Current Assessments of Quality and Safety Competencies in Registered Professional Nurses: An Examination of Nurse Leader Perceptions

Monday, 28 July 2014: 7:00 AM

Elaine Smith, EdD, MSN, MBA, BS, RN, NEA-BC, ANEF
Institute for Nursing, North Shore LIJ Health System, New Hyde Park, NY


The purpose of this study is to determine the degree of satisfaction nurse leaders possess with respect to the six Quality and Safety Education for Nurses(QSEN) core competencies :use of evidence- based practice; teamwork and collaboration; patient-centered care; quality improvement; safety ;and the use of informatics. Are these competencies reflected in the practice of new graduate registered nurses and in the practice of their incumbent experienced staffs?  Nurse leaders differentiated their responses based on the educational level and experience level of the nurses. Additionally, teaching and learning resources within healthcare facilities related to the domains were identified. Facilitators of and barriers to quality and safety learning were explicated.

The research questions included:

  1. To what extent are nurse executives and managers satisfied with their new graduate registered nurses’ practice related to each of the six QSEN core competencies for nursing?

Are there perceived differences based on educational preparation of the new graduate?

  1. To what extent are nurse executives and managers satisfied with their experienced registered nursing staff’s practice related to each of the six QSEN core competencies?

Are there perceived differences based on educational preparation of the experienced      nurse?

3.   What types of learning opportunities that support the six QSEN core competencies are  available to existing registered nurses employed in their clinical agency?

4.    What are the barriers to and facilitators of learning experiences for nurses related to the six QSEN core competencies within healthcare facilities?


This mixed methods study used survey methodology and focus group meaning making activities. The survey was developed based on literature review and content expert opinion. It was fielded with 3 groups of nurse leaders with iterative revisions. The instrument was constructed in Survey Monkey to facilitate blinded data collection and aggregation .The survey contained 12 forced response items with open- ended comments permitted.  Demographic data on respondent title and years of experience,facility location and size were also collected. Following IRB approval, the survey was launched  via the American Organization of Nurse Executives email blast to their membership with an invitation to participate. The survey was open for 3 weeks with two email requests to participate. 110 nurse leaders responded. Two focus groups of nurse leaders from two major tertiary care hospitals were recruited. A total of 11 nurse leaders participated in the 90 minute focus groups. After obtaining informed consent and participant permission, the sessions were audio-taped and field notes were taken. Participants were given the aggregated responses from the electronic survey and asked to discuss the findings using a structured interview guide. Tapes were transcribed and thematic analysis conducted. Focus group findings were reviewed by an external expert reviewer for validation of the emergent themes. Focus group data were presented in content analytic tables with representative comments. Focus groups alone answered research question four.


Differences in nurse leader satisfaction across the six domains were identified among the groups based on education and experience. Nurse leader levels of satisfaction with staff quality and safety competencies do vary based on level of experience and degree type. The competencies rated most highly overall included: patient-centered care; teamwork and collaboration; and safety. Satisfaction with quality improvement was rated lowest for all categories of nurses except experienced associate degree for whom evidence –based practice was lower. New graduate nurses prepared at the associate degree/diploma level received the lowest satisfaction scores across five of the six domains. Only in the area of informatics did they score slightly higher than experienced ADN staff members. Baccalaureate prepared nurses both experienced and new graduates receive higher levels of satisfaction than their associate degree counterparts in all six domains. Striking differences were noted in the dimensions of evidence-based practice, informatics and quality improvement. Satisfaction ratings for these three domains were considerably lower for the experienced associate degree/diploma nurse when compared to their experienced BSN counterparts. In fact, BSN new graduates surpass the experienced associate degree nurses in each of these three competencies. With increasing use of technology, it is encouraging to note that new graduate baccalaureate nurses also slightly exceed their BSN experienced counterparts in the areas of informatics.

As a subset of experienced nurses, clinical preceptor proficiency in the six quality and safety competencies ,regardless of educational preparation, is cause for concern  given  the predominance of this model for promoting skill acquisition in nurses. Without addressing preceptor knowledge and skill in the QSEN competencies and their ability to successfully impart it, an ineffective teaching/learning dyad is reinforced.

  A wide variety of learning opportunities are available within healthcare facilities to promote quality and safety competency development. Orientation and preceptor- led clinical experiences are the most widely reported methods. One unexpected finding was the relatively low utilization of new graduate residency programs reported by leaders. These programs are noted to be very effective in the overall professional development and retention of new graduate nurses.

Several barriers to and facilitators of quality and safety learning in healthcare facilities were identified. Given the complexity and acuity of healthcare environments, the most frequently cited barrier is the lack of time practicing staff nurses have available in the work environment for learning activities. Leaders have a large role to play in facilitating quality and safety learning. Setting clear expectations for continued growth and professional development and establishing supportive unit cultures promotes the development of these critical competencies.


This study has provided insight on nurse leader satisfaction with the quality and safety competencies of their registered nurse staffs. The findings have illustrated areas of strength and limitation for both new graduate and experienced nurses. Differences are noted in the performance of associate degree/diploma prepared nurses and baccalaureate prepared nurses particularly in the domains of evidence based practice and quality improvement.  These differences have several implications and calls for action by nurse leaders and educators. It has been learned that quality and safety education is provided through an array of educational strategies inside healthcare facilities but that more emphasis needs to be placed on learning activities to promote development of quality improvement expertise. It is hoped by focusing attention on patient-centered care, teamwork and collaboration, quality improvement, evidence- based practice, safety, and informatics that the practice of incumbent registered nurses can be enhanced to promote safer patient care and to improve the healthcare environments in which they work. Nursing has a significant role to play in the provision of high quality, safe patient care and it requires the joint forces of academic and service partners to assure that healthcare becomes safer than it is.