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Quality and safety education for advanced

nursing practice
Linda Cronenwett, PhD, RN, FAAN
Gwen Sherwood, PhD, RN, FAAN
Joanne Pohl, PhD, RN, FAAN
Jane Barnsteiner, PhD, RN, FAAN
Shirley Moore, PhD, RN, FAAN
Dori Taylor Sullivan, PhD, RN, NE-BC, CNL, CPHQ
Deborah Ward, PhD, RN, FAAN
Judith Warren, PhD, RN, BC, FAAN, FACMI

The Quality and Safety Education for Nurses (QSEN) aculties of medicine, nursing, and other health pro-
project is a national initiative to transform nursing edu- fessions were challenged by the 2003 Institute of
cation to integrate quality and safety competencies. Medicine (IOM) Health Professions Education re-
This article describes a two-year process to generate port1 to mindfully alter learning experiences that form
educational objectives related to quality and safety the basis for professional identity formation so that grad-
competency development in graduate programs that
uates would be educated to deliver patient-centered care
prepare advanced practice nurses in clinical roles.
Knowledge, skills, and attitudes for each of 6 compe-
as members of an interdisciplinary team, emphasizing
tencies are proposed to stimulate development of evidence-based practice, quality improvement ap-
teaching strategies in programs preparing the next proaches, and informatics. Simultaneously, the educa-
generation of advanced practice nurses. tional preparation for entry into advanced practice was
a prominent debate.2–4 One result was the proposal
from the American Association of Colleges of Nursing
(AACN) for a new doctorate of nursing practice
Linda Cronenwett, PhD, RN, FAAN, is Professor, School of Nursing,
(DNP) degree, with an emphasis on programmatic con-
University of North Carolina at Chapel Hill, Chapel Hill, NC. tent related to evidence-based practice, quality improve-
Gwen Sherwood, PhD, RN, FAAN, is Professor and Associate Dean for ment, and systems thinking,5 content relevant to the
Academic Affairs, School of Nursing, University of North Carolina at quality and safety goals outlined by the IOM.1
Chapel Hill, Chapel Hill, NC. During this same period, the first phase of Quality and
Joanne Pohl, PhD, RN, FAAN, is Professor, School of Nursing, University
of Michigan, Ann Arbor, MI.
Safety Education for Nurses (QSEN) was funded by the
Jane Barnsteiner, PhD, RN, FAAN, is Professor of Pediatric Nursing, Robert Wood Johnson Foundation (RWJF) (PI: L. Cro-
School of Nursing, University of Pennysylvania, Philadelphia, PA. nenwett) to address the challenge of preparing nurses
Shirley Moore, PhD, RN, FAAN, is Professor and Associate Dean for with the competencies necessary to continuously improve
Research, Frances Payne Bolton School of Nursing, Case Western the quality and safety of the healthcare systems in which
Reserve University, Cleveland, OH.
Dori Taylor Sullivan, PhD, RN, NE-BC, CNL, CPHQ, is Associate
they work. In keeping with the recommendations from
Dean for Academic Affairs and Clinical Professor, Duke University the Health Professions Education report,1 QSEN leaders
School of Nursing, Durham, NC. proposed definitions for 6 competencies that describe
Deborah Ward, PhD, RN, FAAN, is Associate Clinical Professor, Betty essential features of what it means to be a competent
Irene Moore School of Nursing (proposed), University of California at Da- and respected nurse. To clarify educational objectives,
vis, Davis, CA.
Judith Warren, PhD, RN, BC, FAAN, FACMI, is Christine A. Hartley
they also proposed statements of the knowledge, skills,
Centennial Professor, University of Kansas School of Nursing and Direc- and attitudes (KSAs) for each competency that should
tor of Nursing Informatics at the KU Center for Healthcare Informatics, be developed during prelicensure nursing education.6
Kansas City, KS. As the panel worked to identify the knowledge, skills,
Corresponding author: Dr. Linda Cronenwett, Professor, School of Nurs- and attitudes for prelicensure nurses, questions emerged
ing, University of North Carolina at Chapel Hill, Carrington Hall, CB
#7460, Chapel Hill, NC 27599-7460.
about the relevance for graduate nursing education. An
E-mail: lcronenwett@unc.edu expert educator joined the QSEN Advisory Board as a rep-
resentative of the National Organization of Nurse Practi-
Nurs Outlook 2009;57:338-348. tioner Faculties (NONPF).7 The QSEN faculty and
0029-6554/09/$–see front matter
Copyright ª 2009 Mosby, Inc. All rights reserved.
advisory board members determined that the following
doi:10.1016/j.outlook.2009.07.009 questions needed to be answered to fully address the

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Table 1. *,**Patient-centered Care. Definition: Recognize the Patient or

Designee as the Source of Control and Full Partner in Providing
Compassionate and Coordinated Care Based on Respect for Patient’s
Preferences, Values, and Needs
Knowledge Skills Attitudes

Analyze multiple dimensions of pa- Elicit patient values, preferences, Value seeing health care situations
tient-centered care: and expressed needs as part of through patients’ eyes
 patient/family/community prefer- clinical interview, diagnosis, im- Respect and encourage individual
ences, values plementation of care plan and expression of patient values, pref-
 coordination and integration of evaluation of care erences, and expressed needs
care Communicate patient values, pref- Value the patient’s expertise with
 information, communication, and erences and expressed needs to own health and symptoms
education other members of health care Honor learning opportunities with
 physical comfort and emotional team patients who represent all aspects
support Provide patient-centered care with of human diversity
 involvement of family and friends sensitivity, empathy, and respect Seek to understand one’s person-
 transition and continuity for the diversity of human experi- ally held attitudes about working
Analyze how diverse cultural, ethnic, ence with patients from different ethnic,
spiritual, and social backgrounds Ensure that the systems within cultural, and social backgrounds
function as sources of patient, which one practices support Willingly support patient-centered
family, and community values patient-centered care for indi- care for individuals and groups
Analyze social, political, eco- viduals and groups whose whose values differ from own
nomic, and historical dimen- values differ from the majority or Value cultural humility
sions of patient care processes one’s own.
and the implications for patient-
centered care
Integrate knowledge of Assess and treat pain and suffering Seek to understand one’s
psychological, spiritual, social, in light of patient values, personally held values and
developmental, and preferences, and expressed beliefs about the management
physiological models of pain needs of pain or suffering
and suffering
Analyze ethical and legal Respect the boundaries of Value shared decision-making with
implications of patient-centered therapeutic relationships empowered patients and
care families, even when conflicts
Describe the limits and boundaries Acknowledge the tension that may
of therapeutic patient-centered exist between patient
care preferences and organizational
and professional responsibilities
for ethical care
Facilitate informed patient consent
for care
Analyze strategies that empower Engage patients or designated Respect patient preferences for
patients or families in all aspects of surrogates in active partnerships degree of active engagement in
the health care process along the health illness care process
Analyze features of physical Create or change organizational Honor active partnerships with
facilities that support or pose cultures so that patient and patients or designated surrogates
barriers to patient-centered family preferences are assessed in planning, implementation, and
care and supported evaluation of care
Analyze reasons for common Assess level of patient’s decisional Respect patient’s right to access to
barriers to active involvement of conflict and provide access to personal health records
patients and families in their own resources
health care processes
Eliminate barriers to presence of Value system changes that
families and other designated support patient-centered care
surrogates based on patient

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Quality and safety education for advanced practice Cronenwett et al

Table 1. Continued
Knowledge Skills Attitudes
Integrate principles of effective Continuously analyze and improve Value continuous improvement
communication with own level of communication skill in of own communication and
knowledge of quality and encounters with patients, families, conflict resolution skills
safety competencies and teams
Analyze principles of consensus Provide leadership in building Value consensus
building and conflict resolution consensus or resolving conflict in
the context of patient care
Analyze advanced practice Communicate care provided and
nursing roles in assuring needed at each transition in care
coordination, integration,
and continuity of care
Describe process of reflective Incorporate reflective practices Value the process of reflective
practice into own repertoire practice

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

IOM call for education reform to improve quality and sure KSAs and supported the assessment that they were
safety: appropriate for prelicensure graduates.6
As the first phase of QSEN ended, the competency
 Are the QSEN competency definitions relevant to
definitions were considered relevant to all nurses, but
advanced practice nurses?
it was not clear how the KSAs, which had been devel-
 Which of the prelicensure KSAs are also relevant
oped with prelicensure education as the focus, would
objectives for advanced practice nursing (APN)
need to be adapted to be useful for master’s or doctoral
program faculties who were preparing advanced prac-
 What new KSAs, if any, should be added at the grad-
tice nurses.
uate level?
 Will KSAs vary by APN specialty and role or can one
set of KSAs encompass all APNs?
The purpose of this article is to describe the work of ATTITUDES
QSEN in addressing these questions and to present The second phase of QSEN was funded by the RWJF
KSAs that can guide the development of teaching strat- (PI: L Cronenwett) from April 2007 to November
egies for quality and safety competency development in 2008. Because QSEN faculty and advisory board mem-
programs that prepare nurses for advanced practice in bers believed that KSAs for APNs in direct care would
clinical roles. differ from KSAs for nurses in other advanced roles
(eg, administration, informatics, community or public
health, education), groups invited to participate in
COMPETENCY DEFINITIONS Phase II work represented APNs who practiced in di-
The development of prelicensure quality and safety com- rect patient care roles (nurse practitioners, clinical
petency definitions for patient-centered care, teamwork nurse specialists, nurse-anesthetists, and nurse-mid-
and collaboration, evidence-based practice, quality im- wives) through work on standards of practice, accredi-
provement, safety, and informatics was described in the tation of education programs, or certification. QSEN
May-June 2007 issue of Nursing Outlook.6 These com- funded one organizational representative, but organiza-
petency definitions appear again in Tables 1–6 here. tions were invited to bring a second representative at
As part of the process of developing the competency their own expense. The context of the meeting was
definitions, QSEN leaders sought feedback from organi- described as follows:
zations that represented nurse practitioner (NP) and
clinical nurse specialist faculties and accrediting bodies We have no preconceived notions about the final
for nurse anesthesia and nurse-midwifery programs. outcomes of our work together, but we want to ex-
Representatives agreed that the 6 competency defini- plore, with your help, the territory of graduate ed-
tions were appropriate for advanced practice nurses. ucation in the specialties that prepare advanced
They also submitted helpful comments on the prelicen- practice nurses for direct care. Are there common

340 V O L U M E 5 7  N U M B E R 6 N U R S I N G O U T L O O K
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Table 2. *,**Teamwork and Collaboration. Definition: Function Effectively

within Nursing and Interprofessional Teams, Fostering Open
Communication, Mutual Respect, and Shared Decision-making to Achieve
Quality Patient Care
Knowledge Skills Attitudes

Analyze own strengths, Demonstrate awareness of own Acknowledge own contributions

limitations and values as strengths and limitations as to effective or ineffective team
a member of a team a team member functioning
Analyze impact of own Continuously plan for
advanced practice role and improvement in use of self in
its contributions to team effective team development
functioning and functioning
Act with integrity, consistency
and respect for differing views
Describe scopes of practice and Function competently within own Respect the unique attributes
roles of all health care team scope of practice as that members bring to a team,
members a member of the health care including variation in
team professional orientations,
competencies, and
Assume role of team member or
leader based on the situation
Analyze strategies for identifying Guide the team in managing Respect the centrality of the
and managing overlaps in areas of overlap in team patient/family as core
team member roles and member functioning members of any health care
accountabilities Solicit input from other team team
members to improve
individual, as well as team,
Empower contributions of others
who play a role in helping
patients/families achieve
health goals
Analyze strategies that Initiate and sustain effective Appreciate importance of
influence the ability to initiate health care teams interprofessional collaboration
and sustain effective
partnerships with members of
nursing and interprofessional
Analyze impact of cultural Communicate with team Value collaboration with nurses
diversity on team functioning members, adapting own style and other members of the
of communicating to needs of nursing team
the team and situation
Analyze differences in Communicate respect for team Value different styles of
communication style member competence in communication
preferences among patients communication
and families, advanced
practice nurses, and other
members of the health team
Describe impact of own Initiate actions to resolve conflict
communication style on
Describe examples of the impact Follow communication practices Appreciate the risks associated
of team functioning on safety that minimize risks associated with handoffs among providers
and quality of care with handoffs among providers and across transitions in care
and across transitions in care

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Table 2. Continued
Knowledge Skills Attitudes
Analyze authority gradients and Choose communication styles Value the solutions obtained
their influence on teamwork that diminish the risks through systematic,
and patient safety associated with authority interprofessional
gradients among team collaborative efforts
Assert own position/perspective
and supporting evidence in
discussions about patient care
Identify system barriers and Lead or participate in the design Value the influence of system
facilitators of effective team and implementation of solutions in achieving team
functioning systems that support effective functioning
Examine strategies for improving Engage in state and national
systems to support team policy initiatives aimed at
functioning improving teamwork and

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

expectations for quality and safety competency de- imum KSAs for any program that prepares graduates
velopment? Should there be? If so, how would the for APN certification and practice, recognizing that
KSAs for graduate education differ from those higher level skills and greater knowledge in some
we’ve proposed for prelicensure education? competencies might be expected of doctoral-level
In response, the following organizations and numbers
Participants held different views of the extent to
of representatives participated in the April 2007 confer-
which practitioners, faculty, and students already pos-
ence in Lansdowne, Virginia with QSEN faculty and
sessed the KSAs. Most agreed, however, that the current
advisory board members (see Acknowledgments for
quality and safety focus was on educating practitioners
advisory board organizational affiliations):
that could appropriately assess, diagnose, and treat indi-
American College of Nurse Midwives (1) vidual patients. When they brainstormed ideas for
American Nurses Association (2) addressing common system problems related to the
American Nurses Credentialing Center (2) competencies, it was surprisingly easy to express gradu-
American Psychiatric Nurses Association (1) ate level KSAs in language that crossed specialty bound-
American Association of Critical-Care Nurses aries. By the end of the meeting, the group agreed
Certification Corporation (1) unanimously that one document could serve their
Council on Accreditation of Nurse Anesthesia Ed- multiple constituencies.
ucational Programs (COA) (1)
Commission on Collegiate Nursing Education (2)
National Association of Clinical Nurse Specialists
National Organization of Nurse Practitioner Fac-
After the meeting, a draft of proposed graduate KSAs was
ulties (NONPF) (2)
mailed to each conference participant with a request for
Oncology Nursing Certification Corporation (1)
review and feedback. In addition to QSEN advisory board
Pediatric Nursing Certification Board (2)
members, 10 organizational representatives from 7 of the
QSEN faculty (authors Sherwood, Barnsteiner, participating organizations responded to the request.
Moore, Sullivan, Ward, and Warren) presented initial All respondents said that the work they participated in
ideas and trigger questions related to advanced practice at the Lansdowne conference was represented accu-
KSAs for each competency and facilitated small group rately in the draft. There was greater diversity, however,
discussions focused on each of the competencies. Each in response to the question: ‘‘Does the document as
workgroup generated KSAs for graduate education a whole capture your view of what should be expected
without regard to whether the end result was a master’s (in quality and safety competency development) during
or doctoral degree. The goal was to generate the min- graduate education for APN specialties?’’ Nine

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Table 3. *,**Evidence-based Practice.Definition: Integrate Best Current

Evidence with Clinical Expertise and Patient/Family Preferences and Values
for Delivery of Optimal Health Care
Knowledge Skills Attitudes

Demonstrate knowledge of Use health research methods Appreciate strengths and weak-
health research methods and and processes, alone or in nesses of scientific bases for
processes partnership with scientists, to practice
Describe evidence-based prac- generate new knowledge for Value the need for ethical con-
tice to include the compo- practice duct of research and quality
nents of research evidence, Adhere to Institutional Review improvement
clinical expertise, and patient/ Board guidelines Value all components of evi-
family values Role model clinical decision- dence-based practice
making based on evidence,
clinical expertise, and patient/
family preferences and values
Identify efficient and effective Employ efficient and effective Value development of search
search strategies to locate search strategies to answer skills for locating evidence
reliable sources of evidence focused clinical questions for best practice
Identify principles that com- Critically appraise original re- Value knowing the evidence
prise the critical appraisal of search and evidence summa- base for practice specialty
research evidence ries related to area of practice Value public policies that sup-
Summarize current evidence Exhibit contemporary knowl- port evidence-based prac-
regarding major diagnostic edge of best evidence re- tice
and treatment actions within lated to practice specialty
the practice specialty Promote research agenda for
Determine evidence gaps evidence that is needed in
within the practice specialty practice specialty
Initiate changes in approaches
to care when new evidence
warrants evaluation of other
options for improving out-
comes or decreasing ad-
verse events
Analyze how the strength of Develop guidelines for clinical Acknowledge own limitations in
available evidence influ- decision-making regarding knowledge and clinical exper-
ences the provision of care departure from established tise before determining when
(assessment, diagnosis, protocols/standards of care to deviate from evidence-
treatment, and evaluation) Participate in designing sys- based best practices
Evaluate organizational cul- tems that support evidence- Value the need for continuous
tures and structures that pro- based practice improvement in clinical prac-
mote evidence-based tice based on new knowledge

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

respondents provided positive comments about the doc- safety are critical issues, so these competencies are
ument as a whole. Examples of these responses were: timely.’’
 ‘‘Our graduate faculty discussed the document and
 ‘‘The APN KSAs look good. I have just a few
thought it was excellent.’’
 ‘‘There is nothing egregious missing in the area of Representatives of two organizations, COA and
patient safety and quality.’’ NONPF, expressed concerns, with COA contributing
 ‘‘I think they are well written and organized. The ma- a response on behalf of the organization as a whole.
jor areas make sense to me and are consistent with NP Both organizations had a significant number of compe-
education and practice. And, no doubt, quality and tency expectations already and believed that the ‘‘spirit

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Table 4. *,**Quality Improvement. Definition: Use Data to Monitor the

Outcomes of Care Processes and Use Improvement Methods to Design and
Test Changes to Continuously Improve the Quality and Safety of HealthCare
Knowledge Skills Attitudes

Describe strategies for Use a variety of sources of Appreciate that continuous

improving outcomes of information to review quality improvement is an
care in the setting in outcomes of care and essential part of the daily
which one is engaged in identify potential areas work of all health
clinical practice for improvement professionals
Propose appropriate aims
for quality improvement
Analyze the impact of Assert leadership in
context (such as shaping the dialogue
access, cost, or team about and providing
functioning) on leadership for the
improvement efforts introduction of best
Analyze ethical issues Assure ethical oversight of Value the need for ethical
associated with quality quality improvement conduct of quality
improvement projects improvement
Describe features of Maintain confidentiality of
quality improvement any patient information
projects that overlap used to determine
sufficiently with outcomes of quality
research, thereby improvement efforts
requiring Institutional
Review Board oversight
Describe the benefits and Design and use Appreciate the
limitations of quality databases as sources of importance of data that
improvement data information for allows one to estimate
sources, and improving patient care the quality of local care
measurement and data Select and use relevant
analysis strategies benchmarks
Explain common causes Select and use tools (such Appreciate how unwanted
of variation in outcomes as control charts and run variation affects
of care in the practice charts) that are helpful for outcomes of care
specialty understanding variation processes
Identify gaps between local
and best practice
Describe common quality Use findings from root Value measurement and its
measures in the cause analyses to design role in good patient care
practice specialty and implement system
Select and use quality
measures to understand
Analyze the differences Use principles of change Appreciate the value of
between microsystem management to what individuals and
and macrosystem implement and teams can do to improve
change evaluate care care
processes at the
microsystem level

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Table 4. Continued
Knowledge Skills Attitudes
Understand principles of Value local systems
change management improvement (in individual
practice, team practice on
a unit, or in the macrosystem)
and its role in professional
job satisfaction
Analyze the strengths and Design, implement, and evaluate Appreciate that all
limitations of common tests of change in daily work improvement is change, but
quality improvement (using an experiential learning not all change is
methods method such as Plan-Do- improvement
Align the aims, measures, and
changes involved in
improving care
Use measures to evaluate the
effect of change

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

of the QSEN KSAs’’ was embedded in their current lively conversation followed the presentation, with
standards. COA reported that ‘‘we voted to support many speakers emphasizing the need for APNs to
the spirit of the document; however, we cannot support develop the competencies. As a result, the NONPF Board
the implementation, nor support that the document is of Directors decided to undertake a review of their NP
necessary or beneficial at this time.’’ Concerns included Core and DNP competencies to identify areas of overlaps
skepticism that each KSA could be adequately ad- and gaps between the proposed QSEN graduate KSAs
dressed during the graduate program in anesthesia be- and the existing core competencies. A report of their
cause the COA questioned whether competence could work to date appears in this issue of Nursing Outlook.7
be achieved for some of the items, particularly ones
that were broad in scope. Nonetheless, they ‘‘remain
open to continued consideration of the important
work generated by QSEN.’’
Tables 1–6 present the APN KSAs as revised after re-
The views from NP faculty representing the second
ceiving feedback from professional organizational rep-
organization (NONPF) were mixed. A major concern
resentatives. Material that differs from the prelicensure
was whether one could prepare a safe clinician and
KSAs appears in bold, italicized font. For readers who
also attend to the quality and safety KSAs within NP ed-
compare the prelicensure KSAs6 to the APN KSAs, it
ucational programs, particularly MSN programs. The
will be obvious that the basic categories of knowledge,
need to focus on the large body of knowledge and skills
skills, and attitudes are similar. Differences occurred
that enable an individual practitioner to accurately diag-
for the following reasons.
nose and treat an individual patient was considered par-
amount, and it seemed overwhelming to say that  In a few cases, participants in the APN KSA develop-
programs could prepare students to ‘‘lead or participate ment process argued that an item that had been la-
in the design and implementation of systems that sup- beled knowledge was better expressed as an attitude
port effective teamwork’’ or ‘‘design and use databases or skill, resulting in the occasional change in column.
as sources of information for improving patient care.’’  Items have the same stem as the prelicensure KSAs
One person’s summary view was, ‘‘Taken as a whole, I but are introduced by a verb representing a higher-
don’t believe that NP master’s level programs can suc- level objective.
cessfully address all of these KSAs without compromis-  New items under each competency derive from the
ing other critical aspects of graduate education.’’ greater preparation for leadership that is expected at
The NONPF leadership decided to put the issue to its the APN level, regardless of specialty.
members by inviting the QSEN Principal Investigator  Other new items represent the expectations associated
(Cronenwett) to give the keynote speech at its April with mastering a particular specialty and its evidence
2008 33rd Annual Meeting in Louisville, Kentucky. A base, information technologies, and outcome measures.

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Table 5. *,**Safety. Definition: Minimize Risk of Harm to Patients and

Providers through Both System Effectiveness and Individual Performance
Knowledge Skills Attitudes

Describe human factors and Participate as a team member to Value the contributions of stan-
other basic safety design prin- design, promote, and model dardization and reliability to
ciples as well as commonly effective use of technology and safety
used unsafe practices (such as standardized practices that Appreciate the importance of
workarounds and dangerous support safety and quality being a safety mentor and
abbreviations) Participate as a team member to role model
Describe the benefits and limita- design, promote, and model Appreciate the cognitive and
tions of selected safety-en- effective use of strategies to re- physical limits of human
hancing technologies (such as duce risk of harm to self and performance
barcodes, computer provider others.
order entry, and electronic Promote a practice culture con-
prescribing) ducive to highly reliable pro-
Evaluate effective strategies to cesses built on human factors
reduce reliance on memory research
Use appropriate strategies to re-
duce reliance on memory (such
as forcing functions, checklists)
Delineate general categories of Communicate observations or Value own role in reporting and
errors and hazards in care concerns related to hazards and preventing errors
Identify best practices for or- errors to patients, families, and Value systems approaches to
ganizational responses to the healthcare team. improving patient safety in
error Identify and correct system fail- lieu of blaming individuals
Describe factors that create ures and hazards in care Value the use of organizational
a just culture and culture of Design and implement microsys- error reporting systems
safety tem changes in response to
Describe best practices that identified hazards and errors
promote patient and pro- Engage in a systems focus rather
vider safety in the practice than blaming individuals when
specialty errors or near misses occur
Report errors and support mem-
bers of the healthcare team to
be forthcoming about errors
and near misses
Describe processes used to Participate appropriately in Value vigilance and monitoring
analyze causes of error and analyzing errors and designing, of care, including one’s own
allocation of responsibility and implementing, and evaluating performance, by patients,
accountability (such as root system improvements families, and other members of
cause analysis and failure the healthcare team
mode effects analysis)
Describe methods of identifying Prevent escalation of conflict Value prevention of assaults
and preventing verbal, Respond appropriately to and loss of dignity for
physical, and psychological aggressive behavior patients, staff, and
harm to patients and staff aggressors
Analyze potential and actual Use national patient safety Value relationship between
impact of national patient resources: national patient safety
safety resources, initiatives,  for own professional develop- campaigns and
and regulations ment implementation in local
 to focus attention on safety in practices and practice settings
care settings
 to design and implement im-
provements in practice

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

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Table 6. *,**Informatics. Definition: Use Information and Technology to

Communicate, Manage Knowledge, Mitigate Error, and Support Decision
Knowledge Skills Attitudes

Contrast benefits and limita- Participate in the selection, de- Value the use of information
tions of common information sign, implementation, and and communication
technology strategies used in evaluation of information technologies in patient care
the delivery of patient care systems
Evaluate the strengths and Communicate the integral role
weaknesses of information of information technology in
systems used in patient care nurses’ work
Model behaviors that support
implementation and appro-
priate use of electronic
health records
Assist team members in adopt-
ing information technology
by piloting and evaluating
proposed technologies
Formulate essential information Promote access to patient care Appreciate the need for con-
that must be available in information for all profes- sensus and collaboration in
a common database to sup- sionals who provide care to developing systems to man-
port patient care in the prac- patients age information for patient
tice specialty Serve as a resource for how to care
Evaluate benefits and limitations document nursing care at Value the confidentiality and
of different communication basic and advanced levels security of all patient records
technologies and their impact Develop safeguards for pro-
on safety and quality tected health information
Champion communication
technologies that support
clinical decision-making, er-
ror prevention, care coordi-
nation, and protection of
patient privacy
Describe and critique Access and evaluate high- Value the importance of stan-
taxonomic and terminology quality electronic sources of dardized terminologies in
systems used in national health care information conducting searches for pa-
efforts to enhance Participate in the design of tient information
interoperability of clinical decision-making Appreciate the contribution of
information systems and supports and alerts technological alert systems
knowledge management Search, retrieve, and manage Appreciate the time, effort, and
systems data to make decisions using skill required for computers,
information and knowledge databases, and other technol-
management systems ogies to become reliable and
Anticipate unintended conse- effective tools for patient care
quences of new technology

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

The graduate KSAs for the IOM/QSEN competen- ued, although the number and level of some KSAs
cies represent ambitious educational objectives, yet were viewed as problematic for some accrediting
the consensus of APN organizational representatives organizations.
was that development of these KSAs was essential to The process used to generate the APN KSAs did not
advanced practice educational programs of the future. involve employers of APNs or patient perspectives. In
For all groups, the goals set by these KSAs were val- addition, all participants were from American-based

N O V E M B E R / D E C E M B E R N U R S I N G O U T L O O K 347
Quality and safety education for advanced practice Cronenwett et al

institutions and organizations. We have no way of know- and advisory board members for their contributions to the develop-
ing whether these KSAs would be judged relevant or ap- ment of the competency definitions and KSAs: Paul Batalden, MD
(Dartmouth); Geraldine Bednash, PhD, RN, FAAN (American As-
propriate in other countries and cultures. sociation of Colleges of Nursing); Jean Blackwell, MLS (University
Recognizing these limitations, we share the work on of North Carolina-Chapel Hill); Lisa Day, PhD, RN, CNS (Unive-
graduate KSAs to help individual faculty members bet- sity of California-San Francisco Medical Center); Joanne Disch,
ter understand the scope of the issues. Based on our ex- PhD, RN, FAAN (University of Minnesota); Carol Durham,
periences with prelicensure faculty in the QSEN EdD(c), RN, ANEF (UNC-Chapel Hill); Leslie Hall, MD (Univer-
sity of Missouri-Columbia); Jean Johnson, PhD, RN, FAAN
Learning Collaborative,8 we believe that APN faculties (George Washington University); Mary (Polly) Johnson, MSN,
can use these KSAs to generate ideas appropriate to RN, FAAN (North Carolina Board of Nursing); Maryjoan Ladden,
APN education and transform their teaching strategies PhD, RN (Harvard and RWJF); M. Elaine Tagliareni, EdD, RN,
and curricula to achieve important quality and safety FAAN (Community College of Philadelphia and National League
educational goals. for Nursing).

Nurses in advanced practice, like other health profes-
1. Institute of Medicine. Health professions education: A bridge
sionals, often attribute quality and safety solely to the
to quality. Washington, DC: National Academies Press; 2003.
knowledge (and carefulness) of individual practitioners 2. American Association of Colleges of Nursing: AACN Position
rather than to the teamwork, cultures of safety and sup- Statement on the Practice Doctorate in Nursing. October 2004.
port for informatics, quality improvement, evidence- Available at: http://www.aacn.nche.edu/DNP/DNPPosition
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The IOM/QSEN competencies and many of the preli- doctor of nursing practice. Nurs Outlook 2005;53:173-6.
censure KSAs are embedded in the new AACN Essentials 5. American Association of Colleges of Nursing. The essentials
of Baccalaureate Education,9 and the IOM/QSEN com- of doctoral education for advanced nursing practice. Washing-
ton, DC: AACN; 2006.
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Nursing Practice.5 We hope that nursing programs will Nurs Outlook 2007;55:122-31.
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tencies are included as expected learning outcomes. If Cross mapping QSEN graduate competencies with NONPF’s
this goal is achieved, advanced practice nursing graduates NP core and practice doctorate competencies. Nursing Outlook
will be better prepared to continuously improve the qual- 2009;57:349-55.
ity and safety of the systems within which they work. 8. Cronenwett L, Sherwood G, Gelmon S. Improving quality and
safety education: A learning collaborative. Nursing outlook
Quality and Safety Education for Nurses is funded by the Robert
Wood Johnson Foundation. 9. American Association of Colleges of Nursing. AACN’s The
Principal Investigator, Linda R. Cronenwett, University of North Essentials of Baccalaureate Education for Professional Nurs-
Carolina at Chapel Hill. ing Practice. 2008. Available at: http://www.aacn.nche.edu/
The authors gratefully acknowledge the following QSEN faculty Education/bacessn.htm. Accessed February 5, 2009.

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