When the faculty in a 4-year baccalaureate nursing program revised the undergraduate curriculum, attention to quality care and patient safety was a critical consideration. Faculty integrated the Quality and Safety Education for Nurses (QSEN) competencies across the curriculum and included quality care and patient safety among the areas of study identified as Core Nursing Knowledge in the Organizing Framework of the curriculum.
Although the concept of safety had long been a component of the Essentials of Nursing Practice course, it was clear that the original safety content was dated and did not address the specifics of the QSEN competency of Safety as it pertains to the requisite knowledge, skills, and attitudes (KSAs) that students need to ensure patient safety within the current health care system. Essentials of Nursing Practice is a sophomore-level course that focuses on the evidence from nursing research that supports best practices related to patient care skills. The integration of updated safety content provided the impetus for the development and implementation of evidence-based teaching strategies that would actively engage students in learning. The purpose of this article is to describe the development and implementation of a semester-wide approach involving student-centered teaching strategies designed to foster nursing students' KSAs related to the QSEN Competency of Safety.
Background
The need for reform in how health care professionals are educated became apparent in 2003 when the Institute of Medicine identified significant, system-wide concerns related to quality care and patient safety.1 In response to these concerns, the American Association of Colleges of Nursing identified 6 QSEN competencies, which provided a framework for preparing nurses for practice in an environment in which excellence is measured in terms of nurse-sensitive outcomes.2,3
To decrease the risk of harm to patients, nurses are expected to assume individual responsibility for patient safety and work in teams of health care professionals to create a "culture of safety."4(p12) Nursing programs are beginning to implement and study the effects of specific teaching strategies related to patient safety. However, more evidence is needed to support appropriate student-centered teaching strategies to integrate the concept of safety into prelicensure education and to provide nursing students with the KSAs necessary to care for patients within the existing safety culture in health care today.5-7
Development and Implementation
Faculty developed learning objectives specific to the requisite KSAs of the QSEN Safety competency.2 Specifically, students will be able to (1) discuss the relationship between quality care and patient safety within the context of the health care system, (2) demonstrate competence in maintaining patient safety during all patient encounters, and (3) value the importance of ensuring safety when providing patient-centered care.
To support students in meeting these learning objectives, faculty enhanced previously applied approaches and developed new, student-focused methods to facilitate the delivery of the QSEN safety content throughout the semester. Student-focused teaching strategies are specific evidence-based methods consciously selected by faculty that enhance students' ability to create meaningful knowledge through active involvement with the information. The selected teaching strategies were adapted from information on the QSEN Institute Web site and the professional nursing education literature.8-10
The new and adapted teaching-learning strategies that were used to actively engage students included a preassigned learning module, an unfolding case study, online discussion boards, and a formative capstone simulation scenario (Table 1). These teaching strategies were designed to facilitate students' ability to achieve the identified learning objectives and, in addition, attain a deeper comprehension of the meaning of safety, analyze and appreciate the importance of safety, and motivate students to apply this knowledge in the clinical setting.4
In preparation for the initial day of class, students first completed Learning Module 17 from the QSEN Institute Web site,9 which included videos and a Selective Attention Test and then responded to associated study questions generated by the course faculty. The videos in this learning module covered background information related to patient safety, culture of safety, and preventable medical errors in health care. Students were notified of this assignment before the end of the previous semester and were reminded of this requirement during semester break. The study questions were due the first day of class. Students earned 1 point toward their course grade for completion of the assignment. Because students came prepared having completed this homework assignment, faculty were able to address foundational safety content on the first day of class through interactive discussion rather than lecture and PowerPoint.
On the first day of the course, faculty explained the rationale for integrating safety into every unit in the course and that Unit 1, Quality Care and Patient Safety, contained all the necessary foundational knowledge. In addition to being explained in class, all required assignments were also available on the online Course Management System and in the Course Book.
At the conclusion of the first class period, students were introduced to Mrs Roberts, the patient in the faculty-generated unfolding case study (Table 2). Mrs Roberts was an older adult woman who sustained a fall at home and was being admitted with dehydration and fractured pelvis. The initial case study information simulated report to a medical-surgical nurse from an emergency department nurse, including basic demographic information, height and weight, vital signs, history of present illness, medical history, altered mental status, pain assessment, and hydration status. Faculty explained that Mrs Roberts' situation would "unfold" as the semester evolved and would relate specifically to weekly course content, allowing safety content to be integrated throughout the semester.
At the end of class each week, new information for the unfolding case study that related to the following week's content was introduced. Students then worked in preassigned groups of 5 to 7 outside of class to answer discussion questions related to Mrs Roberts. Each group's responses to the weekly discussion questions were posted on an online discussion board in the Course Management System. During each class period, faculty facilitated a discussion about the case study and related discussion questions. This gave each student group an opportunity to offer their responses to the class and critique each other's responses. The questions enabled faculty to address content that was not taught in class, such as falls, safe use of restraints, alternatives to restraints, and safe application of heat and cold. By completing the discussion questions ahead of time, students were required to come to class prepared, having read and discussed related material that was available on the Course Management System.
Students used the standardized situation, background, assessment, and recommendation (SBAR) report, which includes the patient's situation, background, assessment, and recommendations, to keep a running record of Mrs Roberts' evolving case throughout the semester. The goal of using the SBAR format was for students to practice taking report in an organized manner to promote patient safety through effective handoff.11 Because this was a formative experience, there was no need for faculty to evaluate the students' use of SBAR. Using this strategy allowed the students to integrate safety content from unit to unit such as falls, safe use of restraints, application of heat and cold, infection control, and safe medication administration.
Working in the same preassigned groups of 5 to 7 students outside of class time, students completed a WebQuest online Discussion Board that was adapted from a teaching strategy on the QSEN Institute Web site.10 The QSEN WebQuest on Patient Safety and Quality10 includes links to a variety of health care organizations and initiatives related to safety. Course faculty adapted this teaching strategy by choosing the Web sites that were appropriate to address specific course objectives, developing related discussion questions, and requiring the students to complete the assignment in groups rather than as individuals. During the second week of class, each group was assigned to visit a specific health care safety Web site such as The Joint Commission, The Institute for Healthcare Improvement, or the National Patient Safety Foundation and respond to related course faculty developed discussion questions, for example, describe the purpose of the initiative or organization. The students posted their group responses on the Discussion Board on the Course Management System.
During the third week of class, each group responded to all other groups' postings and compared and contrasted the primary focus of their assigned Web site to those discussed by the other groups, thus allowing all students to learn about each of the safety organizations. This assignment fostered peer learning in that students met and discussed both their initial responses and their analysis of the responses of the other groups. Students earned 1 point towards their course grade for completion of this assignment: 0.5 point for the initial posting and 0.5 point for the response postings. Because this was a peer-to-peer activity, faculty did not participate in the Discussion Board; their responsibility was to ascertain that each group completed both parts of the assignment in order to earn credit.
Safety also was integrated into the associated laboratory course, Practicum in Essentials of Nursing Practice, which is a sophomore-level course that provides students with the opportunity to practice the evidence-based patient care skills learned in the theory course, Essentials of Nursing Practice. Safety content was addressed in every laboratory and culminated in the safety-focused formative capstone simulation scenarios. The overall goal of the capstone simulation scenarios, which were scheduled for the last laboratory day just before initial clinical practicum, was to decrease anxiety related to, and prepare students for, their first clinical experience. One of the 3 scenarios focused specifically on patient and nurse safety and fostered students' ability to implement the KSAs related to safety in the practice setting. The students received SBAR report on Mrs Ainsworth, an 82-year-old patient admitted with shortness of breath and alteration in mental status. Using the QSEN 60-Second Situational Awareness,12 the students identified safety concerns such as no call bell or side rails, the bed in the high position, incorrect intravenous solution and oxygen flow rate, and improperly positioned nasal cannula. The students were expected to apply principles of biomechanics, safe use of restraints, and infection control as well as to perform a focused health assessment, which included a determination of Mrs Ainsworth's risk for falling. Peer learning and self-reflection were also implemented into the capstone simulation scenario through the use of a faculty-generated critical element checklist, which enabled students to reflect on their own performance and provide objective feedback to each other during scenario debriefing.
To familiarize students with expectations related to safety in the clinical setting, faculty introduced the existing, curriculum-wide Clinical Evaluation Instrument (CEI) during the Safety-focused capstone simulation scenario debriefing. One of the objectives on the CEI focuses on student application of the principles of safety during patient care, such as patient identification, application of infection control, and correct use of body mechanics. The CEI was used to structure the capstone simulation scenario debriefing and draw the students' attention to clinical expectations specifically related to safety.
Lastly, the Safety section of the Assessment Paper, a comprehensive patient assessment assignment that students complete during their first clinical experience, was revised to integrate the safety content presented in Essentials of Nursing Practice into the clinical setting. Students were required to complete a fall risk assessment on a clinical patient as well as answer multiple questions specific to the patient's safety needs.
Discussion
Well-documented concerns regarding the education of health care professionals, particularly in relation to quality care and patient safety, prompted faculty in a baccalaureate nursing program to develop and implement student-centered teaching strategies to foster sophomore students' KSAs related to the QSEN Competency, Safety. The teaching strategies, which included a preassigned learning module, an unfolding case study, online discussion boards, and a formative capstone simulation scenario, actively engaged students in the learning process. Students have informally commented to faculty that the group work associated with the WebQuest assignment and unfolding case study fostered discussion of the course material outside of class and allowed them to apply the content more readily on a personal level. Engaging students both inside and outside of class and promoting application of theory content are challenges for all nursing faculty. The strategies described in this article offer 1 way to support the active engagement of students in the relevant application of course content to promote deeper learning. Future plans include a research study to evaluate the effect of student-centered teaching strategies versus standard educational modalities on student outcomes related to the KSAs of the QSEN competency, Safety.
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