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3 A National Initiative: Quality and Safety Education for Nurses

       Linda R. Cronenwett, PhD, RN, FAAN, and Jane Barnsteiner, PhD, RN, FAAN

      As I was writing this chapter, a colleague sent an email saying, “I’ve been doing grant reviews for HRSA [US Health Resources and Services Administration], and half or more of the applications cite QSEN [Quality and Safety Education for Nurses] competencies or QSEN work as part of their justification.” Two textbook authors inquired about permission to reprint QSEN materials. A visiting scholar from Sweden reported that QSEN is being used as the framework for action for nursing in Sweden this year. Medical colleagues set up a conference call to talk about what they could learn from QSEN to apply to a national initiative on interprofessional education. The number of forum paper and poster presentations doubled from 2010 to 2011.

QSEN is an initiative that has been funded since 2005 by the Robert Wood Johnson Foundation (RWJF). The purpose of this chapter is to posit answers to the questions often asked of those of us who have been involved in leading QSEN: namely, how did QSEN come to be and what do you think accounts for the extent of its spread and impact? A summary of aims and activities for the first three QSEN grants is provided in Figures 3.1 and 3.2 . Further information about QSEN outcomes is reported elsewhere, for example for QSEN Phase I (Cronenwett et al., 2007 ; Smith, Cronenwett, and Sherwood, 2007), Phase II (Cronenwett, Sherwood, and Gelmon, 2009a; Cronenwett et al., 2009b ), and initial activities of Phase III (Sherwood, 2011 ). What follows in this chapter is the history of the QSEN story, a story that is not yet over. Future historians will evaluate QSEN’s outcomes using data that will emerge during the decade to come.

      The title Quality and Safety Education for Nurses emerged one summer afternoon in 2005 when I spent many hours on my screened porch generating an endless list of ideas for what to call a grant proposal that was due to the RWJF offices within the month. But of course, QSEN began long before that day.

QSEN Origins: 2000–2005

Any initiative of the magnitude of QSEN depends on two groups of leaders: thought leaders in the field and thought leaders within a funding organization. Within the professional community, the seeds for what became QSEN were sown in a series of annual summer week‐long conferences initiated and led by Paul Batalden, a pediatrician and one of the earliest health care quality thought leaders (Kenny, 2008). Started in 1995, these Dartmouth Summer Symposia (DSS) were invitational meetings for 60–70 participants, about 12–20 of whom in any given year were nurses. The nurse, physician, and hospital administrator educators who attended DSS described themselves as “an interprofessional community of educators devoted to building knowledge for leading improvement in health care.” Linda Norman, Associate Dean at Vanderbilt, was the first nursing leader who worked with Dr. Batalden to attract nursing deans and faculty members to this work.

Figure 3.1 QSEN Phases I and II: Aims and Actions. IOM, Institute of Medicine.

      I had worked with Dr. Batalden during my years at Dartmouth‐Hitchcock Medical Center (1984–1998), participated in Quality Improvement Camp training, attended one summer symposium, and worked on a number of quality improvement projects. After I became a faculty member at the University of North Carolina (UNC) at Chapel Hill in 1998, I was invited to DSS regularly and subsequently served as the second representative of nursing in the leadership of the DSS community.

From 1997 to 2002, the DSS topics involved work underway within the physician community to alter educational objectives, curricula, and residency training accreditation and certification standards to include requirements for competency development related to the continuous improvement of health care. Leaders of the professional organizations responsible for these initiatives participated with us as we created and advanced ideas about content and learning opportunities that would, as was the stated DSS goal, “change the world.” Many subsequently participated in the Institute of Medicine (IOM) conference that resulted in the 2003 IOM publication Health Professions Education: A Bridge to Quality, wherein the charge was issued that all health professionals should be educated to deliver patient‐centered care as members of an interdisciplinary team, emphasizing evidence‐based practice, quality improvement approaches, and informatics. It was fascinating and exciting work.

Figure 3.2 QSEN Phase III: Embedding New Competencies. AACN, American Association of Colleges of Nursing; UNC, University of North Carolina‐Chapel Hill; VAQS, Veterans Administration Quality Scholars Program.

Each summer, Dr. Batalden would ask who was going to lead this work for nursing. We nurses would plot strategies for finding funding to advance this agenda and agreed that if anyone could secure funding, the rest of us would help. Each took away an assignment, and, for a couple of years, we came back empty‐handed. I presented proposal ideas to RWJF and one other foundation without results. Yet we persisted.

      During this same period, seeds were being sown for QSEN on the RWJF leadership side as well. When I first unsuccessfully proposed the idea for a nursing faculty development initiative in quality and safety education to RWJF’s nursing leader, Susan Hassmiller, she was involved in directing the RWJF initiative Transforming Care at the Bedside (TCAB). She had recognized the importance of linking nursing faculty to the TCAB initiative and its quality/safety/cost goals. Beginning in 2002, first I and then Patricia Chiverton, dean of the University of Rochester School of Nursing, initiated attempts to work with the faculty in schools affiliated with the hospitals involved in the initiative. Few successes were achieved, however, primarily because nursing faculty were generally disconnected from the patient safety/quality improvement methods and goals being adopted by hospitals at the time. As Dr. Hassmiller pressed hospital leaders to engage nursing faculty in their projects, she experienced the faculty knowledge gap at first hand, and this evidence of the need for faculty development would eventually provide the strong rationale Dr. Hassmiller used to convince RWJF executive leaders to fund QSEN.

      In another development, Rosemary Gibson, a senior program officer for RWJF and co‐author of the book Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans (Gibson and Singh, 2003), joined the DSS community in 2003 as a participant who could

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