Quality and safety education for advanced
nursing practice
Linda Cronenwett, PhD, RN, FAAN
Gwen Sherwood, PhD, RN, FAAN
Joanne Pohl, PhD, RN, FAAN
Jane Barnsteiner, PhD, RN, FAAN
Shirley Moore, PhD, RN, FAAN
Dori Taylor Sullivan, PhD, RN, NE-BC, CNL, CPHQ
Deborah Ward, PhD, RN, FAAN
Judith Warren, PhD, RN, BC, FAAN, FACMI
The Quality and Safety Education for Nurses (QSEN)
project is a national initiative to transform nursing edu-
cation to integrate quality and safety competencies.
This article describes a two-year process to generate
educational objectives related to quality and safety
competency development in graduate programs that
prepare advanced practice nurses in clinical roles.
Knowledge, skills, and attitudes for each of 6 compe-
tencies are proposed to stimulate development of
teaching strategies in programs preparing the next
generation of advanced practice nurses.
Linda Cronenwett, PhD, RN, FAAN, is Professor, School of Nursing,
University of North Carolina at Chapel Hill, Chapel Hill, NC.
Gwen Sherwood, PhD, RN, FAAN, is Professor and Associate Dean for
Academic Affairs, School of Nursing, University of North Carolina at
Chapel Hill, Chapel Hill, NC.
Joanne Pohl, PhD, RN, FAAN, is Professor, School of Nursing, University
of Michigan, Ann Arbor, MI.
Jane Barnsteiner, PhD, RN, FAAN, is Professor of Pediatric Nursing,
School of Nursing, University of Pennysylvania, Philadelphia, PA.
Shirley Moore, PhD, RN, FAAN, is Professor and Associate Dean for
Research, Frances Payne Bolton School of Nursing, Case Western
Reserve University, Cleveland, OH.
Dori Taylor Sullivan, PhD, RN, NE-BC, CNL, CPHQ, is Associate
Dean for Academic Affairs and Clinical Professor, Duke University
School of Nursing, Durham, NC.
Deborah Ward, PhD, RN, FAAN, is Associate Clinical Professor, Betty
Irene Moore School of Nursing (proposed), University of California at Da-
vis, Davis, CA.
Judith Warren, PhD, RN, BC, FAAN, FACMI, is Christine A. Hartley
Centennial Professor, University of Kansas School of Nursing and Direc-
tor of Nursing Informatics at the KU Center for Healthcare Informatics,
Kansas City, KS.
Corresponding author: Dr. Linda Cronenwett, Professor, School of Nurs-
ing, University of North Carolina at Chapel Hill, Carrington Hall, CB
#7460, Chapel Hill, NC 27599-7460.
E-mail: lcronenwett@unc.edu
Nurs Outlook 2009;57:338-348.
0029-6554/09/$–see front matter
Copyright ª 2009 Mosby, Inc. All rights reserved.
doi:10.1016/j.outlook.2009.07.009
338 V O L U M E 5 7  N U M B E R 6 N U R S I N G
F
aculties of medicine, nursing, and other health pro-
fessions were challenged by the 2003 Institute of
Medicine (IOM) Health Professions Education re-
port1 to mindfully alter learning experiences that form
the basis for professional identity formation so that grad-
uates would be educated to deliver patient-centered care
as members of an interdisciplinary team, emphasizing
evidence-based practice, quality improvement ap-
proaches, and informatics. Simultaneously, the educa-
tional preparation for entry into advanced practice was
a prominent debate.2–4 One result was the proposal
from the American Association of Colleges of Nursing
(AACN) for a new doctorate of nursing practice
(DNP) degree, with an emphasis on programmatic con-
tent related to evidence-based practice, quality improve-
ment, and systems thinking,5 content relevant to the
quality and safety goals outlined by the IOM.1
During this same period, the first phase of Quality and
Safety Education for Nurses (QSEN) was funded by the
Robert Wood Johnson Foundation (RWJF) (PI: L. Cro-
nenwett) to address the challenge of preparing nurses
with the competencies necessary to continuously improve
the quality and safety of the healthcare systems in which
they work. In keeping with the recommendations from
the Health Professions Education report,1 QSEN leaders
proposed definitions for 6 competencies that describe
essential features of what it means to be a competent
and respected nurse. To clarify educational objectives,
they also proposed statements of the knowledge, skills,
and attitudes (KSAs) for each competency that should
be developed during prelicensure nursing education.6
As the panel worked to identify the knowledge, skills,
and attitudes for prelicensure nurses, questions emerged
about the relevance for graduate nursing education. An
expert educator joined the QSEN Advisory Board as a rep-
resentative of the National Organization of Nurse Practi-
tioner Faculties (NONPF).7 The QSEN faculty and
advisory board members determined that the following
questions needed to be answered to fully address the
O U T L O O K
Quality and safety education for advanced practice
Table 1. *,**Patient-centered Care. Definition: 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
Knowledge
Analyze multiple dimensions of pa-
tient-centered care:
 patient/family/community prefer-
ences, values
 coordination and integration of
care
 information, communication, and
education
 physical comfort and emotional
support
 involvement of family and friends
 transition and continuity
Analyze how diverse cultural, ethnic,
spiritual, and social backgrounds
function as sources of patient,
family, and community values
Analyze social, political, eco-
nomic, and historical dimen-
sions of patient care processes
and the implications for patient-
centered care
Integrate knowledge of
psychological, spiritual, social,
developmental, and
physiological models of pain
and suffering
Analyze ethical and legal
implications of patient-centered
care
Describe the limits and boundaries Acknowledge the tension that may
of therapeutic patient-centered
care
Analyze strategies that empower
patients or families in all aspects of
the health care process
Analyze features of physical
facilities that support or pose
barriers to patient-centered
care
Analyze reasons for common
barriers to active involvement of
patients and families in their own
health care processes
Skills
Elicit patient values, preferences,
and expressed needs as part of
clinical interview, diagnosis, im-
plementation of care plan and
evaluation of care
Communicate patient values, pref-
erences and expressed needs to
other members of health care
team
Provide patient-centered care with
sensitivity, empathy, and respect
for the diversity of human experi-
ence
Ensure that the systems within
which one practices support
patient-centered care for indi-
viduals and groups whose
values differ from the majority or
one’s own.
Assess and treat pain and suffering Seek to understand one’s
in light of patient values,
preferences, and expressed
needs
Respect the boundaries of
therapeutic relationships
exist between patient
preferences and organizational
and professional responsibilities
for ethical care
Facilitate informed patient consent
for care
Engage patients or designated
surrogates in active partnerships
along the health illness
continuum
Create or change organizational Honor active partnerships with
cultures so that patient and
family preferences are assessed
and supported
Assess level of patient’s decisional Respect patient’s right to access to
conflict and provide access to
resources
Eliminate barriers to presence of
families and other designated
surrogates based on patient
preferences
N O V E M B E R / D E C E M B E R
Cronenwett et al
Attitudes
Value seeing health care situations
through patients’ eyes
Respect and encourage individual
expression of patient values, pref-
erences, and expressed needs
Value the patient’s expertise with
own health and symptoms
Honor learning opportunities with
patients who represent all aspects
of human diversity
Seek to understand one’s person-
ally held attitudes about working
with patients from different ethnic,
cultural, and social backgrounds
Willingly support patient-centered
care for individuals and groups
whose values differ from own
Value cultural humility
personally held values and
beliefs about the management
of pain or suffering
Value shared decision-making with
empowered patients and
families, even when conflicts
occur
Respect patient preferences for
degree of active engagement in
care process
patients or designated surrogates
in planning, implementation, and
evaluation of care
personal health records
Value system changes that
support patient-centered care
N U R S I N G O U T L O O K 339
Quality and safety education for advanced practice Cronenwett et al

Table 1. Continued
Knowledge
Integrate principles of effective
communication with
knowledge of quality and
safety competencies
Analyze principles of consensus
building and conflict resolution
Analyze advanced practice
nursing roles in assuring
coordination, integration,
and continuity of care
Describe process of reflective
practice
Skills Attitudes
Continuously analyze and improve Value continuous improvement
own level of communication skill in of own communication and
encounters with patients, families, conflict resolution skills
and teams
Provide leadership in building Value consensus
consensus or resolving conflict in
the context of patient care
Communicate care provided and
needed at each transition in care
Incorporate reflective practices Value the process of reflective
into own repertoire practice

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

IOM call for education reform to improve quality and
safety:
 Are the QSEN competency definitions relevant to
advanced practice nurses?
 Which of the prelicensure KSAs are also relevant
objectives for advanced practice nursing (APN)
education?
 What new KSAs, if any, should be added at the grad-
uate level?
 Will KSAs vary by APN specialty and role or can one
set of KSAs encompass all APNs?
The purpose of this article is to describe the work of
QSEN in addressing these questions and to present
KSAs that can guide the development of teaching strat-
egies for quality and safety competency development in
programs that prepare nurses for advanced practice in
clinical roles.
COMPETENCY DEFINITIONS
The development of prelicensure quality and safety com-
petency definitions for patient-centered care, teamwork
and collaboration, evidence-based practice, quality im-
provement, safety, and informatics was described in the
May-June 2007 issue of Nursing Outlook.6 These com-
petency definitions appear again in Tables 1–6 here.
As part of the process of developing the competency
definitions, QSEN leaders sought feedback from organi-
zations that represented nurse practitioner (NP) and
clinical nurse specialist faculties and accrediting bodies
for nurse anesthesia and nurse-midwifery programs.
Representatives agreed that the 6 competency defini-
tions were appropriate for advanced practice nurses.
They also submitted helpful comments on the prelicen-
sure KSAs and supported the assessment that they were
appropriate for prelicensure graduates.6
As the first phase of QSEN ended, the competency
definitions were considered relevant to all nurses, but
it was not clear how the KSAs, which had been devel-
oped with prelicensure education as the focus, would
need to be adapted to be useful for master’s or doctoral
program faculties who were preparing advanced prac-
tice nurses.
KNOWLEDGE, SKILLS, AND
ATTITUDES
The second phase of QSEN was funded by the RWJF
(PI: L Cronenwett) from April 2007 to November
2008. Because QSEN faculty and advisory board mem-
bers believed that KSAs for APNs in direct care would
differ from KSAs for nurses in other advanced roles
(eg, administration, informatics, community or public
health, education), groups invited to participate in
Phase II work represented APNs who practiced in di-
rect patient care roles (nurse practitioners, clinical
nurse specialists, nurse-anesthetists, and nurse-mid-
wives) through work on standards of practice, accredi-
tation of education programs, or certification. QSEN
funded one organizational representative, but organiza-
tions were invited to bring a second representative at
their own expense. The context of the meeting was
described as follows:
We have no preconceived notions about the final
outcomes of our work together, but we want to ex-
plore, with your help, the territory of graduate ed-
ucation in the specialties that prepare advanced
practice nurses for direct care. Are there common

340 V O L U M E 5 7  N U M B E R 6 N U R S I N G O U T L O O K
Quality and safety education for advanced practice
Table 2. *,**Teamwork and Collaboration. Definition: Function Effectively
within Nursing and Interprofessional Teams, Fostering Open
Communication, Mutual Respect, and Shared Decision-making to Achieve
Quality Patient Care
Knowledge
Analyze own strengths,
limitations and values as
a member of a team
Analyze impact of own
advanced practice role and
its contributions to team
functioning
Describe scopes of practice and
roles of all health care team
members
Analyze strategies for identifying
and managing overlaps in
team member roles and
accountabilities
Analyze strategies that
influence the ability to initiate
and sustain effective
partnerships with members of
nursing and interprofessional
teams
Analyze impact of cultural
diversity on team functioning
Analyze differences in
communication style
preferences among patients
and families, advanced
practice nurses, and other
members of the health team
Describe impact of own
communication style on
others
Describe examples of the impact
of team functioning on safety
and quality of care
Cronenwett et al
Skills Attitudes
Demonstrate awareness of own Acknowledge own contributions
strengths and limitations as to effective or ineffective team
a team member functioning
Continuously plan for
improvement in use of self in
effective team development
and functioning
Act with integrity, consistency
and respect for differing views
Function competently within own Respect the unique attributes
scope of practice as that members bring to a team,
a member of the health care including variation in
team professional orientations,
competencies, and
accountabilities
Assume role of team member or
leader based on the situation
Guide the team in managing Respect the centrality of the
areas of overlap in team patient/family as core
member functioning members of any health care
Solicit input from other team team
members to improve
individual, as well as team,
performance
Empower contributions of others
who play a role in helping
patients/families achieve
health goals
Initiate and sustain effective Appreciate importance of
health care teams interprofessional collaboration
Communicate with team Value collaboration with nurses
members, adapting own style and other members of the
of communicating to needs of nursing team
the team and situation
Communicate respect for team Value different styles of
member competence in communication
communication
Initiate actions to resolve conflict
Follow communication practices Appreciate the risks associated
that minimize risks associated with handoffs among providers
with handoffs among providers and across transitions in care
and across transitions in care
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Quality and safety education for advanced practice Cronenwett et al

Table 2. Continued
Knowledge
Analyze authority gradients and
their influence on teamwork
and patient safety
Identify system barriers and
facilitators of effective team
functioning
Examine strategies for improving
systems to support team
functioning
Skills Attitudes
Choose communication styles Value the solutions obtained
that diminish the risks through systematic,
associated with authority interprofessional
gradients among team collaborative efforts
members
Assert own position/perspective
and supporting evidence in
discussions about patient care
Lead or participate in the design Value the influence of system
and implementation of solutions in achieving team
systems that support effective functioning
teamwork
Engage in state and national
policy initiatives aimed at
improving teamwork and
collaboration

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

expectations for quality and safety competency de-
velopment? Should there be? If so, how would the
KSAs for graduate education differ from those
we’ve proposed for prelicensure education?
In response, the following organizations and numbers
of representatives participated in the April 2007 confer-
ence in Lansdowne, Virginia with QSEN faculty and
advisory board members (see Acknowledgments for
advisory board organizational affiliations):
American College of Nurse Midwives (1)
American Nurses Association (2)
American Nurses Credentialing Center (2)
American Psychiatric Nurses Association (1)
American Association of Critical-Care Nurses
Certification Corporation (1)
Council on Accreditation of Nurse Anesthesia Ed-
ucational Programs (COA) (1)
Commission on Collegiate Nursing Education (2)
National Association of Clinical Nurse Specialists
(2)
National Organization of Nurse Practitioner Fac-
ulties (NONPF) (2)
Oncology Nursing Certification Corporation (1)
Pediatric Nursing Certification Board (2)
QSEN faculty (authors Sherwood, Barnsteiner,
Moore, Sullivan, Ward, and Warren) presented initial
ideas and trigger questions related to advanced practice
KSAs for each competency and facilitated small group
discussions focused on each of the competencies. Each
workgroup generated KSAs for graduate education
without regard to whether the end result was a master’s
or doctoral degree. The goal was to generate the min-
imum KSAs for any program that prepares graduates
for APN certification and practice, recognizing that
higher level skills and greater knowledge in some
competencies might be expected of doctoral-level
graduates.
Participants held different views of the extent to
which practitioners, faculty, and students already pos-
sessed the KSAs. Most agreed, however, that the current
quality and safety focus was on educating practitioners
that could appropriately assess, diagnose, and treat indi-
vidual patients. When they brainstormed ideas for
addressing common system problems related to the
competencies, it was surprisingly easy to express gradu-
ate level KSAs in language that crossed specialty bound-
aries. By the end of the meeting, the group agreed
unanimously that one document could serve their
multiple constituencies.
ORGANIZATIONAL REVIEW AND
COMMENT
After the meeting, a draft of proposed graduate KSAs was
mailed to each conference participant with a request for
review and feedback. In addition to QSEN advisory board
members, 10 organizational representatives from 7 of the
participating organizations responded to the request.
All respondents said that the work they participated in
at the Lansdowne conference was represented accu-
rately in the draft. There was greater diversity, however,
in response to the question: ‘‘Does the document as
a whole capture your view of what should be expected
(in quality and safety competency development) during
graduate education for APN specialties?’’ Nine

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Quality and safety education for advanced practice Cronenwett et al

Table 3. *,**Evidence-based Practice.Definition: Integrate Best Current

Evidence with Clinical Expertise and Patient/Family Preferences and Values
for Delivery of Optimal Health Care
Knowledge Skills Attitudes

Demonstrate knowledge of
health research methods and
processes
Describe evidence-based prac-
tice to include the compo-
nents of research evidence,
clinical expertise, and patient/
family values
Identify efficient and effective
search strategies to locate
reliable sources of evidence
Identify principles that com-
prise the critical appraisal of
research evidence
Summarize current evidence
regarding major diagnostic
and treatment actions within
the practice specialty
Determine evidence gaps
within the practice specialty
Analyze how the strength of
available evidence influ-
ences the provision of care
(assessment, diagnosis,
treatment, and evaluation)
Evaluate organizational cul-
tures and structures that pro-
mote evidence-based
practice
Use health research methods
and processes, alone or in
partnership with scientists, to
generate new knowledge for
practice
Adhere to Institutional Review
Board guidelines
Role model clinical decision-
making based on evidence,
clinical expertise, and patient/
family preferences and values
Employ efficient and effective
search strategies to answer
focused clinical questions
Critically appraise original re-
search and evidence summa-
ries related to area of practice
Exhibit contemporary knowl-
edge of best evidence re-
lated to practice specialty
Promote research agenda for
evidence that is needed in
practice specialty
Initiate changes in approaches
to care when new evidence
warrants evaluation of other
options for improving out-
comes or decreasing ad-
verse events
Develop guidelines for clinical
decision-making regarding
departure from established
protocols/standards of care
Participate in designing sys-
tems that support evidence-
based practice
Appreciate strengths and weak-
nesses of scientific bases for
practice
Value the need for ethical con-
duct of research and quality
improvement
Value all components of evi-
dence-based practice
Value development of search
skills for locating evidence
for best practice
Value knowing the evidence
base for practice specialty
Value public policies that sup-
port evidence-based prac-
tice
Acknowledge own limitations in
knowledge and clinical exper-
tise before determining when
to deviate from evidence-
based best practices
Value the need for continuous
improvement in clinical prac-
tice based on new knowledge

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

respondents provided positive comments about the doc-
ument as a whole. Examples of these responses were:
 ‘‘The APN KSAs look good. I have just a few
comments.’’
 ‘‘There is nothing egregious missing in the area of
patient safety and quality.’’
 ‘‘I think they are well written and organized. The ma-
jor areas make sense to me and are consistent with NP
education and practice. And, no doubt, quality and
safety are critical issues, so these competencies are
timely.’’
 ‘‘Our graduate faculty discussed the document and
thought it was excellent.’’
Representatives of two organizations, COA and
NONPF, expressed concerns, with COA contributing
a response on behalf of the organization as a whole.
Both organizations had a significant number of compe-
tency expectations already and believed that the ‘‘spirit

N O V E M B E R / D E C E M B E R N U R S I N G O U T L O O K 343
Quality and safety education for advanced practice Cronenwett et al

Table 4. *,**Quality Improvement. Definition: 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
Knowledge Skills Attitudes

Describe strategies for Use a variety of sources of Appreciate that continuous

improving outcomes of information to review quality improvement is an
care in the setting in outcomes of care and essential part of the daily
which one is engaged in identify potential areas work of all health
clinical practice for improvement professionals
Propose appropriate aims
for quality improvement
efforts
Analyze the impact of Assert leadership in
context (such as shaping the dialogue
access, cost, or team about and providing
functioning) on leadership for the
improvement efforts introduction of best
practices
Analyze ethical issues Assure ethical oversight of Value the need for ethical
associated with quality quality improvement conduct of quality
improvement projects improvement
Describe features of Maintain confidentiality of
quality improvement any patient information
projects that overlap used to determine
sufficiently with outcomes of quality
research, thereby improvement efforts
requiring Institutional
Review Board oversight
Describe the benefits and Design and use Appreciate the
limitations of quality databases as sources of importance of data that
improvement data information for allows one to estimate
sources, and improving patient care the quality of local care
measurement and data Select and use relevant
analysis strategies benchmarks
Explain common causes Select and use tools (such Appreciate how unwanted
of variation in outcomes as control charts and run variation affects
of care in the practice charts) that are helpful for outcomes of care
specialty understanding variation processes
Identify gaps between local
and best practice
Describe common quality Use findings from root Value measurement and its
measures in the cause analyses to design role in good patient care
practice specialty and implement system
improvements
Select and use quality
measures to understand
performance
Analyze the differences Use principles of change Appreciate the value of
between microsystem management to what individuals and
and macrosystem implement and teams can do to improve
change evaluate care care
processes at the
microsystem level

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Quality and safety education for advanced practice Cronenwett et al

Table 4. Continued
Knowledge Skills Attitudes
Understand principles of Value local systems
change management improvement (in individual
practice, team practice on
a unit, or in the macrosystem)
and its role in professional
job satisfaction
Analyze the strengths and Design, implement, and evaluate Appreciate that all
limitations of common tests of change in daily work improvement is change, but
quality improvement (using an experiential learning not all change is
methods method such as Plan-Do- improvement
Study-Act)
Align the aims, measures, and
changes involved in
improving care
Use measures to evaluate the
effect of change

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

of the QSEN KSAs’’ was embedded in their current
standards. COA reported that ‘‘we voted to support
the spirit of the document; however, we cannot support
the implementation, nor support that the document is
necessary or beneficial at this time.’’ Concerns included
skepticism that each KSA could be adequately ad-
dressed during the graduate program in anesthesia be-
cause the COA questioned whether competence could
be achieved for some of the items, particularly ones
that were broad in scope. Nonetheless, they ‘‘remain
open to continued consideration of the important
work generated by QSEN.’’
The views from NP faculty representing the second
organization (NONPF) were mixed. A major concern
was whether one could prepare a safe clinician and
also attend to the quality and safety KSAs within NP ed-
ucational programs, particularly MSN programs. The
need to focus on the large body of knowledge and skills
that enable an individual practitioner to accurately diag-
nose and treat an individual patient was considered par-
amount, and it seemed overwhelming to say that
programs could prepare students to ‘‘lead or participate
in the design and implementation of systems that sup-
port effective teamwork’’ or ‘‘design and use databases
as sources of information for improving patient care.’’
One person’s summary view was, ‘‘Taken as a whole, I
don’t believe that NP master’s level programs can suc-
cessfully address all of these KSAs without compromis-
ing other critical aspects of graduate education.’’
The NONPF leadership decided to put the issue to its
members by inviting the QSEN Principal Investigator
(Cronenwett) to give the keynote speech at its April
2008 33rd Annual Meeting in Louisville, Kentucky. A
lively conversation followed the presentation, with
many speakers emphasizing the need for APNs to
develop the competencies. As a result, the NONPF Board
of Directors decided to undertake a review of their NP
Core and DNP competencies to identify areas of overlaps
and gaps between the proposed QSEN graduate KSAs
and the existing core competencies. A report of their
work to date appears in this issue of Nursing Outlook.7
KNOWLEDGE, SKILLS, AND
ATTITUDES FOR APN EDUCATION
Tables 1–6 present the APN KSAs as revised after re-
ceiving feedback from professional organizational rep-
resentatives. Material that differs from the prelicensure
KSAs appears in bold, italicized font. For readers who
compare the prelicensure KSAs6 to the APN KSAs, it
will be obvious that the basic categories of knowledge,
skills, and attitudes are similar. Differences occurred
for the following reasons.
 In a few cases, participants in the APN KSA develop-
ment process argued that an item that had been la-
beled knowledge was better expressed as an attitude
or skill, resulting in the occasional change in column.
 Items have the same stem as the prelicensure KSAs
but are introduced by a verb representing a higher-
level objective.
 New items under each competency derive from the
greater preparation for leadership that is expected at
the APN level, regardless of specialty.
 Other new items represent the expectations associated
with mastering a particular specialty and its evidence
base, information technologies, and outcome measures.

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Quality and safety education for advanced practice
Table 5. *,**Safety. Definition: Minimize Risk of Harm to Patients and
Providers through Both System Effectiveness and Individual Performance
Knowledge
Describe human factors and
other basic safety design prin-
ciples as well as commonly
used unsafe practices (such as
workarounds and dangerous
abbreviations)
Describe the benefits and limita-
tions of selected safety-en-
hancing technologies (such as
barcodes, computer provider
order entry, and electronic
prescribing)
Evaluate effective strategies to
reduce reliance on memory
Delineate general categories of
errors and hazards in care
Identify best practices for or-
ganizational responses to
error
Describe factors that create
a just culture and culture of
safety
Describe best practices that
promote patient and pro-
vider safety in the practice
specialty
Describe processes used to
analyze causes of error and
allocation of responsibility and
accountability (such as root
cause analysis and failure
mode effects analysis)
Describe methods of identifying
and preventing verbal,
physical, and psychological
harm to patients and staff
Analyze potential and actual
impact of national patient
safety resources, initiatives,
and regulations
*All tables are open source.
**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.
346 V O L U M E 5 7  N
Skills
Participate as a team member to
design, promote, and model
effective use of technology and
standardized practices that
support safety and quality
Participate as a team member to
design, promote, and model
effective use of strategies to re-
duce risk of harm to self and
others.
Promote a practice culture con-
ducive to highly reliable pro-
cesses built on human factors
research
Use appropriate strategies to re-
duce reliance on memory (such
as forcing functions, checklists)
Communicate observations or
concerns related to hazards and
errors to patients, families, and
the healthcare team.
Identify and correct system fail-
ures and hazards in care
Design and implement microsys-
tem changes in response to
identified hazards and errors
Engage in a systems focus rather
than blaming individuals when
errors or near misses occur
Report errors and support mem-
bers of the healthcare team to
be forthcoming about errors
and near misses
Participate appropriately in
analyzing errors and designing,
implementing, and evaluating
system improvements
Prevent escalation of conflict
Respond appropriately to
aggressive behavior
Use national patient safety
resources:
 for own professional develop-
ment
 to focus attention on safety in
care settings
 to design and implement im-
provements in practice
U M B E R 6 N U R S I N G O U T L O O K
Cronenwett et al
Attitudes
Value the contributions of stan-
dardization and reliability to
safety
Appreciate the importance of
being a safety mentor and
role model
Appreciate the cognitive and
physical limits of human
performance
Value own role in reporting and
preventing errors
Value systems approaches to
improving patient safety in
lieu of blaming individuals
Value the use of organizational
error reporting systems
Value vigilance and monitoring
of care, including one’s own
performance, by patients,
families, and other members of
the healthcare team
Value prevention of assaults
and loss of dignity for
patients, staff, and
aggressors
Value relationship between
national patient safety
campaigns and
implementation in local
practices and practice settings
Quality and safety education for advanced practice Cronenwett et al

Table 6. *,**Informatics. Definition: Use Information and Technology to

Communicate, Manage Knowledge, Mitigate Error, and Support Decision
Making
Knowledge Skills Attitudes

Contrast benefits and limita-
tions of common information
technology strategies used in
the delivery of patient care
Evaluate the strengths and
weaknesses of information
systems used in patient care
Formulate essential information
that must be available in
a common database to sup-
port patient care in the prac-
tice specialty
Evaluate benefits and limitations
of different communication
technologies and their impact
on safety and quality
Describe and critique
taxonomic and terminology
systems used in national
efforts to enhance
interoperability of
information systems and
knowledge management
systems
Participate in the selection, de- Value the use of information
sign, implementation, and and communication
evaluation of information technologies in patient care
systems
Communicate the integral role
of information technology in
nurses’ work
Model behaviors that support
implementation and appro-
priate use of electronic
health records
Assist team members in adopt-
ing information technology
by piloting and evaluating
proposed technologies
Promote access to patient care Appreciate the need for con-
information for all profes- sensus and collaboration in
sionals who provide care to developing systems to man-
patients age information for patient
Serve as a resource for how to care
document nursing care at Value the confidentiality and
basic and advanced levels security of all patient records
Develop safeguards for pro-
tected health information
Champion communication
technologies that support
clinical decision-making, er-
ror prevention, care coordi-
nation, and protection of
patient privacy
Access and evaluate high- Value the importance of stan-
quality electronic sources of dardized terminologies in
health care information conducting searches for pa-
Participate in the design of tient information
clinical decision-making Appreciate the contribution of
supports and alerts technological alert systems
Search, retrieve, and manage Appreciate the time, effort, and
data to make decisions using skill required for computers,
information and knowledge databases, and other technol-
management systems ogies to become reliable and
Anticipate unintended conse- effective tools for patient care
quences of new technology

*All tables are open source.

**Bold, italicized text indicates a change in comparison with pre-licensure KSAs.

The graduate KSAs for the IOM/QSEN competen-
cies represent ambitious educational objectives, yet
the consensus of APN organizational representatives
was that development of these KSAs was essential to
advanced practice educational programs of the future.
For all groups, the goals set by these KSAs were val-
ued, although the number and level of some KSAs
were viewed as problematic for some accrediting
organizations.
The process used to generate the APN KSAs did not
involve employers of APNs or patient perspectives. In
addition, all participants were from American-based

N O V E M B E R / D E C E M B E R N U R S I N G O U T L O O K 347
Quality and safety education for advanced practice
institutions and organizations. We have no way of know-
ing whether these KSAs would be judged relevant or ap-
propriate in other countries and cultures.
Recognizing these limitations, we share the work on
graduate KSAs to help individual faculty members bet-
ter understand the scope of the issues. Based on our ex-
periences with prelicensure faculty in the QSEN
Learning Collaborative,8 we believe that APN faculties
can use these KSAs to generate ideas appropriate to
APN education and transform their teaching strategies
and curricula to achieve important quality and safety
educational goals.
SUMMARY
Nurses in advanced practice, like other health profes-
sionals, often attribute quality and safety solely to the
knowledge (and carefulness) of individual practitioners
rather than to the teamwork, cultures of safety and sup-
port for informatics, quality improvement, evidence-
based practice, and patient-centered care in the systems
within which they work. Faculties have been challenged,
however, to incorporate these new foci in all types of
health professions educational programs.1
The IOM/QSEN competencies and many of the preli-
censure KSAs are embedded in the new AACN Essentials
of Baccalaureate Education,9 and the IOM/QSEN com-
petencies and many graduate KSAs are embedded in
AACN’s Essentials of Doctoral Education for Advanced
Nursing Practice.5 We hope that nursing programs will
someday have graduate faculties with the will and ideas
to implement curricula where quality and safety compe-
tencies are included as expected learning outcomes. If
this goal is achieved, advanced practice nursing graduates
will be better prepared to continuously improve the qual-
ity and safety of the systems within which they work.
Quality and Safety Education for Nurses is funded by the Robert
Wood Johnson Foundation.
Principal Investigator, Linda R. Cronenwett, University of North
Carolina at Chapel Hill.
The authors gratefully acknowledge the following QSEN faculty
348 V O L U M E 5 7  N U M B E R 6 N U R S I N G
Cronenwett et al
and advisory board members for their contributions to the develop-
ment of the competency definitions and KSAs: Paul Batalden, MD
(Dartmouth); Geraldine Bednash, PhD, RN, FAAN (American As-
sociation of Colleges of Nursing); Jean Blackwell, MLS (University
of North Carolina-Chapel Hill); Lisa Day, PhD, RN, CNS (Unive-
sity of California-San Francisco Medical Center); Joanne Disch,
PhD, RN, FAAN (University of Minnesota); Carol Durham,
EdD(c), RN, ANEF (UNC-Chapel Hill); Leslie Hall, MD (Univer-
sity of Missouri-Columbia); Jean Johnson, PhD, RN, FAAN
(George Washington University); Mary (Polly) Johnson, MSN,
RN, FAAN (North Carolina Board of Nursing); Maryjoan Ladden,
PhD, RN (Harvard and RWJF); M. Elaine Tagliareni, EdD, RN,
FAAN (Community College of Philadelphia and National League
for Nursing).
REFERENCES
1. Institute of Medicine. Health professions education: A bridge
to quality. Washington, DC: National Academies Press; 2003.
2. American Association of Colleges of Nursing: AACN Position
Statement on the Practice Doctorate in Nursing. October 2004.
Available at: http://www.aacn.nche.edu/DNP/DNPPosition
Statement.htm. Accessed February 5, 2009.
3. Dracup K, Cronenwett L, Meleis AI, Benner PE. Reflections on
the doctorate of nursing practice. Nurs Outlook 2005;53:177-82.
4. Mundinger MO. Who’s who in nursing: Bringing clarity to the
doctor of nursing practice. Nurs Outlook 2005;53:173-6.
5. American Association of Colleges of Nursing. The essentials
of doctoral education for advanced nursing practice. Washing-
ton, DC: AACN; 2006.
6. Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson,
Mitchell P, et al. Quality and safety education for nurses.
Nurs Outlook 2007;55:122-31.
7. Pohl J, Savrin C, Fiandt K, Beauchesne M, Drayton-Brooks S,
Scheibmeir M, et al. Quality and safety in graduate education:
Cross mapping QSEN graduate competencies with NONPF’s
NP core and practice doctorate competencies. Nursing Outlook
2009;57:349-55.
8. Cronenwett L, Sherwood G, Gelmon S. Improving quality and
safety education: A learning collaborative. Nursing outlook
2009;57:304-12.
9. American Association of Colleges of Nursing. AACN’s The
Essentials of Baccalaureate Education for Professional Nurs-
ing Practice. 2008. Available at: http://www.aacn.nche.edu/
Education/bacessn.htm. Accessed February 5, 2009.
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