Research Brief

QSEN: Curriculum Integration and Bridging the Gap to Practice

Deborah Y. Lewis, Kimberly P. Stephens, and Ann D. Ciak

Abstract
The purpose of this project was to revise the curriculum at a diploma school of nursing to meet the call issued by QSEN.
Course objectives were revised and principles of quality and safety were threaded throughout the curriculum with
classroom, clinical, and simulation strategies. Students and faculty completed the Healthcare Professionals Patient
Safety Assessment Curriculum Survey, and preceptors were surveyed regarding students ability to meet QSEN
competencies. No difference was found post-implementation, but statistically significant differences were found between
students and faculty and between students at the start of the nursing program and one year later.
KEY WORDS QSEN Curriculum Revision Nursing Education Diploma Education Safety

S
afety is not simply a slogan or an awareness month cam-
paign. Safety principles need to be integrated into the entire
health care system and into the schools that educate future
health care providers. To meet this challenge, schools of nursing
need to seek new, innovative frameworks for their curricula.
The Quality and Safety Education for Nurses (QSEN) initiative
was developed to determine competencies for nursing students
based upon Institute of Medicine (IOM) recommendations (Cronenwett
et al., 2007). QSEN was designed to be a bundled approach with
six competencies integrated into the curriculum. In a review of quality
and safety integration, Mansour (2012) noted that this global per-
spective is not prevalent in the literature. The challenge for nursing
education is multifocal: create a curriculum that is less content satu-
rated and more conceptual; generate new approaches to clinical ed-
ucation instead of always relying on complete patient care; enhance
classroom instruction with web-based opportunities; and support
education with adult learning theory (Giddens et al., 2008).
This article reports on curriculum revision at a diploma school of
nursing designed to integrate quality and safety principles throughout
the curriculum using classroom, clinical, and simulation strategies.
Student, faculty, and preceptor surveys were conducted to assess
changes in attitude about patient safety before and after implementa-
tion of the new curriculum.
The main goal of QSEN is to establish a cultural change toward
quality and safety. Kotters model, as described by Beitler (2006), creates
About the Authors Deborah Y. Lewis, DNP, RN, CNE, is director,
Waynesburg University RN to BSN Program, Waynesburg, Pennsylvania.
Kimberly P. Stephens, DNP, RN, is assistant professor, Waynesburg
University. Ann D. Ciak, PhD, RN, is director, St. Margaret School
of Nursing, Pittsburgh. For more information, contact Dr. Lewis at
dlewis@waynesburg.edu.
Copyright 2016 National League for Nursing
doi: 10.5480/14-1323
a useful framework for leading change and served as a guide throughout
the project. The steps, outlined in Table 1, include: establish a sense of
urgency, create a guiding coalition, develop vision and strategy for the
specific change, communicate the change vision and strategic plan, em-
power employees for action, generate short-term wins, consolidate gains,
produce more change, and anchor the new changes into the culture.
METHOD
Sample
Institutional review board (IRB) approval for this project was obtained
as exempt status. Participants were recruited as a convenience sam-
ple from the school of nursing and medical center hospitals and were
primarily female and Caucasian. Nursing school participants were
divided into two cohorts of second-level (of a two-level curriculum)
RN diploma students:
Cohort 1, 36 students, was surveyed at the start of the pro-
ject in May 2011 and served as the baseline group, prior to
full QSEN competency implementation. This cohort acted
as the control group for future cohorts.
Cohort 2, 42 students, experienced full integration of QSEN
competencies into the curriculum and served as a compari-
son to cohort 1.
Cohort 2 completed the survey in June 2011 at the start of the
nursing program and then again in May 2012. This provided data
to assess any change in attitudes between the beginning of nursing
school and the second level.
Instruments
Both cohorts completed the Healthcare Professionals Patient Safety
Assessment Curriculum Survey (HPPSACS), developed by Chenot
and Daniel (2010) to assess student nurse attitudes about patient
safety. Alpha reliability scores ranged 0.64 to 0.82. Approval was ob-
tained to use the survey and create modifications for the faculty
survey. Statistical analysis was conducted using an independent

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Copyright 2016 National League for Nursing. Unauthorized reproduction of this article is prohibited.
Lewis et al

Table 1: Project Plan Utilizing Kotters Model

Establish Urgency Evaluation Method Outcome
Faculty education (journal clubs, CEU program evaluation Predominantly 4 to 5 on 5-point scale (Range 3-5)
informational session)
QSEN orientation for new faculty Feedback New faculty oriented (n = 1) with positive response
Adaption and leveling of QSEN clinical Number of faculty using strategies per At least one strategy in every course; at least 50% of
strategies (work-around, data mining) QSEN integration chart courses use more than one strategy
Student evaluation of strategies Strategies rated >3.0
QSEN integration class for final Student response Positive feedback during class
semester students
Staff preceptor evaluation of students QSEN competency ratings >4.0
Journal club for staff nurses CEU program evaluation Predominantly excellent (range very good-excellent)
Create a Coalition Evaluation Method Outcome
Got QSEN faculty email updates Informal feedback Positive responses from faculty
Small faculty groups for QSEN strategies Output of completed strategies Faculty created strategies such as quality tool and
simulation scenarios
Vision and Communication Evaluation Method Outcome
Revision of curriculum objectives Student course evaluations Ability of course to meet objectives rated >3.0
Time at faculty meetings for discussion, Revisions and discussions noted on QSEN is a standing item on faculty organization
revision, planning meeting minutes meeting agenda
Empower Employees Evaluation Method Outcome
Strategies accessible on shared Review of shared drive All strategies accessible and updated on shared drive
computer drive
Wins, Success, Change Evaluation Method Outcome
Create care plan based on QSEN Comparison with traditional care plans Demonstrated good understanding of how to apply
competencies for student understanding of competencies competencies in clinical
Students stated they now understand how patient
goals may differ from those of health care team
Creation of survey for hospital preceptors Staff preceptor evaluation of students QSEN competency ratings >4.0
Anchoring Change Evaluation Method Outcome
Education related to error reporting Change in HPPSACS score questions No statistically significant change
related to reporting
Just Culture and systematic program Ongoing
evaluation

t-test and Fishers exact test. Statistical significance was set at
p < 0.05.
The modified version of the HPPSACS was completed by school
of nursing faculty (n = 11) at the beginning of the project and one year
later (n = 10). Three questions were modified to reflect the individual
to whom faculty would report an error.
Clinical practice RNs, who served as preceptors for final semes-
ter students, completed an online QSEN Competency Preceptor
Survey created for this project. The preceptor survey was based
upon the definition of the six QSEN competencies. The purpose of
this survey was to assess how well students performed the QSEN
competencies. Face validity of this survey was determined by faculty
member feedback prior to distribution. For all participants, return of
the survey was considered consent. Using both the HPPSACS and
preceptor survey enabled the researchers to evaluate results in the
academic and clinical environments.
Implementation
Implementation involved both education for faculty and clinical staff
and changes to the curriculum. Faculty education was provided in
a journal club format. The first educational session for faculty was
geared toward establishing a common understanding of the QSEN
competencies and knowledge, skills, and attitudes (KSAs). Subse-
quent journal clubs were developed to increase exposure to various
teaching methods (simulation, case studies, and online teaching
strategies). Staff nurses who served as preceptors for final semester
students were sent an explanation of the QSEN competencies and
how they related to the schools curriculum objectives. Hospital staff
were introduced to the QSEN competencies through a journal club.
Faculty members created change by revising the schools mis-
sion, philosophy, school goals, and curriculum objectives to incorpo-
rate QSEN. The faculty also created a new set of clinical evaluation
tools for all courses. Faculty decided to have one common clinical

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 QSEN: Curriculum Integration

strategy (work-around) from the QSEN (2012) website (www.qsen.

org/view_strategies.php) to use each semester to help familiarize stu- Table 3: Contingency Tables for Student and Faculty
dents with standardized nursing policies, standards of care, and
evidence-based practice (EBP). This strategy was modified into sev-
Responses
eral versions to meet the needs of students at every level of the program. Question Yes No p
Have you observed a medical error in
OUTCOMES your clinical experiences?
There was no statistical difference between faculty responses at pre- Student 28 13 .250
and post-implementation on the total survey or on any of the four
subscales. Likewise, results from the student surveys given at the be- Faculty 9 1
ginning of the second level showed no significant between-group dif- Have you disclosed a medical error
ferences in responses. The responses from the final student and to a faculty member/supervisor?
faculty surveys were compared to see if faculty and students had dif- Student 22 19 .167
ferent attitudes about safety after full QSEN implementation. No sta- Faculty 8 2
tistical differences were found between the two groups for the entire
Have you disclosed a medical error
survey, but statistical between-group differences (p < .05) were to a staff member?
found for the subscales of culture, error reporting, and comfort
(see Table 2). Student 16 25 .033*
Students and faculty were also compared using a Fishers exact Faculty 8 2
test for yes and no responses on the survey. There was no statistical Have you disclosed a medical error
significance for observing an error, reporting an error to a superior, to a fellow student/faculty?
reporting an error to a peer, and coverage of safety in the program. Student 20 21 .30
The association was statistically significant (p <.5) for disclosing an
Faculty 7 3
error to a staff member and reporting an error using an incidence
report (see Table 3). Have you reported an error using an
Finally, change in student attitudes over time was assessed. The incident report?
students from cohort 2 were surveyed upon entry in the program and Student 3 38 .0001*
again in level two. Only data from the entire survey were analyzed. Faculty 8 2
There was a significant difference between the start of the nursing
Did your nursing program of study
program and approximately one year after QSEN integration ( p = provide sufficient coverage on the
.013) with a 95 percent confidence interval. topic of patient safety?
The survey administered to staff nurses functioning as precep- Student 41 0 .196
tors was based upon the definitions of the six QSEN competencies.
The format was a Likert scale, with 1 meaning strongly disagree and Faculty 9 1
5 meaning strongly agree. The highest scoring competencies, *statistically significant p < .05
rated as 4.44, were patient-centered care and safety. Teamwork
and collaboration were rated at 4.38; EBP and informatics were
Findings indicate that there is room for improvement in many schools
rated at 4.25; and the lowest score was quality improvement,
with regard to the integration of all six QSEN competencies (Chenot &
rated at 4.19.
Daniel, 2010; Smith, Cronenwett, & Sherwood, 2007). QSEN was
designed to be a bundled approach with the six competencies inte-
DISCUSSION grated into the curriculum; this project was meant to reflect this
Many authors have reported on a single QSEN strategy or com- bundled approach to QSEN integration.
petency within their curriculum (Barton & Skiba, 2009; Murray, One area identified in the literature as needing further study was
Douglas, Girdley, & Jarzemsky, 2010; Thompson & Tilden, 2009). the assessment of attitudes about safety of faculty and diploma stu-
dents (Chenot & Daniel, 2010; Mansour, 2012). While no statistically
Table 2: Student and Faculty HPPSACS Results significant difference was found between faculty and students overall
in this survey, there were differences in some subscales, particularly
comfort. This can assist faculty in developing strategies for areas in
Student 2012 Faculty 2012 which students need the most assistance.
Category M(SD) M(SD) 95% CI p
It is clear from the data that both students and faculty mem-
Entire survey 3.07 (1.29) 3.17 (1.39) [.29, .09] .305 bers witnessed errors in the clinical realm. The survey revealed that
Culture 4.04 (1.00) 4.39 (.81) [.65, .05] .024* 68 percent of second-level students and 90 percent of faculty mem-
bers (one-year follow-up) answered yes when asked if they had ob-
Error Reporting 2.93 (1.15) 2.62 (1.26) [.04, .58] .025*
served an error. This leads to the question of what happens after
Denial 1.78 (.93) 1.9 (1.03) [.46, .21] .460 errors are witnessed. From a faculty perspective, 80 percent had re-
Comfort 3.4 (1.1) 4.0 (.78) [.87, .33] .0001* ported an error by completing an incident report or reporting to a
supervisor or staff member. Only 70 percent of faculty reported dis-
*statistically significant p < .05
closing the error to another faculty member. This may indicate room

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Copyright 2016 National League for Nursing. Unauthorized reproduction of this article is prohibited.
Lewis et al
for improved transparency, or it may be a reflection of faculty concern
that sharing information might violate student privacy rights.
The HPPSACS survey revealed that students were less likely to
report an error. While 68 percent observed an error, only 54 percent
reported an error to their supervising faculty, 49 percent to a fellow
student, and 39 percent to a staff member. A surprisingly low per-
centage (7 percent) of students responded yes to having reported
an error by using an incident report.
Previous studies have found that, quantitatively, students score
low on the ability to report errors and near misses. From a qualitative
perspective, previous studies report limited instruction on incident re-
ports and error reporting (Sullivan, Hirst, & Cronenwett, 2009).
The survey of nurse preceptors helped assess how students are
performing in the clinical world. This information further assists in
bridging the gap between academia and clinical practice. It is
reassuring that students were given positive scores by the staff
nurses with regard to the QSEN competencies. The lowest scoring
competency was quality improvement (M = 4.19), which had previ-
ously been identified by faculty at a journal club session as an area
needing further development.
IMPLICATIONS FOR PRACTICE
It is vital for schools of nursing to meet the needs of todays complex
health care systems by including principles of quality and safety
throughout the curriculum. Understanding student and faculty atti-
tudes toward safety can assist in guiding educational reform. This
project developed a plan for integration and included methods to
create and modify learning strategies to meet students needs in a
variety of courses throughout the program.
Future research based on the findings from this project might in-
clude a qualitative survey to help uncover if self-report on the survey
reflects practice. For example, although students disagreed with the
statement that if they saw an error they would keep it to themselves,
the rate that students claimed to have reported an error was relatively
low. Further research could investigate if working with students
100 March/April 2016
Copyright 2016 National League for Nursing. Unauthorized reproduction of this article is prohibited.
on QSEN competencies led to improvement in knowledge for the
clinical preceptors.
This project demonstrated many successes in teamwork, inte-
gration, and strategy development. Such strategy development for
classroom, clinical, and lab should be an ongoing process. QSEN
integration into the nursing school curriculum, with the involve-
ment of clinical staff, will go a long way toward anchoring a culture
of quality and safety.
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