Quality and Safety Education for Nurses (QSEN): Integrating Systems Thinking for Enhanced Healthcare
Over a decade has passed since the Institute of Medicine's reports highlighted the critical need to improve the American healthcare system. Despite these calls to action, national healthcare quality organizations report that only slight improvement in quality and safety has been demonstrated. The Quality and Safety Education for Nurses (QSEN) initiative emerged as a response, aiming to integrate quality and safety competencies into nursing education. The current challenge lies in enabling nurses to move beyond applying QSEN competencies to individual patients and families, and to incorporate systems thinking into quality and safety education and healthcare delivery. This article will explore the history of QSEN, propose a framework where systems thinking is a critical aspect of applying QSEN competencies, and provide examples of how this framework expands nursing focus from individual care to system-level care. Furthermore, it will suggest methods for teaching and measuring systems thinking.
The Genesis of QSEN
In 2005, nursing leaders responded to the IOM call to improve the quality of healthcare by forming the Quality and Safety Education for Nurses (QSEN) initiative funded by the Robert Wood Johnson Foundation. The QSEN initiative consisted of the development of quality and safety competencies that serve as a resource for nursing faculty to integrate contemporary quality and safety content into nursing education (QSEN Institute, 2013). The QSEN initiative was funded by the Robert Wood Johnson Foundation in 2005, with subsequent phases building upon the initial work. The major QSEN contribution to healthcare education was the creation of six QSEN competencies (modeled after the IOM reports) and the pre-licensure and graduate-level knowledge, skills, and attitude (KSA) statements for each competency (Cronenwett et al., 2007). The competency statements provide a tool for faculty and staff development educators to identify gaps in curriculum so that changes to incorporate quality and safety education can be made (Barnsteiner et al., 2013).
The QSEN faculty members adapted the Institute of Medicine(1) competencies for nursing (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics), proposing definitions that could describe essential features of what it means to be a competent and respected nurse. Using the competency definitions, the authors propose statements of the knowledge, skills, and attitudes (KSAs) for each competency that should be developed during pre-licensure nursing education.
The focus of QSEN, now the QSEN Institute, has expanded from undergraduate nursing students’ education to include quality and safety education for all nurses. The mission of QSEN is to address the challenge of assuring that nurses have the knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the healthcare systems in which they work. QSEN is a national movement that guides nurses to redesign the ‘what and how’ they deliver nursing care so that they can ensure high-quality, safe care.
The QSEN Competencies
The QSEN initiative identified six core competencies essential for nurses:
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- Patient-Centered Care
- Teamwork and Collaboration
- Evidence-Based Practice
- Quality Improvement
- Safety
- Informatics
QSEN competencies have been used by national nursing organizations and are the central focus of the National Council of State Boards of Nursing (n.d.) Nurse Residency program, the foundational concepts in the Massachusetts Future of Nursing Framework (Massachusetts Department of Higher Education, 2010), and the Ohio Hospital Association (Ohio Organization of Nurse Executives, 2013).
Integrating Systems Thinking into QSEN
Viewing nurses’ work through the lens of quality and safety requires a contemporary approach that incorporates systems thinking. A crucial skill, systems thinking helps nurses to meet the challenge of improving healthcare as they move beyond the application of the QSEN competencies from individual patients and families to accelerate the overall improvement of healthcare quality and safety. The full effect of the QSEN competencies to improve the quality and safety of care can only be realized when nurses apply them at both the individual and system levels of care.
Traditionally, nurses have focused primarily on vigilant individual care; less attention has been given to assisting nurses to provide vigilant systems of care. In addition to the emphasis on teaching critical thinking skills (Simpson & Courtney, 2002), nurses also need to be taught the knowledge and skills associated with systems thinking.
Systems thinking is the ability to recognize, understand, and synthesize the interactions and interdependencies in a set of components designed for a specific purpose. This strategy includes the ability to recognize patterns and repetitions in interactions and an understanding of how actions and components can reinforce or counteract each other. These relationships and patterns occur at different dimensions: temporal, spatial, social, technical or cultural (Oshry, 2007). Systems thinking links a person’s environment to his/her behavior. In the delivery of nursing care, this involves the nurse’s understanding and valuing how components of a complex healthcare system influence care of an individual patient. Systems thinking can be viewed as a continuum, ranging from the individual to the larger internal and external environmental components.
How nurses view both themselves as nurses, and their work, is shaped by the structures and processes of the systems in which they work. Most nurses provide care in healthcare organizations that are characterized as complex, multilevel, and multifunctional. Greater knowledge and application of systems thinking skills by nurses have the potential to mitigate errors in practice, improve nurse priority setting and delegation, enhance problem solving and decision-making, improve timing and quality of interactions with other professionals and patients, and enhance workplace quality improvement initiatives.
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The ability to engage in systems thinking has been viewed as a key component in the successful delivery of safe and high quality care (Bataldan & Mohr, 1997; Bataldan & Leach, 2009; Batalden & Stoltz, 1993; Senge, 2006). The importance of systems thinking in quality improvement (QI) initiatives was identified in early literature on application of QI techniques to healthcare (Batalden & Stoltz, 1993; Deeming & Appleby, 2000) and, more recently, was highlighted in reports from the Institute of Medicine (IOM, 2003), the Accreditation Council for Graduate Medical Education (Varkey, Karlapudi, Rose, Nelson, & Warner, 2009), and the article, “Quality and Safety Education for Nurses” (Cronenwett, Sherwood & Barnsteiner, 2007). Given the hypothesized importance of systems thinking in the success of quality and safety in healthcare, it is probable that if nurses engage in better systems thinking, greater improvements in outcomes will be achieved.
Teaching Systems Thinking
Knowledge and skills associated with systems thinking, however, are seldom addressed in basic or continuing nursing education. Systems thinking is an essential skill for nurses. Yet, there has been little knowledge disseminated about how to assist nurses to better engage in this type of thought process, despite their key roles in planning, delivering, and improving patient care in complex organizations. The clinical environment is an ideal place to teach systems thinking in undergraduate, graduate, and staff development education. During the clinical experience, the faculty preceptor can broaden the learner’s problem identification from a focus on personal effort in a single situation to a focus on sequences of events with possible multiple causes for both individuals and populations.
Here are some strategies for teaching systems thinking:
- Expanding the Scope of Thinking: Learners can create grids to expand their scope of thinking from the individual to the system level of care. Students might obtain outcome data from their unit and identify reasons for variation across time. Assessment tools are available from the Clinical Microsystem (2013) Green Books for inpatient, emergency room, long-term care, and outpatient groups. These free workbooks from the Dartmouth Institute have been developed to help individuals assess the complexity of the system in which they work.
- Connecting to National Initiatives: Another approach to expand learners’ scope of thinking to a systems level is to have them connect nursing skills and clinical issues to national quality and safety initiatives (Armstrong & Barton, 2013).
- Process Mapping: Nurses can also learn systems thinking by creating flowcharts or process diagrams that elicit the steps of a care process and the multitude of healthcare workers involved in that process. This mapping technique is one of the first steps of a quality improvement project. For example, to improve the care coordination of preparing hospitalized patients for discharge, teams of healthcare professionals could map steps in the course of a patient’s stay leading to discharge.
- Root Cause Analysis (RCA): Another approach to teach systems thinking is to have learners conduct a root cause analysis (Lambton & Mahlmeister, 2010; Tschannen & Aebersold, 2010). Root cause analysis (RCA) is a widely used technique to assist people to move beyond blame of an individual for errors made in the workplace to understanding the system factors that may have contributed to errors. Healthcare organizations routinely perform RCA after an event so that appropriate changes can be made in the system to prevent future errors. This technique could be used to understand system factors even when events “almost happen.” Having nursing students participate in RCAs during their undergraduate education has been shown to be beneficial (Dolansky, Druschel, Helba, & Courtney, 2013).
- Case Studies and Games: In the classroom setting, systems thinking also can be enhanced by using case studies. The book Set Phasers to Stun (Casey, 1998) includes stories of design, technology, and human error that can be discussed in class. These stories identify the close connection between technology and humans. Another book, Systems Concepts in Action (Williams & Hummelbrunner, 2011), is a practitioner’s toolkit to teach the principles of systems thinking, such as system dynamics, outcome mapping, and social network analysis. Highly effective and very interactive, the game Friday Night in the ER (2009) guarantees learning and fun. The game is played by four people and simulates the challenge of managing a hospital during a 24-hour period. Each player is in charge of a unit.
- Guided Reflection: Lastly, teaching systems thinking requires guided reflection. Faculty need to assist learners to look for and recognize patterns in systems of care by standing back, reflecting on data, and considering the system as a whole. Too often in healthcare we make quick judgments that are based on limited information and preconceived ideas.
Measuring Systems Thinking
To improve systems thinking, we need to be able to measure it. A valid and reliable measure of systems thinking is now available. The Systems Thinking Scale (STS) is an instrument that measures healthcare professionals’ systems thinking specifically related to system interdependencies. Data from recent studies indicated that systems thinking can be taught and learned and an individual’s level of systems thinking can be changed.
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