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Developing a quality framework for annual nursing competencies


Patients expect safe, high-quality care when they enter a healthcare facility, and healthcare facilities pride themselves on the care they provide. With so much emphasis on quality, many people were shocked in 1999 when the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System. This report estimated that 44,000 to 98,000 preventable medical errors occur each year and called for a greater focus on safe, high-quality care in the U.S. healthcare delivery system.

With the problem clearly identified, healthcare facilities have since been brainstorming ways to improve the quality of care they provide. In 2005, the Robert Wood Johnson Foundation funded “Quality and Safety Education for Nurses” (QSEN), an initiative that identified six key areas of focus building on the IOM’s recommendations—patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

QSEN sought to infuse these six key areas into nursing education programs throughout the country. The original pilot programs saw great success. The academic side has been developing a clear, consistent framework of high-quality, safe nursing care. But in the clinical environment, segregated changes have occurred with no consistency among organizations.

This perception intensified when the 2010 IOM report The Future of Nursing: Leading Change, Advancing Health found that quality and safety issues are still prevalent. The report called on healthcare organizations to strengthen continuing-education programs. With this call, an opportunity to integrate QSEN competencies into clinical education has emerged. The framework and standardization of QSEN, based partly on the IOM reports, may be the answer to the need for a structured response to healthcare quality and safety.

QSEN as a model

Seeing an opportunity for quality improvement (QI), I began a QI project focusing on a large teaching hospital in central Pennsylvania. Although the nursing education department and 25 clinical educators form the backbone of annual competency development, they lacked a standard format to guide them from year to year. Nursing leaders at this hospital, which has more than 1,500 nurses in dozens of care areas, were challenged to find a way to hold competencies to a standardized plan while allowing for the unique needs of each unit.

Realizing the QSEN initiative could serve as a model for solving this dilemma, I approached the director of education about a QI project through which to imbed key quality and safety focus areas in a standardized framework for annual competencies. The project was quickly approved, and I posed the following question to guide it: Regarding acute-care clinical nurse educators, what are the effects of a QSEN-based workshop on educator knowledge and ability to develop evidence-based, safe, quality care competencies compared to pre-education knowledge and ability?

Project description

After receiving approval from the institutional review boards of my educational institution and the hospital serving as the project site, I developed an educational plan, which the hospital’s director of nursing education approved. At a staff meeting scheduled before the design of competencies for 2013, I described the project to all educators present; all of them gave their consent to participate.

After the educators completed a pre-knowledge and confidence survey, they viewed a presentation covering the current state of competency design, the gap related to quality and safety, and the ability of the QSEN project to serve as a foundation for a framework. The presentation covered each individual competency area in detail. After the educational session, attendees completed a post-knowledge and confidence survey.

After the live educational session, biweekly emails were sent to all consenting participants over the next 26 weeks. The emails were designed to support educators as they began to design competencies for the 2013 competency year. Topics included a focus on the six key competency areas as well as competency design and overall support for the nurse educator role. Once the 13 biweekly emails were sent and the 2013 competency year was underway in the nursing education department, a summative follow-up computerized survey was sent to solicit final thoughts on the project and the ability to improve the quality and safety aspect of annual nursing competencies. I met with the nurse-educator group for a final summary and wrap-up meeting.

Results of knowledge and confidence surveys

Twelve participants completed the pre- and post-surveys around the live educational session. Quantitative data analysis using statistical computerized software showed significant differences in educators’ knowledge of the QSEN competency project, confidence in designing and implementing annual competencies, and potential for competency development in such key areas as informatics and collaboration. The analysis found marked improvements in educator confidence in designing competencies within the various quality and safety areas after the educational intervention.

Qualitative data analysis of the pre-education surveys showed many focus areas where educators couldn’t identify examples of competencies. But in the post-education survey, educators gave examples for all categories. For patient-centered care, they submitted such competencies as early mobilization and pain control. For informatics, they submitted medication documentation and exit care (patient-education material). Other categories yielded similar responses. Compared to pre-education qualitative data, post-education data showed an overall increase in educator confidence and knowledge in designing competencies in most of the quality and safety areas.

Final survey results

After the biweekly emails and launch of the 2013 competency year, the summative computerized survey was sent; the response rate was 7/12 (58%). The eight survey questions explored how the framework of quality and safety focus areas affects nursing competencies and educators’ ability to design them. All respondents said the framework helped them to better focus and measure competency, specifically in the areas of quality and safety; 88% believed adding the framework strengthened the overall process of competency measurement. A request to identify specific competencies used for each of the six focus areas yielded many responses—except in the informatics area, which got no specific responses. (See Major themes of qualitative survey results below.)

Major themes of qualitative survey results

Qualitative results were analyzed for themes. Three major themes came through:

• Keeping quality and safety at the forefront of the competency program required the framework presented.
• Respondents appreciated the evidence base for the process of competency development.
• Respondents wished to continue the processes that had been started.


This QI project sought to determine the effects of a QSEN-based workshop on the knowledge and ability of acute-care clinical nurse educators to develop evidence-based, safe, quality-care competencies, compared to pre-education knowledge and ability. The project found that providing a workshop focused on nurse educators’ knowledge and ability to design safe, quality-care competencies made a statistically significant difference in annual competency planning. Everyone involved at the project hospital, from administrators to nurse educators, enthusiastically accepted the overall idea of presenting such a focused framework for acute-care nursing competencies. At the initial education session, it was clear that the nursing education department already was focusing on specific areas to achieve quality care but hadn’t broken the work down into a framework.

The framework provided was consistent to hold all areas of acute care accountable, but flexible enough so each diverse unit could create specific competencies related to its patient population. For example, while all units designed a competency around teamwork and collaboration, the step-down unit’s specific competency differed from that of the surgical intensive care unit.

Not all participants preferred email communication, but they agreed it was helpful to have constant reinforcement of key topics to motivate and empower them when designing competencies. The director of nursing education was especially excited about the project because it provided a specific way to document the work being done toward improving the quality and safety of patient care.

Quality and safety are necessities in health care. The nursing profession must respond in specific ways to calls for a higher quality of care. Starting with annual nursing competencies, a great opportunity exists to make a difference by standardizing a framework of competency design that keeps nursing departments accountable to evidence-based focus areas while sustaining the drive toward quality outcomes. This project is a first step in bridging the gap and improving care in clinical areas.

Selected references

Armstrong G, Headrick L, Madigosky W, Ogrinc G. Designing education to improve care. Jt Comm J Qual Patient Saf. 2012; 38(1):5-14.

Conway ME. Competency control. HomeCare. 2009; March.

Disch J. QSEN? What’s QSEN? Nurs Outlook. 2012;60(2):58-9.

Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.

Joint Commission, The. Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. February 23, 2010. www.jointcommission.org/assets/1/18/RWJ_Future_of_Nursing.pdf.
Accessed November 10, 2014.

Quality and Safety Education for Nurses. Competencies. http://qsen.org/competencies. Accessed November 11, 2014.

Aislynn Moyer is the director of professional development for the Pennsylvania State Nurses Association in Harrisburg.

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