Quality and Safety Education for Nurses

Quality and Safety Education for Nurses (QSEN) addresses the challenge of preparing nurses with the competencies necessary to continuously improve the quality and safety of the health care systems in which they work. 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. Quality and Safety Education for Nurses (QSEN) faculty and advisory board members invite the profession to comment on the competencies and their definitions and on whether the KSAs for pre-licensure education are appropriate goals for students preparing for basic practice as a registered nurse.     

Developing an economic IQ in primary care

PURPOSE: To describe elements of an economic intelligence quotient (IQ) that can be used to enhance the nurse practitioner's (NP) fiscal viability in a primary care setting. DATA SOURCES: Anecdotal data from providers and administrators; clinical experiences of the authors; scientific and government publications and guidelines. CONCLUSIONS: In the United States, managed care cost-containment initiatives have led to competition among physicians and NPs for patients and jobs. An understanding of the economic base of a practice is essential to fiscal viability in this market. PRACTICE IMPLICATIONS: When turf and job competition are the norm, it is essential that the NP develop an economic IQ. Knowledge of coding, billing, reimbursement, and documentation are critical to identifying the NP's value to the practice and promoting job retention. The challenge is for the NP to give high-quality, cost-effective, and safe patient care and to be a productive provider.     

A community-oriented primary care nursing model in an international setting that emphasizes partnerships

PURPOSE: To present an interdisciplinary, community-oriented primary care nursing model that effectively draws upon the strengths of advanced practice nurses (APNs), both nurse practitioners and community health nurses. DATA SOURCES: Articles in professional nursing journals, international data sources, and the clinical experiences of the authors, both domestic and international. CONCLUSIONS: The model, developed domestically, was utilized successfully by APNs internationally in a medical mission endeavor in rural Haiti. Many partners, domestic and Haitian, worked as an interdisciplinary team to deliver quality health care to an impoverished population. Graduate nursing students participated in the program, which offered opportunities and challenges for both novice and expert nurses. IMPLICATIONS FOR PRACTICE: Nurse practitioners, community health nurses, and nursing faculty members can use this model to enhance their professional practice. They can learn that clients can be optimally cared for whether the community served is domestic or international. Nursing faculty can teach graduate nursing students about the value of partnerships and collaboration.     

Evidence-based practice in primary care: past, present and future

As in other health care specialities, evidence-based practice is beginning to have an impact on the philosophy and workings of primary care. Some practising clinicians, however, may wish to question its relevance to their everyday work, and whether general practitioners and other members of the primary health care team can realistically adopt a new approach to clinical decision making, at a time of such high workload and competing priorities.
Major changes have taken place during the last 20 years as a result of the National Health Service (NHS) reforms, the development of general practice and primary care research, and other health service innovations such as the introduction of new technologies, which have had an important impact on primary care. Issues such as the availability and use of different research methods, the role of experts, and the development of guidelines, audit and evaluation of care, are becoming subject to renewed scrutiny.
Within this context, this article explores the potential of an evidence-based approach in the primary care setting, and discusses possible strategies for change to assist the dissemination of research into practice and the implementation of evidence-based health care.     

Utilizing Academic–Service Partnerships to Advance the Care of Veterans

Challenges encountered in both advanced practice registered nursing (APRN) education and veteran health care include an aging workforce, limited resources, and faculty/staff shortages, which ultimately affect patient outcomes. Academic–service partnerships (ASP) address these challenges by increasing workforce capacity and engagement, promoting interprofessional collaboration and evidence-based practice, creating educational opportunities for nursing students to work with underserved populations, and offering a mechanism for recruitment and retention. This article outlines the systematic approach a large doctor of nursing practice (DNP) program in the southwestern United States used to develop and deploy an ASP program with 2 sizeable veteran-serving community partners.     

Faculty practice in joint appointments: implications for nursing staff development

Faculty joint appointments can capitalize on the talents and unique knowledge of nurses in varied settings. Altered role expectations, recurring emphases on cost control, and demands for accountability in the transforming health care system urge academic nursing faculty and clinically-based nurses to work together to achieve requisite health care and educational outcomes. This article addresses the types of faculty practice models, discusses three major role types of joint appointments, and presents the benefits and challenges of faculty functioning in joint appointments. Implications for nursing staff development are examined.     

Impact of patient-reported outcome measures on routine practice: a structured review

RATIONALE, AIMS AND OBJECTIVES: Regular use of patient-reported outcome measures (PROMs) by health care providers in their routine practice may help to improve the quality of care, but more evidence is needed before routine use of PROMs can be recommended. A structured review was undertaken to examine whether and how regular use of PROMs might improve routine practice. METHODS: A systematic search of Medline accessed through Webspirs Silverplatter was undertaken for the years 1976-2004. Controlled trials in English evaluating the impact of clinical use of PROMs on routine practice were included. Data regarding study design, characteristics of PROMs feedback, patient populations and study results were extracted by three reviewers. RESULTS: Feedback of PROMs results to health care providers appears to have a substantial impact on some processes of care, particularly on diagnosis of mental health conditions. However, the impact on patient health status is less consistent. Most of the published studies evaluated PROMs as a one-off screening technology and measured only provider behaviours and patient health outcomes. CONCLUSIONS: The pattern of results suggests a general lack of clarity in the field, especially regarding appropriate goals for PROMs and the mechanisms by which they might achieve them. To fully evaluate their role in routine practice, studies need to use PROMs that capture issues of importance to patients and to measure impacts relating to the patient-provider relationship and patient contributions to their well-being. Until studies evaluate PROMs as a means facilitate patient-centred care, their full potential in clinical practice will remain unknown.     

Creating and sustaining an academic‐practice Partnership Engagement Model

Public health clinical educators and practicing public health nurses (PHNs) are experiencing challenges in creating meaningful clinical learning experiences for nursing students due to an increase in nursing programs and greater workload responsibilities for both nursing faculty and PHNs. The Henry Street Consortium (HSC), a collaborative group of PHNs and nursing faculty, conducted a project to identify best practices for public health nursing student clinical learning experiences. Project leaders surveyed HSC members about preferences for teaching‐learning strategies, facilitated development of resources and tools to guide learning, organized faculty/PHN pilot teams to test resources and tools with students, and evaluated the pilot team experiences through two focus groups. The analysis of the outcomes of the partnership engagement project led to the development of the Partnership Engagement Model (PEM), which may be used by nursing faculty and their public health practice partners to guide building relationships and sustainable partnerships for educating nursing students.     

A win-win model for an academic nursing center: community partnership faculty practice

A number of schools of nursing have established community nursing centers to provide faculty practice sites, student learning experiences, and a service to the community, most often to a poor underserved population. The current literature concludes that these centers provide a quality clinical service and improve access to health care, and they also provide an avenue for research, training, and faculty practice. Acquiring necessary financial support and the ability to achieve financial independence appear to be the most common difficulties for these centers. Most of the current literature includes an examination of issues relating to funding. The model presented in this article focuses on organizational variables that include both the center and its placement in relationship to other functions and programs in the school and a broadening of the meaning of fiscal responsibility to include an awareness of the broad spectrum of benefits that the community nursing center brings to the entire school. Efforts to coordinate and integrate the needs and functions of several groups are described. Establishing goals and priorities that simultaneously meet the needs of all or most of these groups has been an important outcome. The activities of the center have become an integral part of the everyday life of the school. Achieving financial independence and being fiscally aware and responsible is not the same thing.     

DNP and PhD scholarship: Making the case for collaboration

BackgroundThe Institute of Medicine calls for meaningful collaboration between doctor of nursing practice (DNP)- and doctor of philosophy (PhD)-prepared nurses to improve health outcomes.PurposeThe purpose of this paper is to answer the questions: 1) how do Colleges of Nursing influence DNP and PhD collaboration for faculty and students? 2) how does DNP and PhD collaboration in an academic setting impact health care practices and patient outcomes?MethodsTwo examples of DNP and PhD collaboration (one faculty and one student) are presented.ResultsShared faculty responsibilities and a supportive organizational culture influenced collaboration between faculty and students. Research and practice roles can complement and strengthen each other while improving health outcomes.ConclusionColleges of Nursing should build processes and culture that encourage faculty and students to collaborate across doctoral programs. Successful intraprofessional collaboration has the potential to positively impact healthcare quality, and outcomes, while advancing the nursing profession.     

Pressure ulcers: implementation of evidence-based nursing practice

AIMS: A 2-year project was carried out to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines. This paper describes the implementation of the project and lessons learned. The evaluation and outcomes of implementing clinical practice guidelines to prevent and treat pressure ulcers will be reported in a separate paper. BACKGROUND: The prevalence and incidence rates of pressure ulcers, coupled with the cost of treatment, constitute a substantial burden for our health care system. It is estimated that treating a pressure ulcer can increase nursing time up to 50%, and that treatment costs per ulcer can range from US$10,000 to $86,000, with median costs of $27,000. Although evidence-based guidelines for prevention and optimum treatment of pressure ulcers have been developed, there is little empirical evidence about the effectiveness of implementation strategies. METHOD: The study was conducted across the continuum of care (primary, secondary and tertiary) in a Canadian urban Health Region involving seven health care organizations (acute, home and extended care). Trained surveyors (Registered Nurses) determined the prevalence and incidence of pressure ulcers among patients in these organizations. The use of a computerized decision-support system assisted staff to select optimal, evidence-based care strategies, record information and analyse individual and aggregate data. RESULTS: Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinary team. Lack of visible senior nurse leadership; time required to acquire computer skills and to implement new guidelines; and difficulties with the computer system were identified as barriers. CONCLUSIONS: There is a need for a comprehensive, supported and sustained approach to implementation of evidence-based practice for pressure ulcer prevention and treatment, greater understanding of organization-specific barriers, and mechanisms for addressing the barriers.     

Advanced practice nurses as faculty.

This article details a program through which two child health faculty members who are advanced practice nurses (APNs) combined practice with teaching undergraduate students in a community-based clinical experience on nursing case management. A collaborative agreement between a university-based Children's Special Services Team (CSST) and school of nursing faculty was developed to extend services into the home communities of children with special healthcare needs. Senior students made visits to the homes of the team's clients, conducted assessments, interacted with families, and provided additional care. The team, which included physicians, nurses, a social worker, and therapists (occupational and physical) identified children and families who would benefit from home visits by students nurses who were directed by APNs. Both service and educational goals were accomplished by this community-based case-management experience. The children and their families received additional care from multiple healthcare providers. Students practiced components of community-based case management, and the CSST obtained vital information about their clients' living environments.     

Nurses’ experiences of guideline implementation: a focus group study

Aims. The aim of the study was to address the following questions: What kind of experiences do primary care nurses have of guideline implementation? What do nurses think are the most important factors affecting the adoption of guidelines? Background. The implementation of clinical guidelines seems to be dependent on multiple context‐specific factors. This study sets out to explore the experiences of primary care nurses concerning guideline implementation. Design. Qualitative interview. Methods. Data were generated by four focus group interviews involving nurses working in out‐patient services in primary health centres in Finland. Purposive sampling was used to select health centres. Inductive content analysis was used to identify themes emerging from the data. Results. Four main groups of factors were identified from the analysis of data: (i) factors related to the organisation, (ii) factors related to nurses, (iii) factors related to the anticipated consequences and (iv) factors related to the patient group. Nurses’ awareness and acceptance of guidelines and the anticipated positive consequences facilitate the implementation of guidelines. Organisational support, especially the adapting of guidelines to local circumstances, seems to be crucial for successful implementation. Conclusions. Clinical guidelines can be promising tools in enhancing evidence‐based nursing practice, as nurses see them as practical work tools in patient care and so are willing to adopt them. However, support from management and physicians is needed to ensure the successful implementation of guidelines into nursing practices. Relevance to clinical practice. Based on the findings of this study and previous knowledge of guideline implementation some practical recommendations are suggested. Select the most relevant guidelines to clinical practice, organise the adaptation of guidelines to local circumstances, inform all practitioners involved in treatment and give clear instructions for the adoption of the guidelines.     

Guidelines for clinical practice: development, dissemination and implementation

Clinical guidelines are one of the most promising and effective advances for defining and improving the quality of care (Journal of Nursing Care Quality 11(5) (1997) 48; Medical Care 39(8 Suppl. 2) (2001) II-46). However, their development, dissemination and implementation in practice are rarely straightforward. Within nursing practice, guidelines have the potential to ensure the clinical application of research findings, thus ensuring that the profession rejects ineffective practices while employing those shown to work. Nevertheless, the benefits and limitations of clinical guidelines should be carefully considered by practitioners, managers and consumers of health care alike.     

Using theory and evidence to drive measurement of patient,nurse and organizational outcomes of professional nursing practice

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization‐wide implementation of two nursing‐centric best‐practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence‐informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices.     

Faculty practice and health promotion in a community correctional facility

Faculty practice and health promotion are topics of interest to nursing faculty to prepare students and themselves for the future. Health promotion with vulnerable populations is a focus for the 21st century health care delivery system. Faculty practice emphasizing health promotion with a vulnerable population meets the needs of faculty as they strive to meet personal and professional goals. The development of a faculty practice serving a vulnerable population represented by clients in a community corrections facility will be described. Scope of practice, the development of a research focus, teaching approaches, and future initiatives are presented.     

Evidence-based practice (EBP) is not enough

Certainly times have changed, and incorporation of evidence-based practice into clinical practice is a welcome change from the past. Unfortunately, the expected improved efficiency and clinical outcomes have yet to be observed, and we believe this to be related to multiple disciplines working independently and a lack of focus on an interprofessional, systems-based approach to health care. Shared decision making amongst all members of the health care team is needed with a patient first mindset.