Application of the Quality and Safety Education for Nurses ...

Application of the Quality and Safety

Education for Nurses Competencies in

Orthopaedic Nursing

Implications for Preceptors

Gerry Altmiller

For the last decade, quality and safety have been the ardent

focus of healthcare improvement. Many agencies provide

resources to healthcare providers to assist their endeavors.

The Quality and Safety Education for Nurses (QSEN)

Collaboration developed competencies that define the

concepts of quality and safety in relation to nursing practice

and education. These concepts are not new to orthopaedic

nursing; they are better defined through the QSEN

competencies so that nurses can develop practice behaviors

that ensure quality and safety for the patients they care

for. The QSEN competencies guide the processes that

support the Orthopaedic Core Competencies: Across the

Lifespan. Together, they enhance the orthopaedic specialty

by deepening the focus on patient safety and high-quality

care. Preceptors are in a unique position to influence new

nurses and those transitioning into orthopaedic nursing

to adopt these practices as they develop skills to meet the

requirements of the specialty.

T

o meet the many challenges of healthcare today

and to prepare future workers for interdisciplinary teamwork so that they can provide

high-quality, safe, patient-centered care, national organizations are leading the way providing data,

guidance, and support. The Institute of Medicine (IOM,

2000) initiated the call for change in the way that healthcare is provided with the landmark report To Err Is

Human. In this report, it was identified that as many as

98,000 persons die each year in hospitals as a result of

medical error. Reports followed that outlined mandates

for competencies to protect patients, ensure safety, and

improve the overall quality of the care rendered to them.

Many agencies and healthcare organizations provide

information and resources to address quality and safety

(see Table 1). One such national organization that undertook the challenge of addressing the IOM mandates was

the Quality and Safety Education for Nurses (QSEN)

Collaboration. Funded by the Robert Wood Johnson

Foundation, this group set out to change the way that

nurses are educated by developing six competencies that

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mirrored the IOM mandates for change. They identified

the knowledge, skills, and attitudes needed by nurses to

meet the competencies, which emphasized patient-centered care, collaboration with other members of the

healthcare team, evidence-based practice, quality improvement and safety, and the integrated use of informatics (Cronenwett et al., 2007). Now partnered with

the American Association of the Colleges of Nursing,

they provide support for those on the front lines of

healthcare as well as faculty and students in their initiatives to improve quality and ensure patient safety.

The QSEN Competencies (see Table 2) provide a

framework focused on improving healthcare that is applicable to all nursing specialties. They transparently

overlap the Orthopaedic Core Competencies (National

Association of Orthopaedic Nurses, 2007) and enhance

the role of the orthopaedic nurse by increasing the focus

on quality and safety across the lifespan. The

Orthopaedic Core Competencies (see Table 3) address

pertinent topics in orthopaedic care including subspecialties of pediatrics, geriatrics, and palliative care. The

competencies recognize three levels of nursing practice,

competent, experienced/proficient, and senior practitioner/expert, which can be applied to advanced practice

nursing. Each level requires orthopaedic knowledge,

skills, and attitudes that blend well with the QSEN competencies and support safe, high-quality care. The experienced and expert-level orthopaedic nurse frequently

assumes leadership and preceptor roles, which increase

opportunities to share information and demonstrate

nursing practice that supports quality and safety. These

core competencies can be used within the expanded

practice of the orthopaedic specialty as guidelines for

preceptors as they oversee the nursing orientation of

new-to-practice nurses as well as for facilitating the

Gerry Altmiller, EdD, APRN, ACNS-BC, Assistant Professor, La Salle

University, Philadelphia, PA.

The author and planners have disclosed that they have no financial interests to any commercial company related to this educational activity.

DOI: 10.1097/NOR.0b013e3182879bf2

? 2013 by National Association of Orthopaedic Nurses

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TABLE 1. RESOURCES FOR QUALITY AND SAFETY

Resource

Web Site Address

AHRQ: TeamSTEPPS



teamsteppstools/instructor/

index.html

AHRQ: Patient safety network



AHRQ: National Guidelines

Clearinghouse



ANA: The National Database

of Nursing Quality

Indicators



FAQPage.aspx

Institute of Healthcare

Improvement: Open School



Programs/IHIOpenSchool/

Institute for Safe Medication

Practices



Quality and Safety Education

for Nurses



The Joint Commission



TABLE 2. QSEN COMPETENCIES

QSEN

Competency

Definition

1. Patient-centered

care

Recognize the patient or designee as the

source of control and full partner in

providing compassionate and

coordinated care based on respect for

patient��s preferences, values, and needs.

2. Teamwork and

collaboration

Function effectively within nursing and

interprofessional teams, fostering open

communication, mutual respect, and

shared decision making to achieve

quality patient care.

3. Evidence-based

practice

Integrate best current evidence with clinical

expertise and patient/family preferences

and values for delivery of optimal

healthcare.

4. Quality

improvement

Use data to monitor the outcomes of care

processes and use improvement

methods to design and test changes to

continuously improve the quality and

safety of healthcare systems.

5. Safety

Minimize risk of harm to patients and

providers through both system effectiveness and individual performance.

6. Informatics

Use information and technology to communicate, manage knowledge, mitigate

error, and support decision making.

Note. AHRQ ? Agency for Healthcare Research and Quality;

ANA ? American Nurses Association.

transition of seasoned nurses into orthopaedic patient

care services.

Each level recognized in the Orthopaedic Core

Competencies builds on the expertise achieved at the

previous level. At the level of a competent nurse, the

practitioner assesses and monitors for physical comfort, patient preferences, and family involvement. The

competent nurse functions as a member of the team,

understanding safety principles that guide practice, and

integrating information and technology to achieve consistent positive patient outcomes. At the level of experienced and proficient nurse, the practitioner assesses,

plans, and manages care of patients with complex

needs, incorporating interventions based on evidence.

The experienced nurse mentors peers and works within

the team to develop strategies that improve care delivery processes and correct system design errors that

create threats to patient safety. At the level of a senior

practitioner and expert nurse, the practitioner provides

leadership in the care of patient groups, reinforces

patient-determined goals, and assists in solving problems at the point of care. The expert nurse models an

attitude of partnership with other team members,

acknowledging the contribution that each discipline

makes to meeting the patient needs and helping the

patient achieve his or her best possible state of wellness.

Recognizing the knowledge, skills, and attitudes required for this specialty, the Orthopaedic Core

Competencies dovetail with the implementation of the

six QSEN competencies, creating an increased emphasis on quality and safety in orthopaedic patient care.

The following will review the six QSEN competencies

and connect them to the orthopaedic nursing specialty.

Patient-Centered Care

The first QSEN competency focuses on patient-centered

care and recognizes the patient as the source of control

in his or her care based on individual preferences. In

? 2013 by National Association of Orthopaedic Nurses

Note. QSEN ? Quality and Safety Education for Nurses. Adapted

from ��Quality and Safety Education for Nurses,�� by L. Cronenwett, G. Sherwood, J. Barnsteiner, J. Disch, J. Johnson, P. Mitchell, D. Sullivan, and J. Warren, 2007, Nursing Outlook, 55(3),

pp. 122�C131.

orthopaedic nursing, one of the highest priorities of

patient-centered care is pain management. During orientation, the orthopaedic nurse preceptor demonstrates

the institution��s emphasis on patient-centered care

through the deliberate focus on pain management. For

example, the competent nurse encourages patients to

report pain being experienced, acknowledging that pain

management is highly individualized, particularly

where perceptions are widely varied among patients

such as seen during recovery and rehabilitation following a total knee arthroplasty. The experienced nurse incorporates nonpharmacologic interventions such as

music therapy, relaxation, or guided imagery into the

plan of care for pain based on patient preferences. The

expert orthopaedic nurse has the knowledge and skill to

implement individual and population-based care that

directly affects patient outcomes by developing protocols that address pain management and by evaluating

their effectiveness.

Patient-centered care includes identifying population-based patient safety threats and addressing them.

Osteoporosis is a serious health threat for older individuals and orthopaedic nurses play an important role

in identifying those at risk and connecting them to

treatment. The 2 Million Is 2 Many project is a national

awareness program initiated by the National Bone

Health Alliance (2012). It supports nursing��s effort to

protect patients from osteoporosis-related bone breaks.

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Teamwork and Collaboration

TABLE 3. TOPICS INCLUDED IN THE ORTHOPAEDIC

NURSING CORE COMPETENCIES

Topic

Subtopic

1. Neurovascular assessment

2. Pain management

3. Therapeutic modalities

Immobilization with casts

Immobilization with braces

and splints

External fixators

Traction

Halo traction

Assistive devices

Continuous passive motion

4. Spinal assessment

5. Herniated nucleus pulposus

6. Amputation

7. Total knee arthroplasty

8. Total hip arthroplasty

9. Complications: Compartment

syndrome

10. Complications: Deep vein

thrombosis

11. Complications: Pulmonary

embolism

12. Complications: Fat embolism

13. Complications: Palliative care

14. Care of the orthopaedic patient older than 65 years

15. Newborn assessment

Developmental dysplasia of

the hip; clubfoot deformity

16. Advanced practice nurses

Note. Adapted from Orthopaedic Nursing Core Competencies:

Across the Lifespan, by National Association of Orthopaedic

Nurses, 2007, Chicago, IL: Author.

To support the program��s goal to reduce the incidence of

fractures 20% by 2020, nurses caring for patients aged

50 years or older who experience a fracture can request

a test for osteoporosis to identify those with the condition so that appropriate care can be implemented.

Another way the orthopaedic nurse emphasizes

patient-centered care is by demonstrating to new staff

the importance of acknowledging individual patient

goals. In example, preceptors can emphasize patientcentered care through an initiative to use a white board

in each patient room to list the patient��s daily goal.

Developing the goal provides an opportunity for the

nurse to collaborate with the patient and recognize his

or her priorities. This process acknowledges the value of

patient input and allows the goal to be personal and important to the individual patient, supporting the values

of respect and understanding that exemplify this competency. Through initiatives such as this, preceptors

demonstrate that empowering the patient promotes

communication, acknowledges the priorities of the

individual, and increases patient satisfaction.

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The teamwork and collaboration competency requires

working effectively with nurses and team members

from other disciplines through open dialogue, mutual

respect, and shared decision making to provide highquality patient care that results in consistent positive

outcomes. Competent nurses huddle with team

members to identify concerns and priorities. They use

established communication practices such as SBAR

(situation, background, assessment, recommendation)

to support effective teamwork and clear communication during hand-offs or during transitions between

care phases such as from surgery to recovery to rehabilitation. Experienced nurses cross monitor team interactions, listening and confirming information, which

allows for corrections to be made immediately. They influence the practice of new staff by modeling appropriate delegation techniques and assigning responsibilities

on the basis of scope of practice. Expert nurses provide

leadership and model effective communication during

high stress team efforts such as managing care of a

patient with a fat embolism or supporting staff during

resuscitations.

Preceptors model an attitude of partnership with

other team members by acknowledging the contribution each discipline makes to supporting and improving

the patient��s health status. The complexity of caring for

orthopaedic patients demands this. Consider the care of

a patient admitted for lower extremity amputation,

whose care is complicated by age, diabetes, and longstanding cardiac disease. The orthopaedic nurse coordinates the care of multiple disciplines including a surgical team, a medical team, a physical therapist, an

occupational therapist, and a nutritionist, all focused on

optimizing the patient��s health status. Preceptors demonstrate that strong communication skills and use of

effective communication strategies to ensure safety are

required when so many are involved in the patient��s

care. Safety is supported through the use of strategies

such as the check-back or read-back, which is repeating

back orders and directions to confirm accuracy. The

two-challenge rule ensures that concerns are noted by

restating them a second time if needed. Using this strategy, if a concern is brought forward and it is not

acknowledged by other team members, the nurse has an

obligation to bring it forward a second time to be sure

that it is considered and addressed. In this way, the

preceptor demonstrates skills in patient advocacy.

When an error occurs, frequently it is discovered afterward that someone in the room was concerned that

the error was impending but was not comfortable

speaking up. The use of critical language allows individuals to draw attention to a situation in which they

believe an error may occur. Critical language is an established phrase within the institution that when it is

used, all involved should stop and clarify actions. For

instance, in the case of a patient being prepared for a

procedure on the wrong side, the concerned individual

would say ��I need some clarity�� and the group would

proceed to review what the procedure is, identifying

correct patient and correct side, even if it has already

been done earlier. If a patient was about to receive a

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blood transfusion or treatment that was intended for

another patient, the concerned individual would say ��I

need some clarity�� and the group would review the

treatment and the intended patient. Critical language

provides the vehicle that allows the team to stop errors

before they occur. The Agency for Healthcare Research

and Quality��s (AHRQ��s) TeamSTEPPS (2005a, 2005b),

a program to promote teamwork and communication,

provides short videos to demonstrate some of these

and other techniques that can be utilized by preceptors

as teaching tools to improve communication skills of

new staff.

Evidence-Based Practice

The third QSEN competency focuses on the knowledge,

skills, and attitudes needed for integrating evidencebased practice with clinical expertise to provide current

and expert patient care. The competent orthopaedic

nurse follows standardized practices based on evidence

to promote consistency and safety such as those used

for early mobilization. The experienced nurse works on

committees to determine best practices for common orthopaedic concerns such as transfusion after knee replacement or protocols for deep vein thrombosis prophylaxis. The expert nurse serves as a resource for

others through the use of evidence-based practice. An

example is in promoting safe patient handling and

movement to prevent healthcare workers�� musculoskeletal injuries from lifting and moving patients (Nelson,

2006) in high-risk orthopaedic tasks such as moving and

turning the postoperative total hip replacement patient

(Sedlak, Doheny, Nelson, & Waters, 2009). The expert

nurse also has the opportunity to teach about safe clinical practices supported by evidence such as in the use of

cryotherapy (the use of continuous cold flow units) after

knee replacement surgery (Markert, 2011).

Preceptors can help new staff understand how

evidence-based projects are identified. They can help

them develop knowledge and skills to search for information and navigate evidence-based practice resources

like AHRQ��s National Guideline Clearinghouse (n.d.-a).

The expert nurse can help competent and experienced

nurses weigh the current evidence, determine appropriate recommendations, and share information so that

clinical protocols can be developed on the basis of

knowledge of the most current scientific information.

By encouraging involvement in professional organizations, preceptors help new nurses connect to resources

and information that support the adoption of best practices to provide safe, high-quality, evidence-based care.

Quality Improvement

The competency of quality improvement entails using

data to monitor outcomes of care and using improvement methods to design and test changes in an effort to

continuously improve the quality and safety of the current system. Not only is it important for the competent

nurse to understand the required nursing care, but he or

she must be able to continually analyze and evaluate

that care so that it can be improved upon. The National

Database of Nursing Quality Indicators from The

? 2013 by National Association of Orthopaedic Nurses

American Nurses Association provides benchmarked

data for hospitals that enroll and participate. Preceptors

can show new staff how current trends for nurse-sensitive indicators within the institution compare nationally to outcome measurement data at similar institutions. Some important nurse-sensitive indicators for

orthopaedic care include data on surgical site infections, pain assessment, information regarding falls, and

pressure ulcer development. A complete list of indicators that are tracked can be found on the American

Nurses Association (2012) website.

Experienced nurses realize that quality and safety

cannot be attributed to knowledge and carefulness of

individuals alone; hence, they use data to optimize system-based solutions to protect patients. Threats to quality and safety where investigation or improvement may

be warranted can be identified through interaction with

patients and through discussions with peers. Debriefing,

a discussion that can be led by the experienced or expert

nurse, provides an opportunity for review and feedback

after care is delivered. The debriefing should focus on

what was done well, what was done poorly, and what

could be done better in the future.

As preceptor, the orthopaedic nurse contributes to

the overall quality within the organization by assisting

the nurse��s transition to orthopaedic care and promoting retention of competent personnel. By providing constructive feedback, preceptors help others grow professionally and narrow the gap between current

performance and desired performance. Feedback is

most effective when it focuses on the task, the process

used, or on self-regulation (the ability to identify one��s

errors and self-correct) and should always be followed

with options for improvement (Hattie & Timperley,

2007). It is least effective when focused on the individual. Whether positive or negative, feedback should always be an unbiased account of what occurred and

should lead to discussion of evidence-based practice so

that quality can be improved (Clynes & Raftery, 2008).

In addition, orthopaedic nurses are involved in quality improvement on a national level. Own the Bone is a

quality improvement program developed by the

American Orthopaedic Association (2011) to address

the treatment gap for osteoporosis and provide prevention strategies for secondary fragility fractures. This

clinically proven program provides a web-based patient

registry and offers 10 prevention measures along with

tools that healthcare institutions can use to establish a

fracture liaison service. An experienced or expert nurse

functions in the important role of a care coordinator of

the fracture liaison service to ensure that postfracture

patients are identified and receive the appropriate care

including evaluation, diagnosis, and treatment for osteoporosis under the supervision of their primary

healthcare provider, orthopaedic surgeon, or osteoporosis specialist.

Safety

The competency of safety aims to minimize risk of harm

through system effectiveness and through individual

performance. Orthopaedic nurses minimize risk by upholding standards and working with other disciplines to

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develop strategies that support high reliability processes

that contribute to consistent positive outcomes for patients. For example, the competent nurse prevents injury by maintaining range of motion for patients�� joints

and conducting neurovascular assessments to ensure

adequate circulation. Falls-prevention techniques are a

high priority with this population. Prompt removal of

urinary catheters act to decrease the risk of infection.

The experienced nurse recognizes the complexity of

care for patients with complications such as malunion,

pin track infection, or compartment syndrome. Through

careful observation, the expert nurse identifies unintended effects or complications and acts quickly to provide remedy that will contribute to a favorable outcome.

Expert nurses support a culture of safety rather than a

culture of blame and encourage team members to be

forthcoming about errors and near misses so that

systematic problems that contribute to error can be addressed to reduce risk. They are familiar with errorreporting agencies such as the Institute for Safe

Medication Practices (n.d.), which promote sharing

information regarding errors so that agencies can

improve care based on the experiences of others.

Expert nurses familiarize themselves with and share the

many resources for patient safety information, standards,

and strategies such as the National Patient Safety Goals

from The Joint Commission (n.d.), the AHRQ Patient

Safety Network (n.d.-b), and Open School at the Institute

for Healthcare Improvement (n.d.). The Open School provides online courses focused on quality and safety.

Registrants can earn contact hours as they complete the

modules, which are free to those registering as students.

Preceptors recognize that stressful situations may interfere with effective, professional communication, placing patients at risk. Communication was identified by

The Joint Commission as the root cause of 66% of the

sentinel events between l995 and 2005 (AHRQ, n.d.-b).

Experienced nurses respond to aggressive communication with de-escalation techniques that bring the focus of

the interaction back to patient-centered care. Preceptors

are in an excellent position to teach new staff assertion

techniques such as cognitive rehearsal or the language of

safety to use during difficult communications. Cognitive

rehearsal (Griffin, 2004) uses rehearsed statements as responses when under duress to keep emotions in check,

helping the individual stay focused on the problem at

hand. The language of safety encourages effective communication by providing tools for advocacy. An example

is the CUS strategy, an acronym for the words concerned,

uncomfortable, and safe. Using these words, the nurse

conveys that he or she is concerned with an aspect of

care, he or she is uncomfortable with the patient presentation or the treatment, and he or she doesn��t believe it is

safe for the patient. Preceptors are in a unique position

to counsel new staff as they assume their role on the interdisciplinary team and can teach these techniques to

help them establish effective communication patterns to

maintain patient safety.

Informatics

The final QSEN competency focuses on the use of technology to communicate, manage knowledge, prevent

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error, and support decision making. The competent

nurse maintains a hands-on ability to safely operate the

complex equipment used in the day-to-day care of patients such as machines to provide continuous passive

motion or smart pumps to deliver accurate medication

dosages. The introduction of new technologies and

patient care devices may be accompanied by resistance

due to knowledge deficits for safe operation and accurate interpretation of data (Zuzelo, Gettis, Whitekettle,

& Thomas, 2008) so experienced and expert nurses are

expected to build consensus for their use among staff

and participate in the evaluation process. Preceptors

have the additional responsibility of providing clear

instruction as well as continuous monitoring for new

staff as they develop skills and confidence in their abilities to operate unfamiliar equipment safely.

In addition, as many facilities move to electronic

health records, nurses are required to have proficient

knowledge and skills in using and retrieving information from databases such as Orthogate (2011), a database where healthcare professionals can retrieve information about rare orthopaedic conditions. The

competent nurse is able to navigate the information system used by the institution and maintain accurate

records. The experienced nurse may serve as a resource

for complex or specialized charting and is able to search

for specific information regarding treatments or specialized equipment needed for patients. Expert nurses

demonstrate skills in effectively retrieving information

from national quality and safety resources to integrate

safety strategies into system changes that promote safe

practice, protect patients from unintended effects, and

enhance communication among caregivers.

Summary

The QSEN competencies guide the processes that support the Orthopaedic Core Competencies Across the

Lifespan. They enhance the orthopaedic specialty by

deepening the focus on patient safety and high-quality

care. The knowledge, skills, and attitudes that are the

underpinnings of the QSEN competencies encourage

the nurse, regardless of level of practice, to focus on

patient-centeredness, work as an effective member of

the team, to provide high-quality care based on current

evidence, utilize information and technology, and keep

the patient safe from harm. These concepts are not new

to orthopaedic nursing; they are better defined through

the QSEN competencies so that nurses can develop

practice behaviors that ensure quality and safety for the

patients they care for. Because of nurses�� specialized

abilities to contribute to the plan of care, carry out orders to support the plan of care, attend to the patient��s

and family��s concerns regarding preferences, and coordinate care between members of the team, they remain

active stakeholders in supporting quality and safety

practices. Preceptors are in a unique position to influence new nurses and those transitioning into the

specialty to implement quality and safety practices as

they develop skills to meet the Orthopaedic Core

Competencies. Their distinct knowledge of the orthopaedic specialty, intertwined with their knowledge of

quality and safety practices, provides them with the

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