1

Integrating Safety into Nursing Courses in a Concept Based Curriculum Project Plan
A. Clearly explain the quality improvement project what exactly are you planning to do?
Grand Rapids Community College (GRCC) is in the process of redesigning their
curriculum into a concept-based curriculum. One of the concepts that will be threaded
throughout the curriculum is safety. My project will be to thread the concept of safety into two
nursing courses (NUR 102 and NUR 103), specifically considering medication safety. Both
courses are in the first semester of the nursing program. NUR 102 is theory on and NUR 103
contains both theory and clinical.
B. Provide evidence based support that establishes a need for this project. Also include
research support for effectiveness of the proposed improvement project.
Reports published by the Institute of Medicine in 1999 and 2001 brought national
attention to quality and safety in healthcare (Chenot & Daniel, 2010). When considering the
number of medical errors that occur each day, it is evident that healthcare professionals need to
be prepared with the knowledge and skills to provide safe, quality care. However, only marginal
evidence shows pre-licensure students are equipped with the skills needed to scrutinize safety
and quality concerns (Chenot & Daniel, 2010).
A significant safety concern in healthcare is medication errors. Medication-related errors
are a significant cause of morbidity and mortality, contributing to more than 7,000 deaths each
year (Hughes & Blegen, 2008). Medication administration is traditionally performed by nurses
and nurses can also be responsible for dispensing and preparation of medications. A study
completed by the Food and Drug Administration that examined deaths caused by medication
errors, found the most common causes of errors were related to human factors, trailed by
miscommunication (Hughes & Blegen, 2008). The number of medical errors noted in the
literature suggests that healthcare professionals are inadequately prepared (Chenot & Daniel,
2010).

2
Nurses need to be equipped with the skills to examine patient safety issues, such as
medication errors. However, there is little evidence showing that nursing students are being
prepared with the necessary skills to scrutinize safety issues (Chenot & Daniel, 2010). Though
there have been many efforts to drive improvement in patient safety and quality, more needs to
be done. The role of the educational leader in quality and safety improvement is becoming
apparent (Chenot & Daniel, 2010). According to an article by Chenot & Daniel (2010),
educational leaders in health care should strive to develop curriculum frameworks that place
appropriate emphasis on patient safety (p. 560). The shift to patient-centered, safe, quality care
calls for a shift in nursing curriculum.
To develop a culture of safety in a learning institution and prepare students with the
knowledge, skills, and attitudes needed to deliver safe, quality care; safety and quality concepts
need to be assimilated throughout the entire nursing curriculum (Jones, 2013). The importance
of incorporating QSEN competencies into nursing education has been revealed in the literature,
highlighting the need to begin incorporating QSEN competencies in the first semester through
the last (Jones, 2013).
In the past, nursing students have not been adequately prepared by a traditional nursing
curriculum to transition to a professional role (Jones, 2013). The QSEN initiative provides
valuable information, tools and strategies to incorporate quality and safety into a nursing
curriculum and bridge the gap between nursing education and professional practice (Jones,
2013). The QSEN initiative competencies are applicable in a practical nursing curriculum and
will aid in developing nursing professionals providing high quality patient care at all levels
(Jones, 2013).
Nursing programs need to evaluate and redesign curriculums in response to national
initiatives including QSEN (Armstrong, Spencer, & Lenburg, 2009; Disch, Barnsteiner, &
McGuinn, 2013). Schools of nursing need to redesign the curriculum to reflect current shifts in

3
health care practices that contribute to more effective systems that ensure patient safety
(Armstrong, Spencer, & Lenburg, 2009, p. 686). Many nursing programs are adopting a
concept-based curriculum in response to the call for curriculum redesign that incorporates quality
and safety education (Giddens, Wright, & Gray, 2012). Many nursing competencies, including
QSEN, align well with conceptual learning (Giddens, Wright, & Gray, 2012).
C. Where will this project take place? Describe the environment/facility/unit etc.
My project will take place at Grand Rapids Community College (GRCC). GRCC is
located in Grand Rapids, Michigan. GRCC was founded in 1914 (GRCC, 2014a). GRCC has
more than 2,000 liberal arts and occupational courses and enrolls more than 17,000 students each
year (GRCC, 2014a).
Grand Rapids Community College has an Associate Degree Nursing (ADN) program.
The ADN program is accredited by the Accreditation Commission for Education in Nursing.
Completion of the ADN program at GRCC involves five and a half semesters (GRCC, 2014b).
The course work involves one semester of pre-nursing followed by four and half semesters of
nursing (GRCC, 2014b). The nursing courses are limited to 38 students and 8-9 students in
theory and clinical, respectively. Approximately, 25 to 30 students graduate from the program
three times a year (C. Beute, personal communication, July 1, 2014).
D. Who else will be involved in this project? What will their roles be? (Include the agency
and preceptor in this section, and provide an overview of the agency and the preceptors
qualifications, title, and contact information. A signed agreement from the agency
representative and preceptor should be included in this section.)
Cora Beute will be my preceptor. Cora is an Assistant Professor in the nursing program
at GRCC. Cora has been a faculty member for 20 years. Cora was adjunct faculty for 14 years
and began fulltime six years ago. Prior to education, Cora worked in bedside nursing for 15-20
years. Cora also has worked part-time in quality assurance, professional development, and

4
informatics. Currently, a significant portion of Coras time is in the clinical setting, though she
does teach some theory.
Cora earned her MSN from University of Phoenix in 2002. Cora is a Certified Nurse
Educator and is also American Nurses Credentialing Center Nursing Professional Development
board certified. Coras extensive knowledge, experience, and education make her an ideal
preceptor for my project.
Cora Beute, RN-BC, MSN, CNE
Assistant Professor
cbeute@grcc.edu
(W) 616-234-4569
(C) 616-970-0999
I will have the opportunity to attend weekly nursing faculty meetings. The meetings will
provide opportunity for me to introduce this project, as well as discuss the progression of the
project with faculty members. Opportunities to assess the project with faculty members will be
available during the meeting time, in addition to identifying any needs for revision.
See Appendix A.
Appendix A is the preceptor agreement with Cora Beute. The facility agreement is also
available. Clinical hours will be completed at Metro Health Hospital, awaiting signature.
E. Complete an assessment of the QSEN graduate level competencies. Consider a minimum
of 3 KSAs within the 6 competencies that you will focus on as a part of the overall quality
improvement project. (Note: These should align with your project goals.)
Competency
Quality Improvement

Knowledge/Skill/Attitude
Skill: Lead improvement

Alignment with Project

This project will provide the

efforts, taking into account

opportunity to act as a leader

context and best practices

in quality and safety. The

based on evidence (QSEN,

concept of Safety will be

2014).

incorporated throughout the

course using content and
activities supported by the

Safety

Evidence-Based

Knowledge: Identify best

literature.
To successfully develop

practices that promote patient,

course activities and content,

community, and provider

it is imperative that best

safety in the practice setting

practices related to safety can

(QSEN, 2014).

be identified.

Skill: Implement care

Care practices taught in the

practices based on strength of

classroom and clinical will be

available evidence (QSEN,

evidenced based.

2014).
F. Complete an assessment of the ANA Scope & Standards of Practice for your specialty
role. Identify a minimum of three professional standards that will be met by completion of
this project. (Note: These should align with your project goals.)
NLN Scope of Practice
Competency 1 Facilitate Learning (NLN,

Alignment with Project

This project will require the development and

2012).

use of multiple teaching strategies to meet the

Competency 3 Use Assessment and

desired learning outcomes.

This project will require use of a variety of

Evaluation Strategies (NLN, 2012).

assessment and evaluation strategies. The

strategies will be appropriate for the learner

Competency 4 Participate in Curriculum

and evidence-based.
This project will require evaluation of the

Design and Evaluation of Program Outcomes

current course, as well as redesign to reflect the

(NLN, 2012).

concept of safety. This will include developing

objectives, learning activities and selecting

Competency 7- Engage in Scholarship (NLN,

pertinent evaluation strategies.

This project will require examining the

2012).

literature and identifying evidence to guide

appropriate teaching strategies, activities and

evaluation approaches.
G. Complete an RCA or FMEA with key stakeholders and/or peers with an understanding
of the issue you will be addressing. Include a conceptual map as part of your plan. (Note:
Examples you may use are included in this project guide.)
A Root Cause Analysis was completed to assess the cause/factors that contribute to the
value students place on safety, as well as factors/causes of errors. The categories assessed
included instructors, students, environment, and clinical setting. I believe the most important
issues discovered include different methods and various amounts of instruction on safety related
to different instructors, students not fully understanding the role of a just culture and safety in
patient outcomes, and a lack of a standardized safety concept teaching plan. See Appendix D.
The FMEA identified failure modes associated with the teaching plan and data analysis of
medication near misses and errors. The FMEA highlighted the need to use evidence-based
material when developing the teaching plan for this project, as well as allowing adequate time for
the instructors to research and review the material. It will also be important to discard any
material that is no longer relevant and is not evidence-based to maintain assurance that it will not
be used by faculty. Finally, to allow for analysis of data it is necessary to provide education to
faculty that identifies what constitutes a medication near miss and/or error. The education
should also provide the steps on how to document and report near misses and errors which will
allow for accurate reporting and analysis. See Appendix C.
H. Identify a change and leadership theory that you will employ during project
implementation. Support.

7
An important relationship exists between leadership and safety (Sherwood & Barnsteiner,
2012). The promotion of safety is a crucial role any leader must fulfill, specifically in healthcare
(Sherwood & Barnsteiner, 2012). The literature has found that when leaders engage in more
safety-related behavior, followers also engage in more safety-related behavior (Sherwood &
Barnsteiner, 2012). This is important to consider in the role as an educator, as students often
view educators as role models and leaders. Through transformational leadership, the educator
can champion needed safety improvements.
Throughout my project, I will employ the transformational leadership theory.
Transformational leadership is a style of leadership in which the leader identifies the needed
change, creates a vision to guide the change through inspiration, and executes the change with
the commitment of others (Marshall, 2011, p. 3). Use of this leadership theory is applicable
with faculty members and students. At times, faculty members may feel challenged by the
curriculum redesign and the many changes to courses. This will be an opportunity for me to act
as a leader and inspire members of the faculty. I will be charged with the role of motivating
individuals and igniting a passion in each person reminding why the changes were made, the
importance of the change, and that the change can be accomplished. In regards to students, this
leadership theory will allow me to inspire students to achieve a practice standard that
encompasses a culture of safety.
Kurt Lewins change theory will be employed during project implementation. Lewins
change theory is based on his Field Theory, which analyzes relationships and change (KearneyNunnery, 2009). The change theory involves three phases including unfreezing, moving, and
refreezing (Kearney-Nunnery, 2009).
The first phase, unfreezing, involves preparing for the change (Kearney-Nunnery, 2009).
At this phase, the problem is recognized, a need for change is identified, and the need for change
is becoming apparent to others (Kearney-Nunnery, 2009). Currently, the school of nursing at

8
GRCC is in the unfreezing phase. The problem and need for change has been identified, which
is the need to redesign the curriculum to align with QSEN competencies and other national
quality and safety initiatives. The faculty members are aware of the needed change.
The next phase is moving. This phase will involve developing a plan and setting realistic
goals to make change occur (Kearney-Nunnery, 2009). The change process is almost in this
phase. During this phase, new learning activities and coursework will be developed and will be
implemented. The implementation will allow for testing of the proposed change. This phase
will need the characteristics of a transformational leader. Faculty and students may resist the
changes, particularly if the changes are not working well. This will be an important time to ask
for honest and constructive feedback from students and faculty members.
The last phase is refreezing, which is establishing a new status quo (Kearney-Nunnery,
2009). This phase will involve maintenance of the final project after any needed changes are
identified. It is vital to work out any weaknesses in the project prior to refreezing or the goal
may not be maintained (Kearney-Nunnery, 2009). This highlights the need to identify a way to
assess or measure whether the project was successful.
I. How will you assess or measure whether your improvement project worked? How/will
informatics technology be used?
At the beginning of the course, students will perform a self-assessment survey of
preparedness to provide safe care and perception of importance of safety in healthcare. This
same self-assessment will be completed at the end of the course. The student will also be
evaluated by the instructor using the same assessment survey after the first week of clinical and
at the end of the semester.
There are two sections of NUR 102. The Lewis Blackman Story is a video discussing
the tragic outcome of a teenage boy who went in for a routine surgery and died. The story shows
the family perspective of the incident and unveils quality and safety concerns in healthcare. One
section will view the video, but discussion will evolve around communication. The second

9
section will have small group discussions, followed by a large group discussion looking at issues
including not only communication but just culture, professional accountability, and transparency
in the workplace. Each group will be given a post-test to assess if the expanded activity made an
impact on safety culture awareness.
GRCC instructors track near misses among students. I will review near misses of past
clinical groups to determine an average number of near misses or errors. The number of near
misses or errors from previous clinical groups will be compared to that of the clinical groups that
had implementation of safety strategy activities.
J. Predict what you think will happen as a result of your improvement project.
The students will have a culture of safety foundation on which to build upon. The
students perceptions on the importance of safety will increase throughout the semester. The
students will value a just culture and understand the role of just culture in healthcare quality and
safety. The aforementioned will lead to delivery of safe care with a decrease in errors. The
number of medication near misses or errors among GRCC students will decline after
implementation of this improvement project.
K. Create goals, objectives, and timelines for the project. Consider the earlier identified
QSEN competencies and DSA components of the PDSA model in completing the grid.
See Appendix B.

10
References
Armstrong, G. E., Spencer, T. S., & Lenburg, C. B. (2009). Using quality and safety education
for nurses to enhance competency outcome performance assessment: A synergistic
approach that promotes patient safety and quality outcomes. Journal of Nursing
Education, 48(12), p. 686-693.
Chenot, T. M. & Daniel, L. G. (2010). Frameworks for patient safety in the nursing curriculum.
Journal of Nursing Education, 49(10), p. 559-568.
Disch, J., Barnsteiner, J., & McGuinn, K. (2013). Taking a deep dive on integrating QSEN
content in San Francisco Bay area schools of nursing. Journal of Professional Nursing,
29(2), p. 75-81.
Giddens, J. F., Wright, M., & Gray, I. (2012). Selecting concepts for a concept-based
curriculum: Application of a benchmark approach. Journal of Education, 51(9), p. 511515.
Hughes, R. G. & Blegen, M. A. (2008). Patient Safety and Quality: An Evidence-Based
Handbook for Nurses. Retrieved from http://www.ahrq.gov/professionals/cliniciansproviders/resources/nursing/resources/nurseshdbk/nurseshdbk.pdf
Jones, A. D. (2013). The impact of integrating Quality and Safety Education for Nurses safety
competency in first-year associate degree nursing students. Teaching and Learning in
Nursing, 8(4), p. 140-146.
Kearney-Nunnery, R. (2009). Advancing your career: Concepts of professional nursing (4th ed).
Philadelphia, PA: F.A. Davis.
Marshall, E. S. (2011). Transformational leadership in nursing: From expert clinician to
influential leader. New York, NY: Springer Publishing Company.
National League for Nursing. (2012). The Scope of Practice for Academic Nurse Educators.
New York, NY: National League for Nursing.
QSEN Institute. (2014). Graduate KSAS. Retrieved from http://qsen.org/competencies/graduateksas/

11
Sherwood, G. & Barnsteiner, J. (2012). Quality and Safety in Nursing: A Competency Approach
to Improving Outcomes. Ames, IO: Wiley-Blackwell.

12
Appendix A

13

14
Clinical Site Observational Agreement for Education Track Students
The purpose of the clinical site observation of a minimum of 16 hours and a maximum of 20
hours, is to provide education track MSN students the opportunity to assess how the quality
improvement initiative for a nursing educational program would transfer to the clinical setting
and to ascertain education-practice gaps as it pertains to the quality improvement project.
Clinical Site name
________________________________________________________________________
Student name _____Amy Herrington____________
Student Telephone # ___616-862-1999________
Clinical Site representative ______________________________
Clinical Site representative Title _________________
Clinical Site representative Telephone #___________________Email__________________
SIGNATURE SIGNIFYING AGREEMENT TO THE TERMS OF THIS AGREEMENT:
Student _________________________________________ Date ___________________
Agency representative _______________________________________ Date ___________

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Appendix B: QUALITY IMPROVEMENT PROJECT PROPOSAL PLANNING GUIDE
Title of Quality Improvement Project:
Goals with QSEN/ANA Support
Goal 1: State Goal

Sub-Objectives to meet Goal

1.1 Evaluate the current course,
particularly focus on safety.

Activities to meet Each Sub-objective

1.1 Review the current course with the
Instructor (my preceptor) in detail.
Ascertain how safety is currently
integrated into the course.

Timeline for each

1.1 Week One-Meet
with Cora

1.2 Assess how safety will be

threaded throughout other courses in
the new curriculum

1.2 Meet with instructors who teach in

higher levels to identify how the concept
of safety can be built upon each
semester as the student advances.

1.2 Week Two/Three

Attend faculty meeting
on Fridays

1.3 Recognize areas of needed

growth in students in the clinical
setting.

1.3 Clinical observation of nursing

students and RNs which will allow for
identification of weaknesses in the safe
delivery of care. (Clinical Hours)

1.3 Week Two/Three

Observe RNs
Research past near
misses and errors

Sub-Objectives to meet Goal

2.1 Evaluate the redesigned
curriculum ensuring alignment of
objectives throughout the curriculum.

Activities to meet Each Sub-objective

2.1 Review the redesigned curriculum
with members of the
committee/preceptor.

Week Seven/Eight
Observe Students
Timeline for each
2.1 To be determinedAnticipating attending
curriculum meeting

2.2 Develop course objectives and

activities supported by literature.
See Appendix E.

2.2 Review literature relating to conceptbased curriculum, as well as the concept

of safety and QSEN competencies.

Identify areas of needed growth in

relation to the concept of Safety in the
current course.
Meets QSEN Competency(ies)/KSA(s):
Quality Improvement: Lead improvement
efforts, taking into account context and
best practices based on evidence.
Meets ANA Scope & Standards for
specialty role:
Participate in Curriculum Design and
Evaluation of Program Outcomes.
Goals with QSEN/ANA Support
Goal 2: State Goal
Develop learning activities that
integrate the concept of safety within
NUR 102 didactic and NUR 103
didactic and clinical that will be
consistent with the Concept-Based
Curriculum at GRCCs School of
Nursing.
Meets QSEN Competency(ies)/KSA(s):
Safety: Identify best practices that
promote patient, community, and provider
safety in the practice setting.

2.2 Week Four-Seven

Further develop teaching
strategies and develop
objectives.
Week Seven-Fifteen
Revise strategies and
objectives as needed.
Participate in employing
teaching strategies.

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Evidence Based Practice: Implement care
practices based on strength of available
evidence.

Meets ANA Scope & Standards for

specialty role:
Facilitate Learning.
Use Assessment and Evaluation
Strategies.
Participate in Curriculum Design and
Evaluation of Program Outcomes.
Engage in Scholarship.

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Appendix C: Failure Modes Effects Analysis (FMEA)

Process Step

Failure Mode

Effect

Cause

Occurrence
Rating

Detection
Rating

Standardize
Teaching
Plan/Material
s

Inappropriat
e Teaching
Materials

Students
receive
inappropriat
e materials
which could
impact
delivery of
safe care.

Not
reviewing
material
thoroughly.

Severit
y
Rating
4

RPN

Recommended
Actions

48

Provide adequate
preparation time to
review and identify
new evidence-based
materials.

Inadvertentl
y using old
material.

Discard old materials

that are no longer
pertinent to current
teaching plan.

Not
reviewing
the
literature.
Standardize
Teaching
Plan/Material
s

Inadequate
Time to
Complete
Teaching
Plan

Students
dont receive
all planned
material
which could
affect their
preparation
for practice.

Great
amount of
content to
cover in
limited time.
Unplanned
time
constraints
(other
activities
went over
time
allotment)

30

Allow some time in

teaching plan for
timing issues.
Have a plan of which
content will be
decreased and which
content cannot if time
becomes an issue.

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Data Analysis
of Near
Misses and
Errors

Data is not
correct/
consistent

Inaccurate
Data

Instructors
may classify
near
misses
differently.
Near
misses or
errors may
not be
documented
completely.

200

Provide education and

have a policy on what
constitutes a near
miss and error, as well
as how each needs to
be documented and
reported.

Appendix D

-Multiple clinical
instructors
-Instructors with
different
expectations
-Various teaching
methods
-Different instructors
may place higher
value on different
aspects of safety
-Culture of
Safety/Just Culture
may vary by
instructor
-Student may not
feel comfortable
reporting errors to
instructor
-Student many not
feel comfortable
asking instructor
questions/for help

Factors
Affecting

Clinical Environment

-Just Culture vs.

Punitive Culture
-Clinical Student to
Instructor Ratio
-Busy unit may make
student feel rushed
-Staff may not be
open to
questions/providing
help to students
-Staff may tell
student its okay to
cut corners/not
follow rules

Materials

Student

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Appendix E
Title: Enhancing Medication Safety
Instructor
Course: NUR 103 Clinical Lab
Setting: Lab using low fidelity simulation
Description: The students will view a video vignette about medication safety. This activity will involve class discussion on safe
aspects of medication safety (five rights, three checks, two identifiers, etc.), as well as discussion regarding appropriate and available
drug guide resources. Following discussion, the students will be given a MAR and a patient chart and will have time to utilize drug
teaching
-Students
guide resources. The instructor will model medication preparation and -Various
administration
in the lab setting. Students
willwith
then prepare
materials
various learning
and administer medications to their patients.
-Conflicting
styles/needs
educational
materials
-Fear of punishment
Title: Errors and Interruptions in the Workplace
when various
if errors reported
Course: NUR 103
materials
used
(need further
Setting: Class or Lab
education-Just
Description: Begin with an activity. Activity: Student in center needs to count by 4s and move each hand back
and forth, while being
Culture)
asked simple questions (type of phone, age, favorite color, favorite food-this illustrates how hard questions can be to answer when we
dont IV pump)
are doing many things at once). Students will surround student asking questions, while also making noises-Students
(phone ringing,
recognize
to mimic what a day in nursing is like.
importance
Following activity, discussion on interruptions in healthcare and how it can cause errors. When do nurses
need of
to safety
concentrate?
measures to patient
Are there times that interruptions are appropriate? How can interruptions affect medication pass? Examples?
outcomes
Title: Managing Interruptions during Medication Preparation and Administration
Course: NUR 103 Clinical Lab
Setting: Lab using low fidelity simulation
Description: After students have participated in medication administration simulation and discussed interruptions in the workplace,
students will perform another medication preparation and administration. However, during this medication pass, the student will face
many interruptions.
Title: Medication Reconciliation
Course: NUR 103
Setting: Clinical Post-Conference Assignment

20
Description: Discuss what medication reconciliation involves and why it is important. As a clinical group, complete a sample
medication reconciliation together. As an assignment, the student will be responsible for reconciling another patients medication
before the patient can discharge home from the hospital. There will be two medications that the patient would have continued taking
by mistake if the reconciliation hadnt been completed. The student will be responsible for examining how the medication error could
have affected the patient, had the reconciliation not been completed.
Title: Sentinel Events: Exploring a Just Culture
Setting: NUR 102 (Two Sections)
Description: Utilizing QSENs The Lewis Blackman Story the sentinel events and the idea of a just culture can be explored. The
videos from The Lewis Blackman Story will be viewed. One section will view the video and discussion will take place on
communication. Students in the second section will be broken up into small groups to discuss just culture, adverse events, and
transparency in the workplace and then each small group can share thoughts with the whole group. After discussing the individual
story and personal thoughts on sentinel events, a Just Culture will be explored and how Just Culture fits into this story. A post-test will
be given to each section to assess impact of activity.
http://qsen.org/videos/the-lewis-blackman-story/
Title: SBAR
Course: NUR 102
Setting: Class
Description: Content on SBAR provided to students. Students will then view a video vignette
(http://onlinetraining.umassmed.edu/sbarcommunication/) demonstrating SBAR. Students will break into groups of three. Students
will be given a case scenario (three scenarios will be developed). Each scenario will provide an opportunity for the student to practice
utilizing SBAR while calling the physician, as well as an opportunity to practice bedside report. The scenario will require the student
to critically think and identify the need to notify the physician, as well as identify pertinent information for report.