Impact of the Fuld Fellowship Program on Patient Safety Competence and Systems Thinking

Purpose: The growing complexity of healthcare worldwide is driving a need for nurse leaders with patient safety and quality improvement competencies. However, patient safety and quality improvement content has historically been omitted from nursing education, and its integration into curricula has proved to be a challenge. The lack of faculty prepared to teach such courses, the limited time available, and increase of instruction done through simulation are all factors the complicate the incorporation of this much-needed content into Baccalaureate nursing education. The Fuld Fellows Leadership Program is an innovative curriculum designed to provide nursing students with a solid foundation in the science of safety and quality improvement and leadership skills. The purpose of this paper is to describe how students involved in this innovative curriculum improved in their systems thinking and patient safety competence compared to their colleagues who were not in the Fuld Fellows Program.

Methods: The Fuld Fellows Leadership Program consists of 4 courses taken throughout the Baccalaureate curriculum, a 6-month mentored, service-learning project with leaders across Johns Hopkins Health System, and a 3-day interprofessional intersession course. Cohorts I through V have completed the program as of August 2015 and cohorts VI through VIII are ongoing. Using a quasi-experimental design, the Fuld Fellows in cohorts III through V were compared to their colleagues not involved in the program on outcomes of patient safety competence and systems thinking. This evaluation occurred at the time of their graduation from the Baccalaureate program. System thinking was measured using the Systems Thinking Scale (STS), a 20-item instrument that evaluates participants’ systems thinking in quality improvement work. The STS measures items on a 5-point Likert-type scale and are scored 0 to 4; the total score can range from 0 to 80 and is created by calculating the sum of responses for each item. Patient safety competence was evaluated using the Health Professional Education in Patient Safety Survey (H-PEPSS). H-PEPSS measures self-reported patient safety competence through focusing on six domains of safety competencies: culture of safety, working in teams with other healthcare providers, effective communication, managing risk, optimizing human and environmental factors, and recognizing and responding to adverse events to measure patient safety learning. H-PEPSS consists of 16 items measured using a 5-point Likert type scale. Pre-Post change scores were calculated and mean change scores for Fuld Fellows and non-Fuld Fellows were compared using t-tests. The Fuld Fellows and non-Fuld Fellows’ post-program STS scores were compared using t-tests. End-of-program focus groups were conducted for each of the Fuld cohorts to evaluate the success of the Fellowship.

Results: Both the Fuld Fellows (n=36) and non-Fuld Fellows (n=37) who participated in the evaluation reported a significant increase (p<0.00) across all six domains of safety competencies. The Fuld Fellows reported a significantly higher (p<0.05) mean change score in comparison to the non-Fuld Fellows in five of the six domains of safety competencies: effective communication, working in teams with other healthcare providers, optimizing human and environmental factors, and culture of safety. The Fuld Fellows reported a higher, insignificant mean change score in the domain of recognizing and responding to adverse events. The Fuld Fellows reported a mean STS score of 70.73±5.96; this score was significantly higher (p<0.00) than the non-Fuld Fellows reported mean STS score of 61.63±7.43. In the focus groups, the Fuld Fellows emphasized the value of exposure to patient safety and quality improvement education and hands-on projects. One Fellow stated: “I believe I will be more aware of quality improvement and safety issues and this will make me a leader in the workforce.” Fuld Fellows gave feedback that they were excited to apply their knowledge as they embarked on their nursing careers and planned to be involved in patient safety and quality improvement projects in their future workplaces.

Conclusion: The Fuld Fellowship program effectively introduces Baccalaureate nursing students to essential patient safety and quality improvement concepts. Though all students in the Baccalaureate nursing program reported increased patient safety competence, the Fuld Fellows reported higher levels of systems thinking and greater improvement in patient safety competence after participation in the program than the Baccalaureate students who did not take part in the program. This program can strengthen nursing education by offering an academic model and innovative curriculum for building competencies in quality and safety that can be adapted at other institutions.