Guest Editorial: Quality, safety, and hope
Article Outline
It's the end of August as I write this editorial for a very special issue of Nursing Outlook on quality and safety. It's hot here in Arizona but nowhere near as hot as in the debates over changes in our healthcare system. I find the myths and misunderstandings about healthcare breathtaking in their scope and the depth of passion they reveal in fellow citizens. Behind some of the rhetoric and the fear, I hear very deep feelings about autonomy, respect, provider-patient relationships and, yes, quality and safety. I really didn't anticipate all of this. With my sights on the prize of a better healthcare system, I thought reform would be easier, the need and benefits of change more obvious. What an amazing reminder of the human element in health care—the unpredictability, the depth, and the complexity. And as I think about the messages of this issue on nursing's role in quality and safety and on preparing future undergraduate and graduate nurses for practice, I believe this work is critical. It is a central piece of what we need to be doing and where we need to be. I also believe how we are doing this work is critical—and a harbinger of hope for future change and innovation.
Only 2 years ago, the first set of quality and safety competencies for baccalaureate education were published in Nursing Outlook. In her editorial, Marla Salmon1 challenged us to honor and, at the same time, look beyond our traditional perspectives to drive the quality and safety movement in concert with administrators, other healthcare groups, and consumers. We have made numerous advances. The Quality and Safety Education for Nurses Project (QSEN) funded by the Robert Wood Johnson Foundation (RWJF) has now entered an exciting third phase. We can look with great satisfaction at the groundbreaking research linking nursing practice to quality and safety outcomes coming out of the RWJF-funded Interdisciplinary Nursing Quality Research Initiative (INQRI). Nurses and nursing organizations have expanded their roles and influence in major initiatives at the National Quality Forum (NQF) and the Institute for Healthcare Improvement (IHI). Nurses at the bedside are spearheading hundreds of new ways to improve patient care in RWJF's Transforming Care at the Bedside. These are only a few of the important nursing and interdisciplinary initiatives underway focused on improving quality and safety education, research, and practice.
I should note that my perspective here has been shaped by opportunities I have had to be part of this work, and my reflection on improving quality and safety in an interdisciplinary and increasingly complex healthcare world. I was nominated to serve on the NQF Steering Committee on care coordination by the nursing member organizations of NQF; the nomination process is coordinated across multiple nursing organizations rather than a single entity. As co-chair of this interdisciplinary committee, I have learned many important ways with my physician co-chair, to build the “common ground of healthcare quality and safety” that Marla Salmon urged us to pursue. In QSEN, my team at Emory worked across clinical and classroom settings and involved scores of colleagues in medicine in teamwork and simulation training. In INQRI, we were challenged to walk our interdisciplinary talk and show how integrating theory, methods, and analysis would accelerate our understanding of nursing's impact on quality outcomes.
For me, the amalgam of articles in this issue tells a compelling story of nursing's past and of a strong and realistic commitment to the future. Certainly, the focus on quality and safety are not revolutionary in nursing or healthcare. All of us, I would like to imagine, are well aware of the Institute of Medicine (IOM) quality series and keep current with how we're doing on the goals and objectives for the future. Keeping Patients Safe, now five years old, set the stage for critical dialogues we continue to have about workforce issues and nursing practice. Similarly, the 2003 IOM report Health Professions Education2 launched a new look at quality and safety competencies across health disciplines, including nursing that is so evident in this issue of Nursing Outlook.
The articles in this issue begin to fill in the question marks about how we move from vision to preparation of nurses who can fulfill the vision. They address how we will face our future and our commitments to the knowledge, skills, and values that are essential to practice nursing and provide nursing care in environments of unprecedented complexity and turbulence. In the projects and studies presented here, I am struck by the willingness of nursing faculty, practitioners, and students to face and leave behind the parts of the past that no longer work. At a recent QSEN meeting, I was delighted to hear the demise of sacred cows in statements like, “We don't map course content anymore. It's too easy to just say we're already doing everything—and we know we're not.” I am also struck that, as Marla Salmon suggested, we are leaving behind old notions of consensus and, instead, allowing for debate, dialogue, and unpredictable outcomes. The meeting called to address quality and safety competencies for advanced nursing practice described in the Cronenwett article did not start with, “our goal is to agree on….” Instead, it opened with “we have no preconceived notions about the final outcomes of our work together.”
The work ahead requires bold new approaches. Look closely at the undergraduate and graduate quality and safety competencies. They are not “same old”—and if you think they are, look again. Undergraduate competencies require that nurses are systematically prepared and evaluated on being effective team members and, in appropriate situations, team leaders, on analyzing and using evidence to guide their practice, using quality improvement principles and processes, practicing patient-centered care and carefully building in patient and family preferences, and integrating technology in their practice. The graduate competencies build on these core processes and include greater complexity in leadership and application of evidence and technology, as might be expected.
These articles abound with refreshing new insights and honesty about tackling the work ahead. Students comment on their achievement of quality and safety competencies and their perception of faculty readiness to teach these competencies. Faculty polled in Barton et al's study propose that we sequence course competencies in ways that challenge traditional assumptions and are guaranteed to foment very lively debates. Teaching methods are questioned throughout.
Take the discussions about teamwork competencies as just one example of many. Certainly not a new area in nursing education, teamwork, collaboration, and interdisciplinary education are now considered centerpieces of an effective safety culture. In Taylor Sullivan et al's article, senior nursing students across all types of nursing programs rate their exposure to content on teamwork and collaboration as second lowest across the 6 competencies. They described limited exposure to interdisciplinary practice, a finding that has been echoed by nursing faculty in national meetings3 and an extensive set of national studies and reports. Students also questioned whether faculty members possess the knowledge and skill to teach teamwork, quality improvement, and other competencies.
In response to Barton et al's Delphi survey about when and where in the curriculum teamwork competencies should be introduced, faculty respondents agreed that the vast majority of teamwork competencies be moved to the beginning of nursing programs. The implications of these recommendations on curriculum design and teaching strategies boggle the mind—and give me hope that we can finally overcome the obstacles, like course scheduling and faculty time, that have prevented us from designing more timely and meaningful interdisciplinary experiences for decades. If you believe these problems are new, I invite you to read DeWitt Baldwin's4 reflections on the history of interdisciplinary education in the US. It's time we solved them—and these articles suggest we're on the right path to doing so.
The descriptions of efforts among advanced nursing practice organizations to evaluate their quality and safety competencies in these articles also reflect more open discourse and, in some areas, respectful and clearly-stated disagreement. Importantly, the opinions of multiple stakeholders, including practitioners in the field, have been invited and incorporated into action plans and next steps. When they started cross-mapping quality and safety competencies for advanced nursing practice, Pohl and colleagues unapologetically noted they limited their initial efforts to knowledge competencies rather than all of the domains. Kudos to them for tackling this work and being realistic in their approach. I believe we are much more likely to see meaningful change as a result.
In one paper, a student shares the wish for us to find better ways to bridge classroom and practice in improving healthcare quality and safety and to start earlier. I hope this student reads this issue and hears the undercurrent of change and innovation in nursing education. In the midst of today's debates about the future of our healthcare system, this is foundational work closely linked to our ability to change health policy and our healthcare system. No surprises here—nursing education is inextricably tied to nursing research and practice and our ability to innovate and change. I am hopeful that we are on a path in which we no longer hear “too little too late” (as this student wrote) to comments like “well prepared to improve safety and the quality of the healthcare experience through collaboration, timely and effective use of evidence and technology….”
A final reflection: In his speeches, I often take notice when President Obama talks about the role of nurses in improving our healthcare system. He has spoken eloquently about how nurses have been there for his family during health-related experiences, like the births of his 2 daughters, and the value of a profession that understands these experiences. I believe the work in this issue indicates we not only understand; we will prepare the nurses of the future with knowledge and tools that drive a better healthcare system. As the debates continue, nurses—along with other colleagues from many other professions—are systematically developing and implementing the educational infrastructure required for a better, safer healthcare system. In the midst of a long hot summer, this vision and the evidence in these articles that we are committed to a new way of action gives me hope for a better healthcare system—hopefully soon.
References
- . Guest editorial: Care, quality, and safety: same old?. Nurs Outlook. 2007;55:117–119
- . Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003;
- Quality and safety education for nurses. Nurs Outlook. 2007;55:122–131
- . Some historical notes on interdisciplinary and interprofessional education and practice in healthcare in the U.S. J Interprof Care. 2007;21:23–37
Gerri Lamb, PhD, RN, FAAN, is an Associate Professor, Arizona State University College of Nursing and Health Innovation and Visiting Scholar, Emory University Nell Hodgson Woodruff School of Nursing, Atlanta, GA.
PII: S0029-6554(09)00174-2
doi:10.1016/j.outlook.2009.09.001
© 2009 Mosby, Inc. All rights reserved.
