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Departments: QSEN & Nursing Education

Care Bundles, QSEN, and Student Learning

Altmiller, Gerry EdD, APRN, ACNS-BC, FAAN

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doi: 10.1097/NNE.0000000000000617

The Quality and Safety Education for Nurses (QSEN) competencies mirror the Institute of Medicine competencies, established in 2003.1 While many view QSEN as an initiative of prelicensure or graduate nursing education, the QSEN competencies are actually concepts applicable to all nurses whether a seasoned professional or beginning student. The knowledge, skills, and attitude (KSA) elements clarify interpretations of how each competency is met. Students and nurses meet the competencies with varying degrees of expertise as they progress in their professional development. Just as one's understanding of cultural competence continually evolves,2 the same could be said of quality and safety competencies—there is always room for growth and evolution of their application to patient care. The value is the clear and focused framework the QSEN competencies provide for quality and safety education that begins during prelicensure education and continues with the lifelong learning mandated by the nursing profession.

Nurse educators support the successful transition of students from the academic setting to the work environment by aligning quality and safety requisites in coursework with quality and safety initiatives in practice. One priority for educators should be the implementation of care bundles as a measure to protect patients from hospital-acquired injury or infection. Care bundles have been around for more than a decade, but there is little evidence in the literature that they are included in prelicensure nursing education. The concept was developed by multidisciplinary teams from the Institute for Healthcare Improvement (IHI) in 2001 as a quality improvement initiative.3 Basically, a care bundle is a set of 3 to 5 evidence-based practices that when performed together have been proven to improve patient outcomes.3 Examples include bundles for prevention of central line–associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), methicillin-resistant Staphylococcus aureus (MRSA), ventilator-associated pneumonia (VAP), surgical site infection (SSI), and pressure injuries (see Table, Supplemental Digital Content,

Care bundles are driven by medical science focused on what to do and improvement science focused on how care is delivered.4 Bundles tie together best practices to be performed uniformly and consistently to decrease variation in care. Each element of the bundle is a known practice supported by level 1 evidence, randomized controlled trials. When put into practice alone, each has been shown to improve care, but when combined with other best practices into simple steps in an orderly process and performed consistently, bundles result in better outcomes for patients.5 The key is that all steps must be performed every single time; if even a single step in the process is missed, the protection the bundle offers decreases dramatically. Bundles are different from checklists in that checklists can be composed of many elements, some of which may not be evidence based, but every element of a bundle is evidence based. Ultimately, the purpose of bundles is not only to bring the best evidence into practice but also to redesign work to improve habits and processes, making them more reliable through clearly organized steps for all individuals to follow.

Teaching care bundles to students offers opportunities to align nursing education with practice and dovetails well with the KSAs of the 6 QSEN competencies. Care bundle implementation can emphasize quality and safety in that bundles provide safety for patients, are composed of evidence-based interventions, have been shown to improve the quality of care, are focused on the patient, and frequently rely on teamwork and collaboration to be applied uniformly and consistently. In addition, bundle implementation creates opportunities for discussions about the complexity of care, characteristics of high-reliability systems, and the strong role for nurses as change agents.

Care bundle education can span the curriculum beginning in the first nursing course where students gain an overview of important ideas that will be developed with greater detail in later courses. One strategy to facilitate student understanding of care bundles while supporting QSEN competency development in an introductory nursing course is to engage students to learn about bundles working as a team in a group activity. Teams can be created by randomly assigning students to groups of 4 to 5 on the first day of class, after which all group activities for the remainder of the semester are done within that assigned group, creating a sense of relationship and accountability that aligns with teamwork.

To provide an overview of common bundles used in practice and allow students to begin to appreciate the interdependence of evidence-based practice and implementation science, each team is assigned to investigate a specific bundle to learn the associated interventions and processes. Using their phones or laptops, students are instructed to connect to resources for infection prevention care bundles (CLABSI, CAUTI, VAP, SSI, and MRSA; and the pressure injury prevention bundle ( on the IHI website. Access to these informative resources requires registration at the website, which is free for educators and students. Students are instructed to work in their group for 25 minutes to learn their bundle and, using poster board and markers, create an educational poster to teach their peers about their assigned bundle. Each team then has 5 minutes to present their poster board to the class, explaining the purpose of their assigned bundle and highlighting the associated interventions. Following the presentations, each poster is hung in the classroom as a reference for the remainder of the semester.

Students are creative with this learning activity, using catchy slogans to teach the bundles to peers such as ZAP VAP! Although no grade is assigned, there is clear competition to develop a creative poster and noticeable pride as students share their work. This learning activity sets the groundwork for understanding the elements and purpose of care bundles, which will be key to facilitating their application later to patient populations. Students are not tested on the specific interventions associated with bundles in this introductory course, but they are tested on the general principles of care bundles, that each element is evidence based, and that skipping a single element of the bundle dramatically decreases protection for the patient. Benefits of this teaching strategy include having students actively engaged while learning from each other. An unintended benefit of sorting students into groups early in the semester and implementing regular in-class group activities such as this is increased relationship building and accountability to each other. The result has been greater teamwork and significantly fewer student complaints about members not participating in group presentations and projects assigned throughout the semester.

This purposeful activity, designed to introduce students to the care bundles, facilitates learners in developing KSAs needed to meet the QSEN competencies and translate that learning into actions. The process can be easily adapted as a reinforcing activity for students in leadership courses, for RN-to-BSN students, or for nurse residency programs. The wide reach of care bundles and the many skills that underpin the development, implementation, and measurement of the clearly defined steps associated with them support development of competency in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and use of informatics, helping students to recognize the significant role they will assume as nurses in improving the quality and safety of health care.


1. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; 2003.
2. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J Transcult Nurs. 2002;13(3):181-184.
3. Haraden C. What Is a Bundle? Institute for Healthcare Improvement; 2006. Available at: Accessed June 7, 2018.
4. Marwick C, Davey P. Care bundles: the holy grail of infectious risk management in hospitals? Curr Opin Infect Dis. 2009;22(4):364-369.
5. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2012: Available at: Accessed June 21, 2018.

Supplemental Digital Content

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