Teaching a Culture of Safety - Nursing Education Portfolio



Teaching a Culture of SafetyJoel VeddersFerris State UniversityAbstractIssues surrounding quality and safety abound in today's healthcare environment. It is the responsibility of all healthcare providers to strive to promote patient safety in all situations. Nurse educators are charged with the task of educating prelicensure students and practicing nurses about safe patient care and the prevention of medical errors. The competencies outlined by the Quality and Safety Education for Nurses Initiative can be integrated by nurse educators into their teaching strategies. This paper will discuss two of these strategies, simulation, and the use of presentation/online learning modules that can be used to teach a culture of safety. Two theoretical frameworks are identified that can support these teaching strategies. Keywords: quality, errors, simulation, culture of safetyTeaching a Culture of SafetyThe goal of the academic nurse educator is to prepare prelicensure students to provide safe patient care in the clinical environment as they get ready to transition into practice. Part of this education includes making students aware of errors that can occur within the clinical practice arena, in addition to the importance of the integral role that they can play in reducing these errors. The Institute of Medicine (IOM) once reported that as many as 98,000 deaths occur each year as a result of medical errors, and the number is estimated to be much higher today (James, 2013). Medical errors occur for a variety of reasons which can include poor communication, as well as medication errors. It is therefore critically important for academic nurse educators to employ teaching strategies that address a culture of safety.The IOM's report was actually the genesis for the increased focus on safety in healthcare, which started the national initiative called the Quality and Safety Education for Nurses (QSEN) (Cronenwett, Sherwood, & Gelmon, 2009). The QSEN provides a framework around which nurse educators can choose teaching strategies that are most effective in addressing quality and safety issues. Using the competencies supported by the IOM, QSEN faculty defined six competencies related to quality and safety for nursing. Additionally, certain knowledge, skills, and attitudes (KSA's) to be formed in nursing school were attached to each competency (QSEN Institute, 2013).While the challenge of the academic nurse educator is to prepare the prelicensure student for a culture of safety by addressing the QSEN competencies within the curriculum, the hospital staff educator may need to employ different teaching strategies with practicing nurses to help them learn about error prevention. New graduate nurses account for approximately 10% of nurses within hospitals (Rhodes et al., 2013). This leaves 90% of nurses who are at various stages in their nursing careers, some of whom have very little or no knowledge of quality and safety as it relates to medical errors. It is necessary for the hospital nurse educator to be aware that multiple generations may be represented within this group, and may have to use a variety of teaching strategies based on the learning styles associated with each generation (Pesta, 2011).The purpose of this essay is to discuss two teaching strategies that will assist nursing students and practicing nurses in learning about errors and how to reduce them, using common patient situations where medical errors occur, including medication administration and interdisciplinary communication as examples. The first strategy is the use of simulation in effectively addressing the QSEN competencies in the prelicensure student as it relates to medication administration. The second strategy is a multi modal approach, teaching practicing nurses about ways to prevent errors related to ineffective communication. A brief description of the six QSEN competencies will be provided. Two theoretical frameworks will be discussed to support these teaching strategies. QSEN"QSEN is a national initiative to identify the competencies and KSA's needed by all nurses to continuously improve the quality and safety of healthcare" (Disch, 2012, p. 58). Six competencies with associated KSA's were developed to address quality and safety knowledge within the prelicensure arena. These six competencies include patient centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics and safety (Jarzemsky, McCarthy, & Ellis, 2010). The goal is to incorporate these competencies into teaching strategies and program curriculums. In fact, these competencies have served as a template in reshaping nursing curricula (Disch, 2012).The QSEN was divided into several phases. Phase one involved outlining the six competencies and associated KSA's. Phase two involved a learning collaborative which included fifteen pilot schools to develop and test various teaching strategies that could be used to teach the KSA's associated with each competency (Barnsteiner et al., 2012). Phase three included faculty development, and a further push for continued infusion of the competencies within the curriculum. This included "continued innovation in the development and evaluation of methods to elicit and assess student learning of the KSA's" (Barnsteiner et al., 2012, p. 69). These authors report that while this phase ended in 2012, phase four is currently ongoing, developing graduate QSEN competencies. Adding quality and safety education to prelicensure programs begins with the educators' knowledge of QSEN competencies, associated KSA's, and their ability to infuse these into their teaching strategies. However, barriers do exist. These barriers include undeveloped skills related to teaching quality and safety, fear of the unknown, insufficient resources, conflicting attitudes amongst staff, in addition to being simply unaware of the need for change (Beischel & Davis, 2014). One teaching strategy that can be used to help nursing students learn about errors and how to reduce them is the use of simulation. Theoretical FrameworksIn order for a nurse educator to use simulation as a teaching strategy it is important to have a background knowledge of learning theory. Understanding the concepts of adult learning theory, in addition to those related to Kolb's experiential learning theory will assist the educator in developing simulations that address quality and safety. Adult learning theory assumes that adults need to know the reason for learning something, bring a broad range of life experience to the learning activity, and like to apply new knowledge to real life situations (Vandeveer, 2009). Experiential learning has the participants directly involved in the learning activity. The experiential learning cycle has four components which include active experimentation, concrete experience, reflective observation, and abstract conceptualization (Jeffries, Clochesy, & Hovancsek, 2009). Adult learning theory as well as Kolb's experiential learning theory lend themselves well to using simulation as a teaching strategy for learning about quality and safety. Kolb's theory is "linked directly with simulation and can guarantee a clinical event (concrete experience), reflection (debriefing), conceptualization (reviewing and understanding), and experimentation (learning on the simulator)", (Waxman & Telles, 2009, p. 232). Teaching strategiesSimulationSimulation as defined by Merriam Webster's dictionary is "something that is made to look, feel, or behave like something else, especially so it can be studied or used to train people" ("Simulation," n.d.). Simulation is divided into three categories which include low, medium, and high fidelity. Low fidelity simulation can be as simple as the use of role playing. it is also associated with task training. Task training generally involves a simple mannequin where skills such as inserting a catheter can be practiced over and over again (Leighton & Johnson-Russell, 2011). Medium fidelity simulators are able to replicate some human qualities such as breath sounds, while the high fidelity simulators can mimic a variety of human conditions and be programmed to respond in a variety of ways depending on the learner's actions (Hayden, 2010). The advantage of using simulation is that it provides a safe environment for the learner where mistakes can be made without fear of harming the patient, while assisting the learner to make the connection between didactic content in the classroom with the clinical environment (Leighton & Johnson-Russell, 2011). These authors also report that multiple objectives can be met for multiple students at the same time through the use of simulation. So how can the use of simulation help a student learn about how to prevent medical errors? According to the QSEN Institute there are several KSA's associated with the competency of safety. Academic nurse educators want the students to be able to recognize unsafe practices, have a baseline knowledge of the various technologies used to enhance safety, and to be able to speak to the components of a culture of safety (QSEN Institute, 2013). Students must also be able to demonstrate skills associated with patient safety, including the use of technology, and to understand the importance of reporting errors (QSEN Institute, 2013). It is imperative that students understand that they play a valuable role in patient safety. Medication errors continue to be a threat to providing safe patient care, and despite having supportive software in place such as bar code scanning and the use of medication administration rights, errors are still being made (Cooper, 2014). An example of a simulation that addresses medication errors that could be created is one in which a student is expected to administer the rights of medication administration, demonstrate the proper use of bar code scanning (if this technology is available in the simulation lab), and also be expected to catch errors built into the simulation. These built in errors could include the patient wearing the wrong name band, and a discrepancy between what dose was ordered and what dose was sent by pharmacy. A simulation like this is a great way to teach students about errors and the role they can have in reducing them. It is also possible to repeat this scenario over and over again if needed, in order for the learner to gain the experience needed to take into the clinical environment. It also incorporates two components of the experiential learning cycle which include concrete experience and active experimentation. In order to assist the learners to make the proper connections related to errors, the educator must be skilled in the debriefing portion of the simulation. Debriefing is one of the most crucial components of the simulation (Shinnick, Woo, Horwich, & Steadman, 2011). It provides the students the opportunity to reflect on the simulation and apply the knowledge to practice. It also addresses the other two components of experiential learning which are reflection and conceptualization. In this situation a skilled debriefing will include discussion of the importance technology can play in reducing errors, as the patient's bracelet was scanned to reveal the incorrect name. A discussion will also revolve around the importance of the five rights of medication administration as it was crucial in preventing the wrong dose from being administered to the patient. The debrief will help the students become aware of, and to appreciate the role they play in the prevention of errors. Students will discuss the importance of reporting errors as a way to improve patient safety. " Increasing transparency in reporting medication errors can achieve significant improvements in patient safety" (Cooper, 2014, p. 551). While simulation provides a great evaluation tool to assess student learning, consideration must be given to the amount of time required on the part of faculty to plan and teach the simulation, as well as to the equipment and space required. Time, equipment and space limitations can be stumbling blocks as educators attempt to use simulation as a strategy to teach safety. The expense involved to allocate space, in addition to the cost of equipment required for simulation can be prohibitive (Jarzemsky et al., 2010). Another barrier to simulation is faculty workload and the time it can take to design and run a simulation (Hayden, 2010). Often faculty are stretched so thin that there is not the time or energy to invest in simulation. A quality simulation can take several hours to develop. If a faculty member is already overloaded, chances are low that they will invest this additional time. Finally, faculty often lack sufficient skills to utilize simulation as an effective teaching strategy. This will need to change as more and more schools of nursing are substituting clinical time with simulation. In fact New York University may replace up to 50% of students' clinical time with simulation, as the availability of clinical sites dries up (Edelson, 2011).Presentation/On-line Learning ModulesWhile simulation can be a very effective teaching strategy in preparing nursing students for clinical practice and teaching about medication errors and patient safety, it also has its place in the clinical arena especially as it relates to crises or emergency situations. In fact mock code simulations have shown improved confidence and performance of those who respond to the code in addition to better recognition of the declining patient (Delac, Blazier, Daniel, & N-Wilfong, 2013). Yet it may not be the most effective teaching strategy to use when educating practicing nurses about errors and their role in prevention. When choosing a teaching strategy to use for the practicing nurses the generational make-up of the group must be considered. There are roughly three million practicing nurses today, and of these nurses most are baby boomers, and generation Xers (Robinson, Scollan-Koliopoulos, & Kamienski, 2012). It must also be kept in mind that many of these nurses may not have had as much exposure to quality and safety initiatives as today's nursing students. Taking into account these two factors will be beneficial for the nurse educator when selecting teaching strategies to utilize with this group. A multimodal approach may be the most effective way to teach the different generations of practicing nurses about patient safety and medical errors. Baby boomers enjoy contact with the educator and can also be somewhat reluctant to use technology (Pesta, 2011). Generation Xers on the other hand want to figure things out on their own and enjoy learning independently including through distance learning (Robinson et al., 2012). Some teaching strategies will now be discussed as they relate to educating practicing nurses about how to promote patient safety through the effective use of interdisciplinary communication. SBAR is an acronym which stands for situation, background, assessment and recommendation. It can be used as a method to increase the effectiveness of communication between health care providers. Many errors in the healthcare setting are a result of poor communication (Kuehster & Hall, 2010). In fact, The Joint Commission reports that 60-70% of sentinel events reported over the last decade were related to poor communication (Narayan, 2013). The use of a standardized communication tool such as SBAR can help to enhance communication and prevent medical errors. Implementing SBAR to enhance the culture of safety at an institution is no small undertaking and would involve more than just nurse educators. It would also involve key stakeholders such as bedside nurses, nurse leadership and physicians. A three step process could be used implement this initiative. The first step would involve collecting information from key stakeholders in order to develop ideas for what education should be included. The second step is developing and implementing the educational activities. The third step involves evaluation of these activities (Yoon et al., 2013). One important aspect to the education will be the incorporation of adult learning theory. One key tenant of adult learning theory is that the material must be relevant to practice and the learner must know why it is important. Another key factor in the development of the educational material is that is must be evidence-based. The key is for the practicing nurse to understand their role in building a culture of safety and why SBAR is important in reducing errors. It is essential to keep in mind the generational considerations and learning styles of the practicing nurses as the educator chooses teaching strategies to appeal to these groups. For the baby boomer population the teaching strategy that could be selected would be a short presentation or in-service. Baby boomers appreciate face to face contact and are most likely to prefer a highly structured teacher-centered environment (Pesta, 2011). This author describes that face to face interaction can be very beneficial as it allows the educator to read facial expressions to determine understanding, and it also allows the learner to ask questions if the content is not understood. Case studies can also be incorporated to help attach meaning to the content. It is also important to consider the nurses' time when planning these educational activities. A short in-service will allow nurses to attend during their scheduled shift. The presentation could also be incorporated into existing planned education time (Yoon et al., 2013). The nurse educator would have to be available to present the material on all three shifts at various times throughout the week in order to capture the most learners. This will be especially important as the SBAR training is rolled out. An online learning module would be a teaching strategy that could be used to address the generation Xers. Learners from this generation prefer learning through technology as opposed to direct interaction with the educator. Working alone is often preferred by learners of this generation (Pesta, 2011). EvaluationThe educator will also need to evaluate the effectiveness of these teaching strategies. The presentation or in-service would be accompanied by an evaluation form, most likely one utilizing a Likert scale. The questions would address the nurses' understanding of the importance of SBAR as it relates to patient safety and error reduction, the importance of their role in the use of SBAR, and the effectiveness of the presentation as a learning tool. This type of evaluation is known as summative evaluation and is used at the end of a learning activity and is used to assess the extent to which objectives and outcomes were met for the activity (Bourke & Ihrke, 2009). In order to evaluate the effectiveness of the online learning module a multiple choice test would be attached to the end of the activity. The advantages of multiple choice tests include that they are easily scored, measure different levels of cognition, and can cover a large amount of material on just one test (Twigg, 2009). The major disadvantage of this type of evaluation is that writing good multiple choice questions is difficult and time consuming. This time will have to be accounted for when developing this learning activity. ConclusionNursing faculty and hospital nurse educators play a pivotal role in preparing prelicensure nursing students and practicing nurses to recognize the importance of being involved in the culture of safety. The QSEN competencies can be utilized as a guide when teaching about the prevention of medical errors. Educational strategies such as simulation, in-services, and online learning modules are effective methods to teach a variety of learners. Careful consideration must be given to generational differences when choosing a teaching strategy. Nurse educators must continue to integrate the QSEN competencies into all of their educational offerings, and in doing so can continue to enhance the quality of care and the safety of patients. ReferencesBarnsteiner, J., Disch, J., Johnson, J., McGuinn, K., Chappell, K., & Swartwout, E. (2012). Diffusing QSEN competencies across schools of nursing: The AACN/RWJF faculty development institutes. Journal of Professional Nursing, 29(2), 68-74. , K. P., & Davis, D. S. (2014). A time for change: QSENizing the curriculum. Nurse Educator, 39(2), 65-71. , M. P., & Ihrke, B. A. (2009). The evaluation process: An overview. In D. M. Billings, & J. A. 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