describes the redesign

E d u c a t i o n a l i n n o v a t i o n s

ABSTRACT this article describes the redesign

of the fundamentals of nursing course using an organizing framework and teaching strategies identified in the Quality and safety Education for nurses (QsEn) initiative. six QsEn competencies (patient-centered care, teamwork and collaboration, evidence- based practice, quality improvement, safety, and informatics) are essential for nursing practice. Beginning knowl- edge, skills, and attitudes (Ksas) as- sociated with each competency were identified in a preliminary delphi sur- vey as important to incorporate early in prelicensure nursing curricula. Rede- sign requires a shift in focus from task- training and psychomotor skills devel- opment to incorporation of a systems context, reflecting redefined values and interventions associated with safety, quality, and professional nursing roles.

a course revision, based on the QsEn competencies definitions, selected be- ginning Ksas, exemplar resources, and teaching strategies, is described. the reframing of fundamentals of nursing is essential to prepare new graduates for contemporary practice.

the traditional fundamentals of nursing course, a constant across prelicensure nursing curricula, introduces basic psychomo- tor skills essential for patient care. the organizing framework of fun- damentals of nursing is important because it identifies priority nursing competencies and professional roles. time-honored content and teach- ing approaches focusing on technical skills have lost relevance for contem- porary nursing practice.

this article describes a quality and safety framework for the redesign of the traditional fundamentals of nurs- ing course. Within a quality and safety framework, novices begin to identify with professional nursing roles that reach far beyond tasks, skills, and procedures. they develop beginning awareness of safety and quality in the context of a health care system, nurse sensitive quality indicators, and local and national safety initiatives impact- ing health care delivery. nurses with a strong foundation in patient safety and quality improvement are better able to assimilate into the current complex health care environment.

Time-Honored Approach to Fundamentals of Nursing

Fundamentals of nursing text-

books often provide the organizing framework for the course content and delivery. the most common frame- work, which has endured for decades, is based on performance of skills and procedures, such as maintaining asepsis and administering medica- tion (Harmer & Henderson, 1955).

a second common approach is to organize content around physiologi- cal systems. Perry and Potter (1985) introduced a dual focus, presenting essential skills of nursing practice and care for the patient’s physiologi- cal needs organized around body sys- tems. the iconic Lippincott Manual of Nursing Practice (Mills, 2006) uses biological systems, such as respira- tory, cardiovascular, or neurological, as its organizing framework. con- tinuing the trend, 2009 texts include sections explicitly devoted to either basic nursing skills and therapeutics or physiological systems (craven & Hirnle, 2009; deWit, 2009).

a third common organizing frame- work uses the developmental life stages to introduce associated skills and procedures. although clear or- ganization of content around nursing skills, physiological systems or a de- velopmental context may be logical, a reductionistic perspective of the patient and the nurse’s role is an in- adequate approach for preparing new graduates for current complex sys- tems of care.

Quality and Safety Framework for Revision

the context for reformulating fundamentals of nursing is based on the authors’ work with the Qual-

The New Fundamentals in Nursing: Introducing Beginning Quality and Safety Education for Nurses’ Competencies Gayle J. Preheim, EdD, RN; Gail E. Armstrong, ND, RN; and Amy J. Barton, PhD, RN

Received: March 30, 2009 Accepted: September 23, 2009 Dr. Preheim is Associate Professor and

Director of the Baccalaureate Nursing Pro- gram, Dr. Armstrong is Assistant Professor and Medical-Surgical Coordinator, and Dr. Barton is Associate Professor and Associ- ate Dean for Clinical and Community Affairs, University of Colorado Denver, College of Nursing, Aurora, Colorado.

The authors have no financial or pro- prietary interest in the materials presented herein.

Address correspondence to Gayle J. Preheim, EdD, RN, University of Colorado Denver, College of Nursing, C288-12, Edu- cation 2 North, Room 3240, 13120 East 19th Avenue, Aurora, CO 80045; e-mail: Gayle. Preheim@UCDenver.edu.

doi:10.3928/01484834-20091113-10

694 Journal of Nursing Education

ity and safety Education for nurses (QsEn) initiative. the overall goal of the QsEn initiative, which has been funded since 2005 by the Robert Wood Johnson Foundation, is:

to meet the challenge of prepar- ing future nurses who will have the knowledge, skills and attitudes (Ksas) necessary to continuously improve the quality and safety of the healthcare systems within which they work. (QsEn, 2009, ¶ 1) six competencies (patient-centered

care, teamwork and collaboration, evidence-based practice, quality im- provement, safety, and informatics) were adapted from national initiatives (Greiner & Knebel, 2003) and defined to promote quality and safety within the current complex health care sys- tem. in Phase i of the QsEn initia- tive, leaders developed the Ksas to clarify and provide operational defini- tions for each competency. Feedback was sought to build consensus for in- clusion in prelicensure curricula. in Phase ii, a pilot learning collabora- tive of 15 schools of nursing was es- tablished to develop and test teaching strategies (cronenwett et al., 2007).

using the QsEn Ksas to redesign fundamentals of nursing was a logical starting point to build on the work in Phase ii. during our implementation process, we were overwhelmed with the complexity of incorporating 162 Ksas and sought to “level” them with a developmental approach. after re- porting our work to the collaborative and with the support of QsEn core faculty and fellow pilot schools, we conducted a national delphi survey to gain consensus on the development progression of the Ksas. the study protocol was designated as exempt from full board review and approved by the university’s institutional re- view board.

Between october 2008 and Febru- ary 2009, three rounds of the survey occurred. core faculty and pilot school directors were asked to consider each Ksa in light of where it should be in- troduced and where it should be em- phasized in the nursing curriculum. as a result, each participant defined sequential points in the curriculum as beginning, intermediate, and ad-

vanced, and then recommended the level at which to introduce or empha- size the Ksas (Barton, armstrong, Preheim, Gelmon, & andrus, 2009).

important insights about com- petency development were gained by the delphi survey findings. Patient-centered care and safety are traditional concepts of fundamentals of nursing and continue to be strongly represented in the Ksas, rated impor- tant to introduce early. Perhaps one of the more important and surprising findings is that within each of the six competencies, associated Ksas (with the exception of skill elements in qual- ity improvement) were rated to be in- troduced early in nursing curricula.

of interest is the finding that in- troduction of beginning attitudes for all competencies is encouraged. team- work and collaboration, informatics, and quality improvement traditional- ly are introduced late in the program of study. students often question the relevance of systems-focused concepts and perceive them to be peripheral to direct patient care. a lack of valuing the systems context may contribute to difficulty in meeting expectations of current practice, such as partici- pating in interdisciplinary teams and appreciation for unit-based quality initiatives. Early introduction of at- titudes that represent the values underpinning the nursing profession supports students’ development of a value-based practice.

New Fundamentals for Contemporary Practice

the six QsEn competencies initial- ly may appear to resemble venerable foundations in nursing education and practice. However, the updated defi- nitions reflect current national qual- ity and safety initiatives and reform in health care professions education. a slight adjustment to fundamentals of nursing will not suffice; the needed fundamentals of nursing redesign is radical. significant differences in the long-standing traditional definition and the updated definition of the core competencies are evident, resulting in implications for nursing education and practice.

in the following section, the tra- ditional explanation for each compe- tency is contrasted with the QsEn updated definition (cronenwett et al., 2007). sample Ksas, rated in the del- phi survey as important to introduce in the beginning curricula, are noted. Exemplars of a redesigned, updated fundamentals of nursing course are provided, using selected readings and recommended teaching strategies. all teaching strategies are available at the QsEn Web site (http://www.qsen. org/view_strategies.php) and are wor- thy of exploration.

Patient-Centered Care the traditional concept involves

listening to the patient and demon- strating respect and compassion. the QsEn competency emphasizes rec- ognition of the patient or designee as the source of control and full partner in providing compassionate and coor- dinated care based on respect for pa- tient’s preferences, values, and needs. the Ksas include:

l K—integrate understanding of multiple dimensions of patient-centered care: patient, family, and community preferences and values; coordination and integration of care; information, communication, and education; physi- cal comfort and emotional support; in- volvement of family and friends; and transition and continuity.

l s—Elicit patient values, preferences, and expressed needs as part of the clinical interview, imple- mentation of care plan, and evalua- tion of care.

l a—value seeing health care situations “through patients’ eyes.”

When teaching patient-centered care in fundamentals of nursing, the concept of the “patient as full partner” is reflected in providing hygiene care, overseeing nutrition, and assisting with elimination for patients. the end point of teaching is not limited to skills associated with bathing, feeding, or Foley in- sertion. Rather, skills are centered in the larger context of the patient’s preferences and values. Physical comfort and emotional support are one knowledge aspect of the larger competency.

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an example of relevant reading that can provide the contemporary context for patient-centered care is the report by the Picker institute and the commonwealth Fund (2007), “Patient-centered care: What does it take?” the QsEn’s patient-cen- tered care competence acknowledges that self-awareness of the nurse’s own values and beliefs is an important at- titudinal aspect of patient-centered care. a teaching strategy, “teaching Reflective Practice through the use of Reflection Papers,” addresses the development of reflective practice through a facilitated process that links classroom discussions and clini- cal experiences.

Teamwork and Collaboration the traditional view of teamwork

may involve working side by side with other health care professionals while performing nursing skills. the updat- ed QsEn definition calls for function- ing effectively within nursing and in- terprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care. important be- ginning Ksas include:

l K—describe scope of prac- tice and roles of health care team members.

l s—Follow communication practices that minimize risk associ- ated with handoff among providers and across transition in care.

l a—acknowledge own poten- tial to contribute to effective team functioning.

students begin to value the nurse’s role in planning care and impact on patient outcomes when the nursing scope of practice is learned within the context of interprofessional teams. nurse are often at the center of com- munication for the health care team and frequently facilitate important patient care transitions. communi- cation of patients’ changing status is vital to successful use of rapid response teams. teamwork and col- laboration are essential in managing complex patients’ plans of care. For example, pain management and end- of-life care best occur in the context of teams. “teamwork as a tool for Pa-

tient safety” (cRico/RMF, 2009) and embedded case studies focus on tech- niques for effective communication by improving collaboration through briefings and promoting appropriate assertiveness within teams

Evidence-Based Practice traditional practices involve ad-

hering to internal policies to stan- dardize skills execution. the QsEn definition specifies the integration of best current evidence with clini- cal expertise and patient and family preferences and values for delivery of optimal health care. important, begin- ning Ksas reveal significant changes in fundamentals of nursing:

l K—describe evidence-based practice to include components of re- search evidence, clinical expertise, and patient and family values.

l s—Base individualized care plan on patient values, clinical exper- tise, and evidence.

l a—value the concept of evidence-based practice as integral to determining best clinical practice.

traditional fundamentals of nurs- ing skills can be taught in the context of evidence-based practice. Recent nursing research highlights emerg- ing best clinical practices related to fluid balance, peripheral intravenous insertion and maintenance, urinary catheter insertion, and nasogastric tube insertion. “Evidence-Based Prac- tice course application strategy” is a developmentally appropriate teach- ing strategy, introducing levels of evidence in research studies used for classroom case study discussions.

Quality Improvement a long-standing approach to qual-

ity involves routinely updating nurs- ing policies and procedures. the QsEn updated concept of quality im- provement recommends use of data to monitor the outcomes of care process- es and use of improvement methods to design and test changes to continu- ously improve the quality and safety of health care systems. the Ksas recommended for early introduction include:

l K—Recognition that nursing and other health professions students

are parts of systems of care and care processes that affect outcomes for pa- tients and families.

l s—the delphi ratings did not identify a beginning skill in qual- ity improvement but rather recom- mended introduction and emphasis in intermediate or advanced experi- ences.

l a—appreciate continuous quality improvement as essential in the daily work of all health care pro- fessionals.

Formal systems-focused quality improvement processes that engage a health care team, such as adverse events reporting, should be intro- duced early. Root cause analyses and resulting system changes are rel- evant in fundamentals of nursing. an example of a helpful article about a team approach to quality improve- ment is “a lifesaving checklist” (Ga- wande, 2007). an additional teaching strategy, “Quality improvement Ex- ercise for seniors,” introduces the im- portance of the quality improvement process.

Safety a simplistic, traditional definition

of safety is to use bed rails properly to ensure “that my patient does not fall during my shift.” the QsEn up- date assures recognition of a culture of safety and minimization of risk of harm to patients through both system effectiveness and individual perfor- mance. safety Ksas rated as impor- tant to introduce early include:

l K—Examine human factors and other basic safety design princi- ples as well as commonly used unsafe practices (e.g., workarounds, danger- ous abbreviations).

l s—demonstrate effective use of strategies to reduce risk of harm to self or others.

l a—value the contributions of standardization and reliability to safety.

Rather than focusing blame on in- dividuals for safety issues, QsEn’s definition of safety emphasizes health care team strategies to promote safe care. For example, asepsis is a compo- nent of fundamentals of nursing with multiple associated skills. to address

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this, teaching hand hygiene and ster- ile technique in the context of nation- al safety goals, such as national Pa- tient safety Goals (Joint commission, 2008), 5 Million lives campaign (in- stitute for Healthcare improvement, 2006), and safe Practices for Better Healthcare (national Quality Forum, 2009) help create a meaningful safety context for aspects of nursing practice. among the safety teaching strategies, the “Environmental safety learning activity” is congruent with a growing sense of the broader context of safety in health care. the commonwealth Fund (2006) presents 10 case studies of health care organizations, clinical teams, and learning collaborations that have designed innovations in 5 areas for improving patient safety.

Informatics traditionally, documentation con-

sists of timely and accurate charting. However, the QsEn updated defini- tion is expanded and calls for using information and technology to com- municate, manage knowledge, miti- gate error, and support decision mak- ing. the Ksas identified as important for early introduction include:

l K—Explain why information and technology skills are essential for safe patient care.

l s—apply technology and in- formation management tools to sup- port safe processes of care.

l a—value technologies sup- porting decision making, error pre- vention, and care coordination.

documentation is a vastly expand- ing skill in health care, as all mem- bers of a health care team contribute to an electronic health record, which is used extensively to determine shifting patient care priorities. the broader context of informatics em- phasizes documenting care provided and is useful in teaching about deci- sion management. Relevant read- ing includes “Ending the document Game” (commission on systemic in-

teroperability, 2005), in which nurses and other health care providers relate the importance of information tech- nology in providing timely, safe pa- tient care. another teaching strategy, “data Mining: directed data collec- tion Exercise,” focuses on navigating an electronic health record to “mine” relevant data.

Conclusion Participation in the QsEn learn-

ing collaborative provided the unique opportunity to build a model of clini- cal nursing education redesign by starting at the beginning of the cur- riculum with a single fundamentals of nursing course. the QsEn com- petencies provide a framework, and the delphi survey results support an introduction and emphasis of begin- ning Ksas. the QsEn framework provides a useful organizing scheme, competency definitions, and relevant associations between basic nursing care and contemporary quality and safety national initiatives. although the traditional focus in fundamentals of nursing has been on psychomotor skills, the early introduction of nurs- ing competencies and roles in a sys- tems context of quality and safety is recommended to prepare graduates for contemporary practice.

References Barton, a., armstrong, G., Preheim, G.,

Gelmon, s., & andrus, l. (in press). a national delphi to determine devel- opmental progression of quality and safety. Nursing Outlook.

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Gawande, a. (2007, december 30). a life- saving checklist. The New York Times. Retrieved august 18, 2009, from http:// www.nytimes.com/2007/12/30/opinion/ 30gawande.html?_r=2&oref=slogin

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