some examples included providing a common language for the nursing program by including the 6 QSEN competencies and the ease at which QSEN topics could be transferred from the classroom to clinical sites (Table 2).

Table 2

Table 2

One question posed was about the challenges identified from weaving QSEN throughout the educational plan. Faculty discussed their most significant challenge, which was lack of time. The time factor was especially noted because of the ongoing need to educate new faculty (Table 2).

Faculty members also discussed what they wished for in their own nursing programs in regard to QSEN. All faculty agreed that QSEN education was an important component of their institution’s educational plan. Keeping QSEN concepts a priority was critical. Desires for their school of nursing included adding a hospital representative on a QSEN advisory committee, achieving better buy-in from faculty, and aligning simulation and clinical practice with QSEN concepts (Table 3). Other desires identified by faculty were obtaining 5-year funding to continue the QSEN collaboration among the SFBA nursing schools, continuing as a cohesive group, and increasing support from the deans (Table 3).

Table 3

Table 3

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SFBA Faculty Discovery: Practice Examples

The SFBA nursing faculty were asked to share examples of how they translated each competency into a learning activity. They shared their best practices for including and enhancing the QSEN competencies in nursing education.

The competency of safety was defined as decreasing the risk of harm to both patients and providers. This was achieved by improving both systems and individual performance.4 Examples of methods created to intensify safety issues included use of error and near-miss reporting, development of the role of a quality and safety officer, and implementation of a root cause analysis process. One faculty member disclosed using a “good catch” document to reward making safety a priority.

Patient-centered care was defined to include the patient or designee as full partners in coordinating care. This care should be based on the patient’s preference, identified needs, and values.4 The faculty guided the student’s learning about patient-centered care in the clinical setting using varied assignments such as online videos that demonstrate care from the patient’s viewpoint, identifying the 6 competencies as seen in the clinical setting, advocating for a patient, and discussing with patients their desires for care.

Teamwork and collaboration were defined as interprofessional teams working together to increase communication, encouraging mutual respect, and sharing goals to provide safe patient care.4 Many of the SFBA nursing schools worked together to provide an interprofessional approach to their education. Respiratory therapy, physical therapy, and dentistry students were examples of disciplines that were included in interprofessional learning activities with nursing students.

The competency of EBP meant that decisions for the patient would be based on current evidence. This evidence should be combined with the patient and family’s preferences, which enhances quality of care.4 All of the faculty stated that their students completed an EBP paper or project.

Informatics was the competency that focused on technology and communication of information for patient care. This competency helped to improve communication, decrease the potential of errors, and provide support in decision-making.4 The electronic health record was used at all of the SFBA schools in clinical sites and simulation experiences.

Quality improvement was defined as a method of using data to help ensure that care is safe and outcomes are achieved. This method provided a continual process to improve health care delivery.4 The faculty found clinical practice to be the best place to implement QI projects. They indicated that these projects were appropriate for all levels of students. One example was a project in which students reviewed policies and procedures on the clinical unit looking for deviations.

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The SFBA nursing faculty provided a robust and enthusiastic picture of QSEN incorporation at their nursing schools. All of clinical courses included QSEN content, and there was no decrease in the extent of QSEN content in didactic/theory courses. Significant enhancements were incorporated into the nursing curricula to weave QSEN throughout each level of education. Of note, the 6 QSEN competencies were thoughtfully included throughout the curriculum; however, the extent of coverage of competencies was often unequal. Informatics and QI were least represented in the curriculum. This unequal occurrence in the educational plan has remained the same for the years that QSEN has been incorporated into the nursing program.6

Sustaining QSEN competencies and concepts throughout the nursing curriculum was considered achievable and a priority of the SFBA faculty. Suggestions for continued QSEN success included the priority of maintaining and fostering the SFBA faculty group. Working as a collective member of a QSEN-focused group, either as a private faculty group or as an SFBA faculty member, brought nursing faculty together. The faculty were connected with the same goal of educating nursing students to be safe, effective health care providers. Meeting together fostered collegiality, mentorship, and the sharing of ideas and methods. The implications of this work included a unified focus on QSEN by faculty and the deans of the nursing schools. Methods of achievement were tailored by each school, offering different methods to move QSEN forward.

Barriers existed for the SFBA nursing faculty that made it difficult to maintain and expand the QSEN initiative. Time, money, and dean support led the list. Which individual or group was going to lead the work of QSEN at each school was another issue. The SFBA faculty stated clearly that the mission of QSEN was important to them but were concerned that, without major support from the dean, it was difficult to maintain the emphasis on QSEN over time.

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This 2-part evaluation had limitations. Not all SFBA nursing schools were represented in this QSEN evaluation; 18% were not represented in either the survey or faculty conference. San Francisco Bay Area faculty members who participated were enthusiastic about QSEN, which may have led to a positive bias toward QSEN.

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This convening grant generously provided by the Gordon and Betty Moore Foundation supported the evaluation of the state of QSEN in SFBA nursing schools. The survey and faculty conference demonstrated that QSEN was included throughout the SFBA nursing schools’ curricula and educational plans. Although QSEN was embraced, further work needs to continue to enhance education on informatics and QI for nursing students. In addition, faculty development was time-consuming and an ongoing need.

Continued research needs to be a goal of SFBA nursing faculty. The 2-part evaluation described in this article indicated that QSEN was important and continued to increase in nursing programs. Methods, procedures, and assignments should be studied further to expand the QSEN movement.

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1. Institute of Medicine. To Err is Human: Building a safer Health System. Washington, DC: National Academies Press; 1999.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy of Sciences; 2001.
3. Disch J, Barnsteiner J, McGuinn K. Taking a “deep dive” on integrating QSEN content in San Francisco Bay Area schools of nursing. J Prof Nurs. 2013;29(2):75–81.
4. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook. 2007;55(3):122–131.
5. Cronenwett L. A national initiative: quality and safety education for nurses (QSEN). In: Sherwood G, Barnsteiner J, eds. Quality and Safety in Nursing: A Competency Approach to Improving Outcomes. West Sussex, UK: John Wiley & Sons; 2012:49–64.
6. Barnsteiner J, Disch J, Johnson J, McGuinn K, Chappell K, Swartwout E. Diffusing QSEN competencies across schools of nursing: the AACN/RWJF faculty development institutes. J Prof Nurs. 2013;29(2):68–74.
7. Cooper E. From the school of nursing quality and safety officer: nursing students’ use of safety reporting tools and their perception of safety issues in clinical settings. J Prof Nurs. 2013;29(2):109–116.

nursing curriculum; nursing education; patient safety; Quality and Safety Education for Nurses

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