Current assessments of quality and safety
education in nursing
Elaine L. Smith, EdD(c), MBA, MSN, RN, CNAA
Linda Cronenwett, PhD, RN, FAAN
Gwen Sherwood, PhD, RN, FAAN
Concerns about the quality and safety of health care
have changed practice expectations and created a
mandate for change in the preparation of health care
professionals. The Quality and Safety Education for
Nurses project team conducted a survey to assess
current levels of integration of quality and safety con-
tent in pre-licensure nursing curricula. Views of 195
nursing program leaders are presented, including in-
formation about satisfaction with faculty expertise and
student competency development related to 6 domains
that define quality and safety content: patient-centered
care, teamwork and collaboration, evidence-based
practice, quality improvement, safety, and informatics.
With competency definitions as the sole reference
point, survey respondents indicated that quality and
safety content was embedded in current curricula,
and they were generally satisfied that students were
developing the desired competencies. These data are
contrasted with work reported elsewhere in this issue
of Nursing Outlook1 and readers are invited to con-
sider a variety of interpretations of the differences.
I
n the lead article in this issue of Nursing Outlook,
Cronenwett, Sherwood and colleagues1 described the
work of the Robert Wood Johnson Foundation
(RWJF)-funded Quality and Safety Education for
Nurses (QSEN) project. The QSEN faculty and advi-
sory board members derived 6 core quality and safety
competencies from the Institute of Medicine (IOM)
Elaine L. Smith is a Clinical Assistant Professor at University of North
Carolina at Chapel Hill School of Nursing.
Linda Cronenwett is a Dean and Professor at University of North
Carolina at Chapel Hill School of Nursing.
Gwen Sherwood is an Associate Dean for Academic Affairs and
Professor at University of North Carolina at Chapel Hill School of
Nursing.
Quality and Safety Education for Nurses is funded by the Robert Wood
Johnson Foundation. Principal Investigator, Linda R. Cronenwett, Uni-
versity of North Carolina at Chapel Hill.
Reprint requests: Elaine L. Smith, University of North Carolina at Chapel
Hill School of Nursing, Carrington Hall, Campus Box 7460, Chapel Hill,
NC 27599.
E-mail: elaines@email.unc.edu
Nurs Outlook 2007;55:132-137.
0029-6554/07/$–see front matter
Copyright © 2007 Mosby, Inc. All rights reserved.
doi:10.1016/j.outlook.2007.02.005
132 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G
report Health Professions Education: A Bridge to
Quality2: patient-centered care, teamwork and collabo-
ration, evidence-based practice, quality improvement,
safety, and informatics.1 The proposed competency
definitions (Table 1) were developed with the goal of
being broad enough to be used as frameworks for
educational programs, licensure, and certification for all
registered nurses.
The QSEN faculty believed that significant
changes in curricula were required if students were to
graduate with beginning levels of these quality and
safety competencies. But they did not know if nurse
educators in pre-licensure programs shared their
views. To assess the extent to which educators
believed content related to these 6 competencies
were already integrated in pre-licensure curricula, the
authors surveyed program leaders from a national
sample of baccalaureate and graduate entry programs
(some of whom also offered Associate Degree Nurs-
ing [ADN] programs) and an additional convenience
sample of ADN community college programs in
North Carolina. In this article, we present the survey
results as reported by program administrators or their
designated responders and consider the implications
of the findings for the next steps in improving quality
and safety education for nurses.
REVIEW OF THE LITERATURE
The 2003 Institute of Medicine report on health profes-
sions education2 was published at the same time as an
article by VanGeest and Cummins3 that reported an
educational needs assessment conducted by the Na-
tional Patient Safety Foundation. In 2 phases (focus
groups followed by self-administered mail surveys), the
authors explored physician and nurse experiences with
error, their attitudes toward and knowledge of patient
safety, and the nature of their informational and training
needs.3
The nurse survey used a national random sample of
1200 nurses who were affiliated with the American
Nurses Association (ANA). Over 95% of nurse respon-
dents (n ⫽ 386) identified patient safety as an important
issue in health care. A similar percentage thought
multidisciplinary partnerships were essential to address
the problems of medical errors, which they viewed most
O U T L O O K
Current assessments of quality and safety education
Table 1. Competency Definitions
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.
Teamwork and Collaboration: Function effectively
within nursing and inter-professional teams,
fostering open communication, mutual respect,
and shared decision-making to achieve quality
patient care.
Evidence-based Practice: Integrate best current
evidence with clinical expertise and
patient/family preferences and values for
delivery of optimal health care.
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 health care systems.
Safety: Minimize risk of harm to patients and
providers through both system effectiveness and
individual performance.
Informatics: Use information and technology to
communicate, manage knowledge, mitigate
error, and support decision making.
often as system issues (although only 49% thought that
patient safety is best addressed at the system level).3
The nursing focus group participants thought a compre-
hensive curriculum and “culture of safety” were neces-
sary for improvement. Training opportunities that em-
power nurses to overcome the challenges of health care
hierarchies in implementing error-prevention strategies
were also considered important. Nurses also expressed
concerns about the potential sources of error introduced
by health care technologies and recommended educa-
tion that prepared nurses for proper evaluation and use
of technology on the patient’s behalf.3 Clearly, this
sample of practicing nurses identified many educational
needs related to the IOM2 competencies.
Information management is a component of each
of the quality and safety competencies. In 2005,
McNeil, Elfrink and others4 reported an analysis of
qualitative data from a national survey of baccalau-
reate nursing education programs. Using methods
almost identical to the QSEN survey reported here,
the investigators asked what knowledge and skills
were currently being taught, what additional infor-
mation technology (IT) content should be taught, and
to what extent faculty members were prepared to
teach IT knowledge and skills. They learned that
nursing programs (n ⫽ 266) put greater emphasis on
computer literacy skills than on informatics literacy
skills. Although the educators acknowledged that
students lack core knowledge about information
management, 16% of the programs had no plans for
Smith et al
expansion of learning opportunities. The majority
of schools reported a lack of qualified faculty, re-
sources, and clinical environments supportive of
advanced information management technologies.
Overall, comments reflected “a lack of clarity among
nursing faculty about essential informatics content
and how to effectively integrate this content into the
nursing curriculum.”4
The information management survey, although fo-
cused on a single QSEN competency, reinforced the
need for evaluating the current state prior to implement-
ing strategies to improve quality and safety education
for nurses. It was also helpful in confirming that the
target sample would respond using electronic survey
methods. Finally, the literature review helped affirm
that no prior studies had been conducted that described
the current state of nursing education with respect to the
IOM2 competencies as a whole.
RESEARCH QUESTIONS
The purpose of the survey was to describe the current
state of pre-licensure nursing education with respect to
the 6 QSEN competencies.1 Specifically, the following
questions were posed:
● Does your pre-licensure curriculum contain content/
experiences aimed at the development of the follow-
ing competencies?
● What pedagogical strategies are being used to teach
content related to each competency?
● What is the level of satisfaction with student compe-
tency development for each domain?
● What is the perceived level of faculty preparedness to
teach each competency?
● To what extent would faculty value various approaches
(Website, teaching manual, conferences, DVD) for
provision of curricular resources for quality and safety
education?
METHODS
This descriptive study was conducted using survey meth-
ods and an electronic survey management program.
Instrument
The online survey instrument was developed by the
authors to answer the research questions. The QSEN
faculty and advisory board members provided input on
the design and face validity of the Web-based instru-
ment, and the survey was pilot-tested with nursing
faculty and administrators from 4 schools of nursing.
Pilot schools were selected based on their proximity to
the QSEN project team and permission of the program
directors. Since the survey was going to be sent to both
baccalaureate and associate degree programs, 2 BSN
and 2 ADN programs were chosen for the pilot. A
faculty/program director focus group format was used
to invite critique of the instrument with respect to
content, comprehension, and completion time. Using an
M A Y / J U N E N U R S I N G O U T L O O K 133
Current assessments of quality and safety education
iterative process, revisions were made after each
group’s critique. On average, the survey completion
time was 15 minutes during the pilot phase. Definitions
of the 6 QSEN competencies1 were printed on the
opening page of the survey.
Sample
Member schools of the American Association of
Colleges of Nursing (AACN) (n ⫽ 572) were the
target sample for baccalaureate and graduate-entry
pre-licensure programs. Results from these AACN
sample schools are labeled “BSN” (for schools that
offered BSN as the highest degree) and “BSN/Gradu-
ate” (for schools that offered graduate programs in
addition to pre-licensure programs) in the tables, al-
though a few of these schools offered associate degree
(ADN) programs too. A convenience sample of all
community college ADN programs (n ⫽ 57) in North
Carolina was included as well.
Procedure
Following approval from the university Institutional
Review Board for human subjects, the project team
contacted the deans/directors of sample schools via an
electronic survey management system (Survey Mon-
key). The introductory cover letter explained the proj-
ect and encouraged direct participation or delegation
to a designated responder with knowledge of the
pre-licensure curriculum. The letter contained a link to
the electronic survey. Respondents were assured of the
confidentiality of the information they shared, and
response to the survey served as consent. The survey
was open for 8 weeks and 2 electronic reminder notices
containing a link to the survey were sent to non-
responders to encourage participation before the survey
closed in August, 2006.
Data Analysis
The survey management service provided data on
school characteristics, survey questions, and open-
ended comments to the researchers as a relational
database. Quantitative data were converted into SAS
data files for cross-tabulation purposes. Schools were
classified as ADN-only, BSN, and BSN/Graduate pro-
grams. Satisfaction with student competencies and per-
ceived faculty expertise were compared for each do-
main between ADN-only programs and programs
granting bachelor’s degrees using Analysis of Variance
(ANOVA) or an Exact Test for Ranked Scores when
the distribution of the scores did not meet the assump-
tions of ANOVA.
RESULTS
Responses were returned from 195 of 629 sample
schools for an overall return rate of 31%. Return rates
were 40% for ADN-only programs and 30% for pro-
grams that included baccalaureate and higher degrees.
134 V O L U M E 5 5 ● N U M B E R 3 N
Smith et al
By self-report, 104 respondents (55%) were nursing
program directors or chairpersons, 62 (33%) identified
themselves as Deans (including Associate or Assistant
Deans), and the remaining 22 respondents (12%) were
faculty members (2 people identified as other and 5
skipped the question). Respondents represented most
states in the US, with the largest number of responses
from North Carolina (n ⫽ 27 because of the additional
ADN sample and responses from schools in the other 2
categories) and Pennsylvania (n ⫽ 12). Nine states had
no survey respondents.
Responding schools were public colleges or univer-
sities (58%), private-religious (26%), private-secular
(15%), and one for-profit. Schools were categorized by
program type with 12% ADN-only, 29% BSN, and
55% BSN/Graduate. Seven schools did not respond to
this question. The percentage of schools offering vari-
ous degrees were BSN (84%), masters’ degrees (57%),
ADN (23%), and PhD/DNS (19%). Ten offered DNP
degrees.
Program size was determined by annual graduation
rates. The most common ranges were 0 –50 (33%) and
51–100 graduates per year (36%), with 18% re-
porting 101–150 graduates per year and 7% reporting ⬎
200. Schools reported accreditations by Commission on
Collegiate Nursing Education (CCNE) (56%), Na-
tional League for Nursing Accrediting Commission
(NLNAC) (27%), both CCNE and NLNAC (10%), and
10% not accredited (ADN programs in North Carolina
can be approved by the State Board of Nursing in lieu
of accreditation).
Curricular Content
The majority of respondents (⬎ 95%) reported
that they included content related to each compe-
tency in their programs (Table 2). For the most part,
content was threaded through several courses, though
10 –18% of schools reported having dedicated
courses on evidence-based practice, teamwork and
collaboration, informatics, and quality improvement.
Whether these courses were elective or required was
not assessed.
One response option to the question about content
inclusion was “some, but would like more.” Responses
indicated that 23% would like to include more content
related to evidence-based practice, 38% wanted more
on quality improvement and informatics. Only 4 –11%
of program respondents reported a need to do more with
patient-centered care, teamwork and collaboration, and
safety.
Pedagogical Strategies
Each teaching strategy listed in the survey was used
by some schools in teaching each of the 6 competencies
(Table 3). The most common strategies by competency
(in order, with most frequent first) were:
U R S I N G O U T L O O K
Current assessments of quality and safety education Smith et al

Table 2. Percentage of Programs that Contain Content/Experience by

Competency
Yes, threaded Yes,
throughout dedicated Some, but
several courses on would like Don’t
courses the topic more No Know N

Patient-centered Care 95% (181) 2% (4) 4% (8) 1% (2) 1% (1) 191

Teamwork and Collaboration 82% (156) 15% (28) 10% (19) 0% (0) 1% (1) 190
Evidence-based Practice 73% (139) 18% (34) 23% (43) 2% (3) 0% (0) 191
Informatics 48% (91) 14% (27) 38% (73) 5% (10) 1% (2) 191
Quality Improvement 54% (103) 10% (20) 38% (73) 2% (3) 0% (0) 191
Safety 89% (169) 3% (5) 11% (20) 1% (2) 0% (0) 189

Table 3. Percentages of Schools Using Pedagogical Strategies by

Competency
Patient-centered Teamwork/ Mean
Care Collaboration EBP Informatics QI Safety %

Readings 91 88 88 63 84 89 84
Lecture 94 83 87 59 86 89 83
Clinical Practicum 93 89 66 51 61 89 75
Case Study 87 65 60 16 45 67 57
Paper Assignments 70 55 80 38 45 45 56
Web-based Learning 53 44 62 68 41 44 52
Course Module 47 55 51 36 51 72 52
Problem-based Learning 74 56 51 26 34 52 49
Interprofessional Learning 63 73 36 17 33 37 43
Simulation 70 46 23 30 12 79 43
Return Demo 69 22 14 20 9 83 36

● Patient-centered care: lecture, readings, clinical, case Satisfaction With Student

study.
● Teamwork and collaboration: clinical, readings,
inter-professional learning, case study.
● Evidence-based practice: readings, lecture, paper as-
signments, clinical.
● Quality improvement: lecture, readings, clinical,
course module.
● Safety: clinical, lecture, readings, return demonstra-
tion.
● Informatics: Web-based learning, readings, lecture,
clinical practicum.
Simulation was used less frequently than all other
pedagogical strategies except return demonstrations.
The mean percentage of schools reporting use of the
pedagogical strategies across the 6 competencies were:
readings (84%), lecture (83%), clinical (75%), case
study (57%), paper assignments (56%), course mod-
ules (52%), Web-based learning (52%), problem-based
learning (49%), inter-professional learning (43%), sim-
ulation (43%), return demo (36%).
Competency Development
On a 5-point scale (from very dissatisfied to very
satisfied), respondents’ mean scores were between neu-
tral and very satisfied for “the extent to which you
believe your pre-licensure students achieve beginning
competency in the domains identified” (Table 4).
Scores ranged from a low of 3.3 (evidence-based
practice/ADN and informatics/BSN schools) to a high
of 4.7 (patient-centered care and safety/ADN). Differ-
ences in scores among program types were not
significant.
Faculty Expertise to Teach
the Competencies
School respondents across all program types rated the
majority of undergraduate faculty as expert/very comfort-
able for teaching patient-centered care (86%), safety
(78%), and teamwork and collaboration (75%) (Table 5).
Slightly over half of the respondents rated faculty exper-
tise as intermediate/some comfort for the competencies

M A Y / J U N E N U R S I N G O U T L O O K 135
Current assessments of quality and safety education Smith et al

ited mean ratings of below “satisfied” (but not below

Table 4. Mean Ratings of “neutral”) for levels of student competency achievement.
Satisfaction with Student Similarly, these 3 competencies elicited somewhat lower
Beginning Competencies by ratings of faculty expertise to teach the content. Given that
the goal of the IOM2 report is universal development of
Program Type the competencies among all health professions students,
the survey results indicate room for improvement in
ADN BSN/ All
Only BSN Grad Programs nursing but also a fairly high level of belief that attention
is being paid to student quality and safety competency
Patient-centered 4.7 4.4 4.6 4.6 development.
Care During the time that the electronic survey was being
Teamwork and 4.3 4.0 4.0 4.0 conducted, QSEN faculty and advisory board members
Collaboration
Evidence-based 3.3 3.5 3.9 3.7
finished drafts of the requisite knowledge, skills, and
Practice attitudes (KSAs) that could represent the beginning com-
Informatics 3.6 3.3 3.4 3.4 petencies expected of all pre-licensure nursing students.
Quality 3.4 3.5 3.5 3.5 This information was not available to survey respondents
Improvement who, instead, relied solely on the competency definitions.
Safety 4.7 4.4 4.3 4.4 As reported by Cronenwett, Sherwood, and QSEN facul-
ty,1 faculty focus groups who were asked to critique the
1 ⫽ Very Dissatisfied, 2 ⫽ Dissatisfied, 3 ⫽ Neutral, draft KSAs had reactions that differed markedly from the
4 ⫽ Satisfied, 5 ⫽ Very Satisfied. survey data reported here.
Although the faculty agreed that they should be
teaching these competencies and, in fact, had
evidence-based practice (52%), informatics (51%), and thought they were, focus group participants did
quality improvement (51%). Only informatics (27%) and not understand fundamental concepts related to
evidence-based practice (11%) had ⬎ 10% of the schools the competencies and could not identify pedagog-
reporting that faculty were novice/uncomfortable with the ical strategies in use for teaching the KSAs. An
content of the competency domain. advisory board member led a focus group of new
Respondents from schools with BSN/graduate pro- graduates. Not only did these nurses report that
grams were more likely to rate faculty as expert/very they did not have learning experiences related to
comfortable in the areas of evidence-based practice (47%), the KSAs, they did not believe their faculties had
quality improvement (44%), and informatics (26%); how- the expertise to teach the content.1
ever, the difference for evidence-based practice was the
The contrasting results of the survey and focus groups
only significant difference by program type.
have been shared with groups of nurse educators at fall
2006 meetings of NLN and AACN. Consistently, audi-
Preference for Curricular Resources
ence members report that the KSAs present a new view
Respondents rated the value of various venues for
of what is required in each competency domain. Inter-
access to curricular resources about quality and safety
pretations of the survey data offered in these meetings
education on a 4-point scale (from not valuable to highly
include:
valuable). All formats were rated in the valuable to highly
● Nursing has always valued safety, teamwork, and
valuable range (3.1–3.8) with “Website” receiving the
patient-centered care, and content on these topics are
highest ratings (3.76) across all program types (Table 6).
included in curricula— but the content doesn’t match
the new competency definitions or KSAs.
DISCUSSION ● Program leaders, such as deans, directors, and chairs
The QSEN survey is the first report of the status of quality
may be too far from the actual “curriculum in use” to
and safety education in pre-licensure nursing programs. At
accurately respond to the survey.
face value, the results reflect a relatively high rate of
● Educators often lack exposure to the realities of
adoption of the QSEN core competencies across nursing
practice and, thus, might not have had a way to know
curricula. For patient-centered care, teamwork and col-
that their students were not achieving the competen-
laboration, and safety, high percentages of schools re-
cies and KSAs.
ported inclusion of the content using a variety of peda-
gogical strategies, high satisfaction with student
competency development, and high levels of faculty ex- Limitations
pertise to teach the competencies. Greater numbers of Additional limitations must be kept in mind when
schools (but still a minority) reported that they would like interpreting the results. The majority of schools we
more content in informatics, quality improvement, and queried chose not to respond, and so we cannot con-
evidence-based practice. These same competencies elic- clude that the responses of this sample are representa-

136 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U T L O O K
Current assessments of quality and safety education Smith et al

Table 5. Perceived Faculty Expertise by Competency and Program Type

E I E I E I E I N

Patient-centered Care 85 15 84 14 87 13 86 14 0
Teamwork and Collaboration 78 22 65 29 75 22 73 24 3
Evidence-based Practice 11 70 31 54 47 46 37 52 11
Informatics 15 59 20 47 26 50 23 51 27
Quality Improvement 37 44 33 57 44 49 40 51 9
Safety 89 11 79 21 75 23 78 21 1

ADN Only BSN BSN/Grad All programs

E ⫽ percent rating Expert/Very Comfortable, I ⫽ percent rating Intermediate/Some Comfort, N ⫽ percent rating
Novice/Uncomfortable.

to informatics, quality improvement, and evidence-

Table 6. Mean Ratings of Value based practice. Access to curricular resources to im-
of Curricular Resources by prove quality and safety education was considered
Program Type valuable, with access via Website receiving the highest
rating among a variety of choices.
ADN BSN/ All We are grateful to Nursing Outlook for publishing
Only BSN Grad Programs the survey results in the same issue in which the KSAs
are being reported. We hope readers will decide for
Website 3.62 3.75 3.80 3.76 themselves how to interpret the survey findings in light
Teaching Manual 3.59 3.40 3.35 3.40
Face-to-face Faculty 3.38 3.15 3.12 3.17
of the proposed KSAs. We look forward to continued
Development conversations and future data-based assessments about
DVD 3.38 3.49 3.35 3.39 the state of quality and safety education in nursing.
The authors gratefully acknowledge John Carlson MS, Research
1 ⫽ Not Valuable, 2 ⫽ Somewhat Valuable, 3 ⫽ Valuable, Associate Professor, University of North Carolina at Chapel Hill
4 ⫽ Highly Valuable. School of Nursing for his expert assistance with survey design and
data analysis.

tive of nursing education programs throughout the REFERENCES

country. Results for community college programs based
on a North Carolina sample may not be reflective of
national trends, and diploma programs were not repre-
sented at all.
SUMMARY
With QSEN competency definitions as the sole refer-
ence point, survey respondents reported that quality and
safety content was embedded in current pre-licensure
curricula and, in general, students were developing the
desired competencies. There were opportunities for
improvement in many schools, particularly with respect
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Mitchell P, et al. Quality and safety education for nurses. Nurs
Outlook 2007;55:122-31.
2. Institute of Medicine. Health professions education: A bridge
to quality. Washington, DC: National Academies Press; 2003.
3. VanGeest JB, Cummins DS. Educational needs assessment for
improving patient safety: Results of a national study of phy-
sicians and nurses. Chicago, Il: National Patient Safety
Foundation; 2003. Available at: http://www.npsf.org/download/
EdNeedsAssess.pdf.
4. McNeil BJ, Elfrink V, Beyea SC, Pierce ST, Bickford C.
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