2.16 QSEN: Advocating for Patient Safety and Quality Care in Nursing Education
Ernstmeyer & Christman - Open Resources for Nursing (Open RN)
The Quality and Safety Education for Nurses (QSEN) project began advocating for safe, quality client care in 2005 by defining six competencies for nursing graduates. This initiative was created after a decade of review and investigation into the high number and high cost of medical errors in the United States. The goal of the QSEN initiative was to prepare future nurses with the knowledge, skills, and attitudes needed to improve the quality and safety of the health care system. Historically, nursing education focused on knowledge and skill acquisition, but did not address the attitudes and values of the nurse. The QSEN competencies are designed to train nursing students in prelicensure nursing programs. The six QSEN competencies, as shown in Figure 10.6,[1] are Patient-Centered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, Safety, and Informatics.[2]
Read the QSEN Prelicensure Table of Competencies.
Patient-Centered Care
The Patient-Centered Care QSEN competency advocates for the client as “the source of control and full partner in providing compassionate and coordinated care based on respect for client’s preferences, values, and needs.”[3] This competency encourages nurses to consider clients’ cultural traditions and personal beliefs while providing compassionate care. Client-centered care also includes the family in the care team. The goal of client-centered care is to improve the individual’s health outcomes. Integration of this competency has led to improved client satisfaction scores, reduced expenses, and a positive care environment.[4]
Teamwork and Collaboration
The Teamwork and Collaboration QSEN competency focuses on functioning effectively within nursing and interprofessional teams and fostering open communication, mutual respect, and shared decision-making to achieve quality client care.[5] Effective communication has been proven to reduce errors and improve client safety.[6] The Joint Commission also includes improved communication as one of the National Patient Safety Goals, aligning with this QSEN competency. Collaboration requires information sharing across disciplines with respect for the knowledge, skills, and experience of each team member. Two examples of tools used to promote effective teamwork and collaboration are ISBARR and TeamSTEPPS®. Additionally, “principles of collaboration” have been established by the ANA.
ISBARR
Several communication tools have been developed to improve communication in various health care settings. ISBARR is an example of a well-established communication tool. As previously discussed in the “Collaboration Within the Interprofessional Team” chapter, ISBARR is a mnemonic for the components to include when communicating with other health care team members: Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.[7]
TeamSTEPPS®
As previously discussed in the “Collaboration Within the Interprofessional Team” chapter, TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) is a well-established framework to improve client safety through effective communication in health care environments. It consists of four core competencies: communication, leadership, situation monitoring, and mutual support.
Principles of Collaboration
The American Nurses Association (ANA) and the American Organization of Nurse Executives (AONE) jointly created the “Principles of Collaboration” to guide nurses in creating, enhancing, and sustaining collaborative relationships. These principles include effective communication, authentic relationships, and a learning environment and culture. The principle of authentic relationships includes the following guidelines[8]:
- Be true to yourself – be sure your actions match your words and those around you are confident that what they see is what they get.
- Empower others to have ideas, to share those ideas, and to participate in projects that leverage or enact those ideas.
- Recognize and leverage each other’s strengths.
- Be honest 100% of the time – with yourself and with others.
- Respect others’ personalities, needs, and wants.
- Ask for what you want but stay open to negotiating the difference.
- Assume good intent from others’ words and actions, and assume they are doing their best.
Read more about the “Principles of Collaboration” by the ANA and AONE.
Evidence-Based Practice
The Evidence-Based Practice QSEN competency focuses on integrating scientific evidence with clinical expertise and client/family preferences and values for delivery of optimal health care.[9] See Figure 10.7[10] for an illustration of Evidence-Based Practices (EBP). Read more about EPB in the “Quality and Evidence-Based Practice” chapter. Read examples of evidence-based improvements in the following box.
Read these examples of evidence-based practice improvements:
Intravenous catheter sizes PDF
Quality Improvement
The Quality Improvement QSEN competency focuses on using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.[11] The goal of this competency is to improve processes, policies, and clinical decisions to improve client outcomes and system performance. As the pool of nursing literature grows and nursing practices have been updated to reflect current evidence, health care organizations have seen improvements in quality, safety, and experienced cost savings.[12] Read more about the quality improvement processes in the “Quality and Evidence-Based Practice” chapter.
Safety
The Safety QSEN competency focuses on minimizing “risk of harm to patients and providers through both system effectiveness and individual performance.”[13] Although safety is embedded in all of the QSEN competencies, this competency specifically advocates for preventing client harm. Despite the health care industry’s continued focus on process improvement and improving client outcomes, errors continue to occur, and nurses are often involved in these events as frontline caregivers. Safe nursing practice starts with an awareness of the potential risks for client harm in every situation.
Several initiatives have been adopted to reduce risk for client harm, such as double-checking high-risk medications and verifying a client’s name and date of birth prior to every intervention. However, client safety is compromised when there are gaps in quality measures such as inadequate staff training, broken equipment, or an organizational culture that doesn’t support best practices.
The “Safety” competency is best addressed by organizations establishing a safety culture where every worker commits to keeping client safety at the center of decision-making. An organization that has a culture of safety encourages reporting of unusual incidents, process failures, or other issues that could cause client harm, allowing the organization to investigate the event and take action to prevent the event from occurring in the future. Improvements are made as a result of a culture that questions attitudes, actions, and decisions in client care and recognizes threats to safety. Read more about safety culture in the “Legal Implications” chapter.
Informatics
The Informatics QSEN competency focuses on using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.[14] Health care is filled with various technologies used to promote a safe care environment, such as electronic medical records (EMRs), bedside medication administration devices, smart IV pumps, and medication distribution systems. These technologies provide safeguards and reminders to help prevent client harm, but the nurse must be knowledgeable in using technology, as well as understand how information obtained from technologies is used to improve client outcomes. As information related to technology continues to evolve, it is the responsibility of every nurse to participate in continued professional development related to informatics.
Next: 2.17 Spotlight Application
Media Attributions
- QSEN Competencies by Kim Ernstmeyer
- Evidence Based Practice by Kim Ernstmeyer
- “QSEN Competencies.png” by Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- QSEN. (n.d.). About ↵
- QSEN. (n.d.). About. https://qsen.org/about-qsen/ ↵
- Roseman, D., Osborne-Stafsnes, J., Amy, C. H., Boslaugh, S., & Slate-Miller, K. (2013). Early lessons from four 'aligning forces for quality' communities bolster the case for patient-centered care. Health Affairs, 32(2), 232-241. ↵
- QSEN. (n.d.). About. https://qsen.org/about-qsen/ ↵
- Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager, 39(3), 128-132. ↵
- Enlow, M., Shanks, L., Guhde, J., & Perkins, M. (2010). Incorporating interprofessional communication skills (ISBARR) into an undergraduate nursing curriculum. Nurse Educator, 35(4), 176-180. ↵
- American Nurses Association & American Organization of Nurses Executives. (n.d.). ANA/AONE principles for collaborative relationships between clinical nurses and nurse managers. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-collaborative-relationships.pdf ↵
- QSEN. (n.d.). About. https://qsen.org/about-qsen/ ↵
- “Evidence-Based Practice.jpg” by Kim Ernstmeyer for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- QSEN. (n.d.). About. https://qsen.org/about-qsen/ ↵
- Cullen, L., Titler, M. G., & Rempel, G. (2011). An advanced educational program promoting evidence-based practice. Western Journal of Nursing Research, 33(3), 345-364. ↵
- QSEN. (n.d.). About. https://qsen.org/about-qsen/ ↵
- QSEN. (n.d.). About. https://qsen.org/about-qsen/ ↵
As discussed previously, the American Nurses Association (ANA) defines advocacy at the individual level as educating health care consumers so they can consider actions, interventions, or choices related to their own personal beliefs, attitudes, and knowledge to achieve the desired outcome. In this way, the health care consumer learns self-management and decision-making.[1] Advocacy at the interpersonal level is defined as empowering health care consumers by providing emotional support, assistance in obtaining resources, and necessary help through interactions with families and significant others in their social support network.[2]
What does advocacy look like in a nurse’s daily practice? The following are some examples provided by an oncology nurse[3]:
- Ensure Safety. Ensure the client is safe when being treated in a health care facility and when they are discharged by communicating with case managers or social workers about the client’s need for home health or assistance after discharge so it is arranged before they go home.
- Give Clients a Voice. Give clients a voice when they are vulnerable by staying in the room with them while the doctor explains their diagnosis and treatment options to help them ask questions, get answers, and translate information from medical jargon.
- Educate. Educate clients on how to manage their current or chronic conditions to improve the quality of their everyday life. For example, clients undergoing chemotherapy can benefit from the nurse teaching them how to take their anti-nausea medication in a way that will be most effective for them and will allow them to feel better between treatments.
- Protect Client Rights. Know clients’ wishes for their care. Advocacy may include therapeutically communicating a client’s wishes to an upset family member who disagrees with their choices. In this manner, the client’s rights are protected and a healing environment is established.
- Double-Check for Errors. Know that everyone makes mistakes. Nurses often identify, stop, and fix errors made by interprofessional team members. They flag conflicting orders from multiple providers and notice oversights. Nurses should read provider orders and carefully compare new orders to previous documentation. If an order is unclear or raises concerns, a nurse should discuss their concerns with another nurse, a charge nurse, a pharmacist, or the provider before implementing it to ensure client safety.
- Connect Clients to Resources. Help clients find resources inside and outside the hospital to support their well-being. Know resources in your agency, such as case managers or social workers who can assist with financial concerns, advance directives, health insurance, or transportation concerns. Request assistance from agency chaplains to support spiritual concerns. Promote community resources, such as client or caregiver support networks, Meals on Wheels, or other resources to meet their needs.
Nurses must recognize their unique position in client advocacy to empower individuals to provide them with the support and resources to make their best judgment. The intimate and continuous nature of the nurse-client relationship places nurses in a prime position to identify and address the needs and concerns of their clients. This relationship is built on trust, empathy, and consistent interaction, which allows nurses to gain a deep understanding of their clients' values, preferences, and personal circumstances. By leveraging this close proximity and strong rapport, nurses can effectively advocate for their clients, ensuring that their voices are heard, and their wishes are respected in all aspects of care.[4]
The power of the nurse-client relationship extends beyond the immediate clinical environment. Nurses often act as liaisons between clients and the broader health care team, facilitating communication and ensuring that client preferences are integrated into care plans. This advocacy role is crucial in navigating complex health care systems where clients may feel overwhelmed or marginalized. Nurses can help demystify medical jargon, explain treatment options, and support clients in making informed decisions that align with their values and goals. Through education and emotional support, nurses empower clients to take an active role in their own care, enhancing client autonomy and satisfaction.[5]
In addition to direct client care, nurses play a pivotal role in identifying systemic issues that affect client outcomes. Their frontline perspective provides valuable insights into the barriers clients face in accessing quality care, such as socioeconomic challenges, cultural barriers, and institutional policies. By advocating for policy changes and improvements in health care delivery, nurses contribute to creating a more equitable and client-centered health care system. Their advocacy efforts can lead to the implementation of practices and policies that better address the needs of diverse client populations, ultimately improving health outcomes on a broader scale.[6]
Nurses' advocacy is also essential in situations where clients are unable to speak for themselves, such as in cases of severe illness, disability, or end-of-life care. In these instances, nurses must be vigilant in recognizing and addressing the needs of vulnerable clients, ensuring that their rights and dignity are upheld. This may involve working closely with families and caregivers, coordinating with interdisciplinary teams, and navigating ethical dilemmas to provide the best possible care for the client.
Next: 2.13 Community and Organization Advocacy
Advocacy
The American Nurses Association (ANA) emphasizes that advocacy is fundamental to nursing practice in every setting. See Figure 10.1[7] for an illustration of advocacy. Advocacy is defined as the act or process of pleading for, supporting, or recommending a cause or course of action. Advocacy may be for individuals, groups, organizations, communities, society, or policy issues[8]:
- Individual: The nurse educates health care consumers so they can consider actions, interventions, or choices related to their own personal beliefs, attitudes, and knowledge to achieve the desired outcome. In this way, the health care consumer learns self-management and decision-making.[9]
- Interpersonal: The nurse empowers health care consumers by providing emotional support, assistance in obtaining resources, and necessary help through interactions with families and significant others in their social support network.[10]
- Organization and Community: The nurse supports cultural and social transformation of organizations, communities, or populations. Registered nurses understand their obligation to help improve environmental and societal conditions related to health, wellness, and care of the health care consumer.[11]
- Policy: The nurse promotes inclusion of the health care consumers’ voices into policy, legislation, and regulation about issues such as health care access, reduction of health care costs and financial burden, protection of the health care consumer, and environmental health, such as safe housing and clear water.[12]
Advocacy at each of these levels will be further discussed in later sections of this chapter.
Advocacy is one of the ANA’s Standards of Professional Performance. The Standards of Professional Performance are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently."[13] See the following box to read the competencies associated with the ANA’s Advocacy Standard of Professional Performance.[14]
Competencies of ANA’s Advocacy Standard of Professional Performance[15]
- Champions the voice of the health care consumer.
- Recommends appropriate levels of care, timely and appropriate transitions, and allocation of resources to optimize outcomes.
- Promotes safe care of health care consumers, safe work environments, and sufficient resources.
- Participates in health care initiatives on behalf of the health care consumer and the system(s) where nursing happens.
- Demonstrates a willingness to address persistent, pervasive systemic issues.
- Informs the political arena about the role of nurses and the vital components necessary for nurses and nursing to provide optimal care delivery.
- Empowers all members of the health care team to include the health care consumer in care decisions, including limitation of treatment and end-of-life care.
- Embraces diversity, equity, inclusivity, health promotion, and health care for individuals of diverse geographic, cultural, ethnic, racial, gender, and spiritual backgrounds across the life span.
- Develops policies that improve care delivery and access for underserved and vulnerable populations.
- Promotes policies, regulations, and legislation at the local, state, and national levels to improve health care access and delivery of health care.
- Considers societal, political, economic, and cultural factors to address social determinants of health.
- Role models advocacy behavior.
- Addresses the urgent need for a diverse and inclusive workforce as a strategy to improve outcomes related to the social determinants of health and inequities in the health care system.
- Advances policies, programs, and practices within the health care environment that maintain, sustain, and restore the environment and natural world.
- Contributes to professional organizations.
Reflective Questions
- What Advocacy competencies have you already demonstrated during your nursing education?
- What Advocacy competencies are you most interested in performing next?
- What questions do you have about ANA’s Advocacy competencies?
Next: 2.12 Individual and Interpersonal Advocacy
Learning Objectives
- Assess the effects of current health care policies on health care consumers and nursing practice
- Explore the role of professional organizations in nursing practice
- Discuss legislative policy-making activities that influence nursing practice and health care
- Examine various positions on unions and collective bargaining
- Compare various workplace advocacy models
What do you think of when you hear the word “advocacy”? Nurses act as advocates for their clients (e.g., individuals, families, communities, or populations) by protecting their "client rights" and voicing their needs. Nurses have a long history of acting as client advocates. Early nurses advocated for professional nurses’ value and knowledge and fought for implementation of best practices, safety measures, and other quality improvements. Florence Nightingale advocated for practice changes that improved environmental conditions in health care and reduced life-threatening infections by using data to support her recommendations. Lillian Wald worked to establish public health nursing and improve the lives of immigrant communities.
More recently, nurses led the establishment of Nurse Practice Acts in each state and pushed for multistate licensing via the Nurse Licensure Compact (NLC). The American Nurses Association (ANA) declared 2018 as the “Year of Advocacy” to highlight the importance of advocacy in the nurse’s role. Nurses continue to advocate for building healthier communities as demonstrated in the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report.[16]
In this chapter, we will review how every nurse is responsible for client advocacy and examine the powerful influence nurses can have on local, state, and federal health care policies that affect the nation’s health and the profession of nursing.
Read the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity at Future of Nursing: Campaign for Action.
Next: 2.11 Basic Advocacy Concepts
Learning Objectives
- Assess the effects of current health care policies on health care consumers and nursing practice
- Explore the role of professional organizations in nursing practice
- Discuss legislative policy-making activities that influence nursing practice and health care
- Examine various positions on unions and collective bargaining
- Compare various workplace advocacy models
What do you think of when you hear the word “advocacy”? Nurses act as advocates for their clients (e.g., individuals, families, communities, or populations) by protecting their "client rights" and voicing their needs. Nurses have a long history of acting as client advocates. Early nurses advocated for professional nurses’ value and knowledge and fought for implementation of best practices, safety measures, and other quality improvements. Florence Nightingale advocated for practice changes that improved environmental conditions in health care and reduced life-threatening infections by using data to support her recommendations. Lillian Wald worked to establish public health nursing and improve the lives of immigrant communities.
More recently, nurses led the establishment of Nurse Practice Acts in each state and pushed for multistate licensing via the Nurse Licensure Compact (NLC). The American Nurses Association (ANA) declared 2018 as the “Year of Advocacy” to highlight the importance of advocacy in the nurse’s role. Nurses continue to advocate for building healthier communities as demonstrated in the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report.[17]
In this chapter, we will review how every nurse is responsible for client advocacy and examine the powerful influence nurses can have on local, state, and federal health care policies that affect the nation’s health and the profession of nursing.
Read the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity at Future of Nursing: Campaign for Action.
Next: 2.11 Basic Advocacy Concepts
As discussed previously, the American Nurses Association (ANA) defines advocacy at the individual level as educating health care consumers so they can consider actions, interventions, or choices related to their own personal beliefs, attitudes, and knowledge to achieve the desired outcome. In this way, the health care consumer learns self-management and decision-making.[18] Advocacy at the interpersonal level is defined as empowering health care consumers by providing emotional support, assistance in obtaining resources, and necessary help through interactions with families and significant others in their social support network.[19]
What does advocacy look like in a nurse’s daily practice? The following are some examples provided by an oncology nurse[20]:
- Ensure Safety. Ensure the client is safe when being treated in a health care facility and when they are discharged by communicating with case managers or social workers about the client’s need for home health or assistance after discharge so it is arranged before they go home.
- Give Clients a Voice. Give clients a voice when they are vulnerable by staying in the room with them while the doctor explains their diagnosis and treatment options to help them ask questions, get answers, and translate information from medical jargon.
- Educate. Educate clients on how to manage their current or chronic conditions to improve the quality of their everyday life. For example, clients undergoing chemotherapy can benefit from the nurse teaching them how to take their anti-nausea medication in a way that will be most effective for them and will allow them to feel better between treatments.
- Protect Client Rights. Know clients’ wishes for their care. Advocacy may include therapeutically communicating a client’s wishes to an upset family member who disagrees with their choices. In this manner, the client’s rights are protected and a healing environment is established.
- Double-Check for Errors. Know that everyone makes mistakes. Nurses often identify, stop, and fix errors made by interprofessional team members. They flag conflicting orders from multiple providers and notice oversights. Nurses should read provider orders and carefully compare new orders to previous documentation. If an order is unclear or raises concerns, a nurse should discuss their concerns with another nurse, a charge nurse, a pharmacist, or the provider before implementing it to ensure client safety.
- Connect Clients to Resources. Help clients find resources inside and outside the hospital to support their well-being. Know resources in your agency, such as case managers or social workers who can assist with financial concerns, advance directives, health insurance, or transportation concerns. Request assistance from agency chaplains to support spiritual concerns. Promote community resources, such as client or caregiver support networks, Meals on Wheels, or other resources to meet their needs.
Nurses must recognize their unique position in client advocacy to empower individuals to provide them with the support and resources to make their best judgment. The intimate and continuous nature of the nurse-client relationship places nurses in a prime position to identify and address the needs and concerns of their clients. This relationship is built on trust, empathy, and consistent interaction, which allows nurses to gain a deep understanding of their clients' values, preferences, and personal circumstances. By leveraging this close proximity and strong rapport, nurses can effectively advocate for their clients, ensuring that their voices are heard, and their wishes are respected in all aspects of care.[21]
The power of the nurse-client relationship extends beyond the immediate clinical environment. Nurses often act as liaisons between clients and the broader health care team, facilitating communication and ensuring that client preferences are integrated into care plans. This advocacy role is crucial in navigating complex health care systems where clients may feel overwhelmed or marginalized. Nurses can help demystify medical jargon, explain treatment options, and support clients in making informed decisions that align with their values and goals. Through education and emotional support, nurses empower clients to take an active role in their own care, enhancing client autonomy and satisfaction.[22]
In addition to direct client care, nurses play a pivotal role in identifying systemic issues that affect client outcomes. Their frontline perspective provides valuable insights into the barriers clients face in accessing quality care, such as socioeconomic challenges, cultural barriers, and institutional policies. By advocating for policy changes and improvements in health care delivery, nurses contribute to creating a more equitable and client-centered health care system. Their advocacy efforts can lead to the implementation of practices and policies that better address the needs of diverse client populations, ultimately improving health outcomes on a broader scale.[23]
Nurses' advocacy is also essential in situations where clients are unable to speak for themselves, such as in cases of severe illness, disability, or end-of-life care. In these instances, nurses must be vigilant in recognizing and addressing the needs of vulnerable clients, ensuring that their rights and dignity are upheld. This may involve working closely with families and caregivers, coordinating with interdisciplinary teams, and navigating ethical dilemmas to provide the best possible care for the client.
Next: 2.13 Community and Organization Advocacy
Advocacy: The act or process of pleading for, supporting, or recommending a cause of course of action for individuals, groups, organizations, communities, society, or policy issues.
Collective bargaining: Negotiation of wages and other conditions of employment by an organized body of employees.
Evidence-based practice: Integrating scientific evidence with clinical expertise and client/family preferences and values for delivery of optimal health care.[24]
Grievance process: A process for resolving disagreements between employees and management.
Informatics: Using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.[25]
ISBARR: A mnemonic for the components to include when communicating with another health care team member: Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.
Magnet® Recognition Program: An organizational credential that recognizes quality client outcomes, nursing excellence, and innovations in professional nursing practice.
Patient-centered care: The client is the source of control and full partner in providing compassionate and coordinated care based on respect for client’s preferences, values, and needs.[26]
Quality improvement: Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of health care systems.[27]
Shared governance: A shared leadership model between management and employees working together to achieve common goals.
Social Determinants of Health (SDOH): The conditions in the environments where people live, learn, work, and play that affect a wide range of health, functioning, and quality of life outcomes and risks.
TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety): An evidence-based framework to improve client safety through effective communication in health care environments consisting of four core competencies: communication, leadership, situation monitoring, and mutual support.
Teamwork and collaboration: Functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality client care.[28]
Whistleblower: A person who exposes any kind of information or activity that is deemed illegal, unethical, or not correct within an organization.
