Engaging Clinical Partners Utilizing Nursing Students as Change Agents for Integrating IOM's Quality and Safety Competencies

Abstract

The purpose of this presentation is to impart 3 methods to engage nursing schools’ clinical partners in utilizing students as change agents to improve quality and safety on the hospital units. First, as the academic institution, create a student centered active and latent failure simulation to reinforce quality and safety content from didactic. Second, after the annual safety simulation of active and latent safety infractions, first and second year students identify quality and safety concerns in their clinical setting. During post conference a root cause analysis utilizing the 5 “why’s” methodology reinforces for students how to develop a blameless communication outlook on innovative interventions for improving quality and safety on the units. The clinical instructor facilitates the RCA discussion. The clinical instructor or lead faculty facilitates the students’ created plan, do, study, and act. These learning activities are embedded within their clinical evaluation tool, so to meet objectives; students, as a group, formulate and create solutions.

Once the clinical group agrees upon a root problem and solution(s), they create an educational poster, learning activity, or intervention for the target audience-- patients, staff, or family. With the assistance of the clinical instructor, the plan for improving quality and safety on the unit is presented to unit managers or nursing educators—students are utilized as “change agents.”

Third, clinical partners are invited to an annual student safety simulation.  During the simulation exercises, faculty imparts the language of quality and safety as outlined by the Institute of Medicine Quality and Safety for Nursing Education (QSEN). Furthermore, faculty is transparent on how to relate to the clinical partners how they too, can create a unit or a room of safety infractions, conduct a root cause analysis (RCA), and target a plan, do, study, act (PDSA) for a just culture on the unit. This quality and safety improvement process is reproducible.

Outcomes

Lab of horrors resulted in both increased knowledge retention of a culture of safety and skills for applicability within context on medical surgical units. By instilling a broader view of rationales for maintaining patient safety, attitudes will be changed from a “laying blame” to a “system failure” attitude (AHRQ, 2012; Johnson, 2011). Originally high stakes testing solely demonstrated an increase in knowledge retention for safety hazards (pre-simulation vs. post simulation). Currently, the addition of clinical exemplars (an aspect of the QSEN clinical competency evaluation tool) also capture reflections of attitudes and reasoning in transition for safety and quality in the clinical setting (Benner, Sutphen, Leonard, & Day, 2010; Flores & Shakhshir, 2014; Tanner, 2006).

After reviewing the first and fourth semester students’ completed hospital safety surveys, it was discovered that approximately 40% of the identified safety infractions fell into the infection control category. With the coordination of a nurse educator, unit manager, and charge nurses, a campaign for breaking the chain of infection ensued on a unit of a hospital in Southern California. Students identified unrestrained, loose, long hair of health care professionals as a route for infection. The students designed a poster in which information related to the reason hair should be secured, was displayed on the unit. The observational study to measure outcomes is pending.

The nurse educator of a second hospital partner in Southern California creates rooms of horror on different units, on a quarterly basis. The nurse educator sets up safety, infection control and HIPAA violations.  The nurse educator and hospital partner implemented this safety activity after having participated at our school’s Lab of Horrors. The simulation is duplicable. 

To follow up on creating a culture of safety, collaboration among unit nurse managers, nurse educators, staff, and nursing students will be needed to maintain sustainability of the safety intervention plans. Efficacy of safety interventions will entail another observational survey from the next cohort of nursing students assigned to the same unit. Since 2011, annual safety simulations and unit surveys are embedded within the clinical practicum portion of the program.  

Reflections

With early introduction of the concepts of health care systems, the laying blame stigma of infractions is alleviated (Johnson, 2011). To follow up on creating a culture of safety, the simulation activity would entail linking the safety infractions to a root cause analysis, then developing a process plan for safety. This can become a leadership project during the students' fourth semester. Integration of QSEN core competencies begins in first semester.  Quality, evidenced based, safety, patient centered care, team work collaboration, and informatics are concepts threaded in the entire curriculum, clinical evaluation tools, and simulation exercises. Taking the safety core competency one step further to increase adherence to infection control in our clinical partners will result in better patient outcomes. Immersing nursing students to analyze problems for root causes creates a blameless communication and creates a thinking process as well as attitude for changing the “system.” Ultimately, outcomes result in improved patient satisfaction and outcomes (AHRQ, 2012; Barnsteiner, 2011a; 2011b).

One major challenge relates to the unit managers at five clinical practice sites. They experienced discomfort and became defensive during our safety debriefing. To avoid the “laying blame” culture, clinical partners are invited to celebrate the annual lab of horrors and are included in choosing the students’ change project.

Determine what quality improvement project the staff is “working on” for quality and safety, and then integrate the advance medical surgical clinical students into the unit’s one minute update at start of shift or at a lunch in-service. To warm the unit managers to the safety observational project, the conversation was begun with accolades for the unit's safety compliance behaviors and culture. Inviting the unit managers and educators to the lab of horrors promotes openness and acceptance while experiencing a fun exercise with Halloween treats at the end. To maintain the momentum and sustainability of the change project, a cohort to cohort debriefing occurs at the annual active and latent failure simulation. Utilizing students as "change agents" increases their immersion in the process of implementing quality and safety knowledge, skills, and attitudes. There is no cost to the clinical partner or unit. The clinical partner benefits include creating a just and blameless culture of safety for quality improvement.