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Joan Stanley

In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety

Joan Stanley, PhD, NP, FAAN, FAANP | November 27, 2023 
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Editor’s note: Joan Stanley is the chief academic officer at the American Association of Colleges of Nursing (AACN).  We spoke to her about how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Sarah Mossburg: Doctor Stanley, welcome. Could you tell us a little bit about yourself and describe your current role?

Joan Stanley: Thank you for this opportunity to share. I am the chief academic officer at the American Association of Colleges of Nursing (AACN). In that capacity, I have served on numerous education initiatives, including the recent re-envisioning of the AACN Essentials, and now the Essentials implementation and transition to competency-based education. I have provided leadership and development for all of our past Essentials, which delineate the curricular expectations for baccalaureate, master’s, and doctor of nursing practice education. I am a nurse practitioner by education. I practiced in the University of Maryland Medical Center Primary Care Clinic and then in the Faculty Practice Office for 45 years. I taught in the University of Maryland Nurse Practitioner Primary Care Adult program from 1977 to 1982. So, I consider myself a pioneer of sorts for advanced practice nursing education. My doctorate is in higher education policy and organization from the University of Maryland at College Park.

Sarah Mossburg: For any members of our audience who are not from a nursing background, can you tell us a little bit about AACN and what role it plays in nursing education?

Joan Stanley: AACN, or the American Association of Colleges of Nursing, represents more than 865 baccalaureate and graduate schools of nursing in the United States. We establish quality standards for nursing education and assist schools in implementing those standards. We also promote public support for professional nursing education and offer conferences, webinars, and leadership development opportunities. We collect data each year on enrollment and graduation from professional nursing programs on faculty and dean demographics and academic salaries, which are used by schools to benchmark and by state and federal legislators for making policy decisions.

We also have an autonomous accrediting arm, the Commission on Collegiate Nursing Education, or CCNE, which accredits a majority of the baccalaureate, master’s, and doctor of nursing practice programs in the United States and territories. We have a certifying arm, the Commission on Nurse Certification, which offers the clinical nurse leader (CNL) certification for master’s degree graduates with a special focus on patient safety, quality improvement (QI), care coordination, and interprofessional team communication and leadership.

Sarah Mossburg: That’s great, a very expansive scope covering a lot to do with professional nursing education. As an expert in nursing education, can you speak about what patient safety topics are typically taught in undergraduate nursing settings?

Joan Stanley: Baccalaureate nursing programs for the past 15 years have used the AACN Essentials for Professional Nursing Practice, which were approved by our membership and published in 2008. All of our Essentials documents are consensus-based, so their development involves an iterative process including faculty, deans, and practice representatives. These standards provide a foundation for all baccalaureate and graduate nursing programs to design their curricula. They are required by CCNE, our accrediting arm that accredits a majority of the baccalaureate and graduate programs. The Essentials delineate the curricular expectations, outcomes, and recommended content for programs. The baccalaureate Essentials include domains in areas such as organizational and systems leadership, quality improvement and safety, informatics and healthcare technologies, and interprofessional collaboration. All of these include KSAs (or knowledge, skills, and abilities) related to safety and quality outcomes.

Sarah Mossburg: So within those domains, are there embedded topics such as principles or values of safety with systems approaches, safety culture, teamwork, is that accurate to say?

Joan Stanley: Yes, definitely. The school uses these standards as a foundation for their program. It is the prerogative of the school to design their own curriculum, based on their mission, values, and resources.

Sarah Mossburg: Can you speak to different ways that you’ve seen variation in the curriculum across schools?

Joan Stanley: I would say that programs use a variety of pedagogical strategies to provide this content. This would include lectures, case studies, skills labs, simulation, online and printed resources, as well as supervised patient care experiences in diverse settings. But as I said, it’s the school’s prerogative to design the curriculum and to determine the types of learning experiences. This may depend upon the clinical partners, resources, and the simulation facilities they have access to.

Sarah Mossburg: Are there any best practices for incorporating patient safety into the curriculum?

Joan Stanley: Yes. Since 2010, AACN has supported the work of the Quality and Safety Education for Nurses (QSEN) initiative, which was originally funded by the RWJ Foundation. Under this initiative, AACN offered 12 learning modules, including six focused on undergraduate education and six on graduate nursing education. These modules include patient-centered care, teamwork and collaboration, evidence-based practice, QI, safety, and informatics. Most undergraduate programs have integrated these modules, or what we call the QSEN competencies, into their curriculum. They have been the standard for safety and QI education for the last decade or so.

Sarah Mossburg: Thank you for bringing up QSEN. I think some of our nursing colleagues will be familiar with it. And how do the QSEN competencies relate to the Essentials?

Joan Stanley: Great question. The QSEN competencies have all been integrated into the new 2021 Essentials.

Sarah Mossburg: Could you tell us a little bit more about the Essentials? I believe that will help our readers understand the role that AACN plays in how schools teach about patient safety.

Joan Stanley: So I’ve mentioned that in 2021, the AACN member institutions overwhelmingly approved The Essentials: Core Competencies for Professional Nursing Education. The Essentials delineate the competencies expected of all graduates of a professional entry-level program, which includes the traditional BSN, the RN to BSN, and accelerated BSN, and generic or as they are also named, second-degree master’s nursing programs as well as traditional master’s and doctor of nursing practice programs. We believe the Essentials transform nursing education by calling for a transition to competency-based education.

It took about two and a half years to reach consensus on the competencies and education pathways. The process included input from a wide variety of stakeholders, including input and engagement from clinical stakeholders. In practice, we’re talking about the leaders within a clinical practice, as well as those at the point of care, the care team. That is one of the most exciting things about the 2021 Essentials. Practice representatives were included in the development of the competencies. We continue to engage with them, and we strongly encourage schools to engage with practices more intently, as we begin this transformation and move forward to design learning opportunities, strategies, and assessments. We believe this is critical for creating a more practice-ready nurse. We learned through our conversations with clinical practices that we need a common language and similar expectations for our nurses entering the workforce. Our practice partners have said that the Essentials will provide a platform for them, not only for setting entry-level expectations but also for ongoing professional career development for the nurses that they have in their employment.

So we are very excited about that and believe that the Essentials will help to address many of the issues we have experienced and heard about both from academia and practice. Our goal is to prepare a more practice-ready nurse.

Sarah Mossburg: Could you expand a little bit on the issues that you just mentioned? What are some of those issues?

Joan Stanley: The issues of retention of new and even veteran nurses. Nurses not feeling practice-ready when they enter the workforce. Maybe it’s because they don’t understand the environment in which they’re asked to practice in. It may not be what they’ve experienced or been taught in their program. But that’s why practice and academia need to come together to have a common language, clear expectations for the graduates about what competencies they are expected to be able to demonstrate, and what that looks like. That partnership will keep practicing nurses current in the evolving and changing healthcare environment, which is so important.

Sarah Mossburg: You mentioned competency-based education earlier. Could you expand a bit on how competency-based learning differs from a traditional model?

Joan Stanley: Yes. This is something we are working on now, to provide education and share what we mean by competency-based learning. Not only with academia but also with our practice partners as well. When many people hear about competency-based education, they immediately think about time-variable education, which is where a student could come into a program and pass certain standardized examinations to move more quickly through the program of study. Some schools have done that, but AACN is not telling our schools that they need to transition to a time-variable model. In addition to needing to develop valid and reliable assessment methods, there are a number of regulatory barriers for time-variable education.

The traditional model of education is focused on the learner showing what they know. The faculty member is usually on the “stage,” and they impart the knowledge and information to the student. Competency-based education is focused on being able to demonstrate what the learner can do with what they know or have learned. That is a huge mind shift for both the student and faculty. The learner has a much more active role in their learning, and the faculty are the guide or coach for the learner.

Another big change is the feedback and assessment that must occur frequently across the entire curriculum, particularly assessments and feedback that are not for grading purposes. These assessments provide feedback to the student and learner about where they are in the journey to attaining and being able to demonstrate the competencies, as well as what they can do to further advance their competency development. This could take a variety of forms. It could come from whomever is overseeing the student: mentor, preceptor, or faculty member. It could involve providing feedback on those competencies that were the focus of that particular scenario. For these assessments, the student must know what competencies they’re working on. The faculty and the preceptor must know as well. Then, they can give feedback pertaining to those. It’s not just “what they did or didn’t do right” but “what they can do to advance and develop competence in that area.”

Sarah Mossburg: That’s really helpful. So a very simplified way to think about that is the traditional model is about knowing and the competency-based model is about knowing and doing, is that right?

Joan Stanley: Yes. It’s about being able to know and demonstrate what you can do with what you know, so the competencies must be observable and measurable. Frequently, when we talk about competencies or competency assessment, people think of psychomotor tasks, but that’s not all we’re talking about. That could be a component of a competency to demonstrate a skill, but that is not the primary area. Competencies could be focused on safety-based skills like the ability to communicate, the ability to resolve conflict in a difficult situation, interprofessional communication with a team member, or the ability to demonstrate their clinical reasoning in a patient situation.

Sarah Mossburg: That’s great. That leads me almost directly into my next question, which is how the Essentials incorporate safety topics, like safety culture and teamwork, or more specific things, like the safety harm scenarios that nurses commonly experience related to things like falls or hospital acquired infections?

Joan Stanley: Yes, that’s a great segue into what I was going to share about the new Essentials. The 2021 Essentials have a strong emphasis on safety and quality improvement. There are 10 domains or areas of competence that are considered critical to professional nursing practice. Under each domain there are two sets of subcompetencies that we expect a graduate or a learner to demonstrate before they graduate from an entry-level or advanced-level program.

Quality and safety is one of the 10 domains. In that domain, there are competencies related to established and emerging principles of safety and improvement science. The Essentials recognize “quality and safety as core values of nursing practice to minimize risk of harm to patients and providers through system and individual performance.” And I mentioned previously, all the QSEN competencies are integrated into the Essentials. Another example of safety within the 10 domains would be in the systems-based practice domain with competencies that address understanding and working within systems and the ability to coordinate resources to provide safe, quality, and equitable care to diverse populations.

Sarah Mossburg: How would you expect to see someone demonstrating competency in some of these big concepts you talked about, like safety and improvement science, for example?

Joan Stanley: For example, under the quality and safety domain for an entry-level nurse, some of the competencies are as follows:

  • Recognize a nurse’s essential role in improving healthcare quality and safety.
  • Identify sources and applications of national safety and quality standards to guide nursing practice.
  • Implement standardized evidence-based processes for care delivery.
  • Interpret benchmark and unit outcome data to inform individual and microsystem practice.
  • Compare quality improvement methods in the delivery of patient care.
  • Identify strategies to improve outcomes.
  • Develop a plan for monitoring quality improvement change.
  • Examine basic safety design principles to reduce risk of harm.
  • Assume accountability for reporting unsafe conditions, near misses, and errors to reduce harm.
  • Describe processes used in understanding causes of error.

Under those big broad domain areas that I listed originally, there are very specific behaviors that a learner would be expected to demonstrate to show they had attained the competency. The program would be expected to design the learning experiences, either didactic or clinical, for those expected outcomes.

Sarah Mossburg: You mentioned didactic or clinical learning experiences, and since nursing is a practice-based discipline, I’m curious about how safety is incorporated into clinical rotations for students, and how the Essentials are part of that?

Joan Stanley: I’m glad you emphasized that nursing is a practice discipline because actual practice is a key component of the learning experience. Each school or program designs its curriculum to include direct patient care experiences. Some states have set specific requirements for clinical hours in various types of settings, but the Essentials do not specify a number of clinical hours. However, it does state that all learners in entry-level professional nursing education programs must engage in direct patient care learning activities in four spheres of care across the lifespan: wellness and disease prevention, chronic disease management, regenerative restorative care, and hospice palliative care. The competencies are relevant for any area of practice, including the patient safety-related and quality improvement competencies.

Indirect care experiences are also important, such as designing or evaluating outcome data, looking at safety data, or designing the plans for how they would improve care outcomes. The learner may not be providing the direct care to the patient, but these kinds of experiences should be incorporated as well.

Sarah Mossburg: Are preceptors or clinical sites asked to explicitly cover safety topics?

Joan Stanley: Yes. As I described with competency-based education, a key step to designing experiences is to identify the outcomes that you want for that particular learning experience, whether it’s in a clinical area, in a simulation, or in a classroom. The preceptor, the clinical faculty, and the student have to be very clear about the outcomes and competencies that they will be working on during a particular experience. And the preceptor or the clinical faculty needs to understand their role in providing feedback to the learner on performance specific to those competencies. This kind of feedback is very important to the student’s competency development.

Sarah Mossburg: We saw in a recent literature review exploring the role of education and developing a culture of safety, that the researchers noted students often have trouble translating classroom instruction on safety into the clinical setting. I’d like to hear your thoughts on that, and how schools and instructors could best bridge the gap between those two environments.

Joan Stanley: This is why the practice–academic partnership is so important at all levels. Faculty and practitioners need to have a common understanding and a common language for what is expected of the student in a particular experience and setting. We encourage programs, more and more, to have these practice partners and bring them in to help design the learning experiences. This collaboration is important to ensuring that expectations are clear, and the experiences are preparing students for the evolving healthcare environment. With real-world experiences, students will indeed be developing the competencies needed when they get into the practice environment.

So we believe that a common understanding and language, and being able to know what the new evolving healthcare system looks like, is extremely important. This approach will hopefully address that lack of confidence expressed by many new graduates. Of course, you’re never going to create a fully confident student going into a new environment or a new role, but it should improve that. Graduates should feel more competent, confident, and able to practice in many different settings.

Sarah Mossburg: It’s like a razor’s edge of where we want them to be, because in many ways people who are overly confident as a new graduate are incredibly dangerous. They clearly don’t understand the potential risks and harms that could happen based on their care. But on the other side is someone who is so paralyzed by fear that they have trouble practicing. It’s a challenge to educators to get students graduated at the point where they are functional, realistic, and understand how critical their role is.

Joan Stanley: I think what you just described was the Dunning-Kruger effect. That’s why it’s so important for faculty and preceptors to know how to give feedback to students, and for the students to be able to self-reflect on their ability. Because, as you said, the highest achieving students are the least confident. When they do their self-reflection, they think they may not be doing as well. Whereas students who have no idea what they’re supposed to be doing, and don’t recognize whether they’re safe or not, have the highest level of confidence. So that is a key part of this transition to competency-based education.

Sarah Mossburg: That seems like a good method to help students understand where they personally are, being able to help them self-reflect. Speaking of students, I am curious to hear about students’ experiences of safety events in clinical settings?

Joan Stanley: Well, a lot of it is determined by the curriculum and the learning experiences that are developed. Certainly based on the competencies, we would expect students to be engaged in safety and quality improvement events at different levels. There are many different types of events that a student may observe or engage in in the care setting, or possibly in a simulated experience. If it’s something that’s high risk and may not occur frequently, hopefully it would be done in a simulated environment, so that they would know how to respond.

Students, even entry-level students, could be engaged in many things in a practice setting, such as comparing quality improvement processes that are used in different care settings, identifying actual and potential risks to patients or to providers in the workplace, observing and describing processes used to determine causes of errors. They may be asked to develop a fish-bone diagram or participate in a root-cause analysis. Some of these can be done based on real-life scenarios or cases that have occurred. I mentioned that practice partners are great at identifying and sharing scenarios that can be used in the classroom or in a simulation environment. Students also may participate in the change process of a quality improvement committee, or in implementing a new policy to improve patient or provider safety.

Sarah Mossburg: It sounds like there are many opportunities to engage students in experiences of understanding potential safety events in the clinical setting or using simulation and post-event analysis. Are there any best practices for reviewing safety events or near misses that students witness or are part of?

Joan Stanley: Students should have these experiences either within the clinical environment or simulation, and I think best practices are the case scenarios that come right from practice settings, so that they are able to describe safety issues that we know that they’re likely to face in practice settings. Cases can either be unfolding and become more complex across the curriculum, or depending upon the competencies that are expected, that address safety risks, including both identifying and mitigating risk. We don’t want errors to occur, but graduates can be better prepared to address them through learning experiences focused on identifying when a patient is at risk, looking at potential safety issues, and knowing how to address errors in a simulated environment with debriefing and discussion.

Sarah Mossburg: Debriefing and discussion. That’s a great point. We saw in the literature that there’s some indication that students are afraid to speak up. Can you speak to potential causes for that and any suggestions that could mediate or alleviate that fear?

Joan Stanley: Students, in general, are hesitant to speak up when they witness an error or a potential error, or a risk to a patient or provider, due to the power differential. They may also feel that his or her knowledge is not as advanced, or they may be afraid of retribution. But this is really an important competency that students need to gain to feel empowered. It is their responsibility to speak up when they see something. Practicing these situations in a safe, simulated environment, followed by debriefing and with positive reinforcement and suggestions, will help alleviate some of this reaction by the students. And it is the faculty’s role to coach the student and empower them to speak up when they see something, and to help students realize that this is part of their role.

One of the key competencies in the Essentials is to assume accountability for reporting unsafe conditions, near misses, and errors in order to reduce harm. I know schools will be working on developing scenarios and cases to measure this competency.

Sarah Mossburg: That’s great. I’m glad to hear that’s such an important competency as part of the Essentials. We recently talked to Patricia McGaffigan from the Institute for Healthcare Improvement about the National Action Plan for Safety and Total Systems Safety. Part of that conversation was about health systems re-engaging in the core work of safety using proactive approaches. You’ve talked a lot about academics engaging practice partners to develop that common language. I would be curious to hear you talk about how practice partners could engage academics and incorporate students into proactive approaches to safety in their organizations.

Joan Stanley: I think many people assume that only advanced-level students work on policy or in committees to develop proactive approaches. But entry-level students can also have these opportunities to engage in initiatives, policy discussions, change processes, and implementation efforts. They could also be part of looking at what change might be needed, including coming up with recommendations for policies and processes, and conducting an assessment of current practices. Students must have opportunities to go beyond just reading about something. They should be able to engage and demonstrate desired behaviors and practice.

Through true partnerships between practice and academia, whether it’s at the faculty or leadership level, we’ve seen multiple opportunities for research participation. Academia can bring that expertise to the practice setting, identifying where research might be engaged and how practice can be engaged with it. For example, looking at processes and looking at outcome data and trends. This needs to be a bi-directional process and partnership, and students need to engage in these types of activities if we want them to be able to do it when they get out into practice.

Sarah Mossburg: That’s a great point. We’ve had such a rich discussion. I’m sure we could continue talking for a while, but being cognizant of your time, is there anything that we didn’t discuss that you’d like to cover?

Joan Stanley: Well, I have mainly been addressing entry-level professional nursing education. However, much of what I have said also applies to graduate or advanced-level nursing education. One thing that I do want to share with the readers is that in 2004, AACN started a national discussion on what nursing needed to do to address the multitude of errors that were occurring in this country’s health system. As a result of that discussion, many competencies have evolved and were integrated into the 2021 Essentials.

But we also created a new role and set of competencies specific to a master’s degree in nursing called the CNL. This master’s degree-prepared nurse has a heavy emphasis on addressing safety, quality improvement, risk assessment, interprofessional communication, and leadership, particularly at the microsystem or unit level. Though the role has primarily been implemented in acute care, the CNL has been effectively implemented in a variety of care settings, including home care, long-term care, and school health. Many large health systems have incorporated and are using CNLs in their care delivery models. They have realized significant improvements in care outcomes and cost savings specifically related to patient safety, quality improvement, and risk assessment. We continue to work with systems and academic settings to develop these programs and to inform them about the focus on quality and safety, and the outcomes that are being realized.

Sarah Mossburg: That’s wonderful. Thank you for sharing that. I have really enjoyed our conversation today. Any final thoughts?

Joan Stanley: There is one resource that I forgot to mention. We have developed an interactive toolkit for the Essentials, and it’s all online. It includes multiple resources, including learning and assessment strategies for programs. I wanted to bring it up because it’s going to be a living, evolving product, so we want others to contribute if they have a learning strategy, or a resource, or an assessment strategy that they think should be included and available to other schools. There is a form that educators can fill out to submit a strategy and have it peer reviewed. They can cite this contribution on their CVs if it is accepted.

Sarah Mossburg: That is really helpful. Thank you very much.

Joan Stanley: Thank you for the opportunity.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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