1. Knowledge, Skills and Attitudes: Opportunities for Quality Improvement in Long Term Care Agencies Assessed by Nursing Students Cydney King Mullen, PhD, RN Professor, Nursing Sandhills Community College

2. Objectives At the conclusion of this presentation, the learner will be able to: 1. Describe how the Q.I. project integrated the QSEN framework. Examine outcomes and satisfaction of participants in project Evaluate the usefulness of this Q.I. project towards educational practice.

3. Disclosures Conflict of interest—this presenter has indicated that they have no bias or conflict of interest.

4. Knowledge, Skills and Attitudes

5. College program introduction Sandhills Community College Curriculum--integrated, concept base The “typical” student

6. SCC Campus

7. Long Term Care Facility and SCC Partner

10. Comparison of students The NLN Biennial Survey from 2014 demonstrated that 42% of all students were 30 years old or older. At SCC, 44% of our students are 30 or older. 77% are white, and 94% are female.

11. Goals For students For community For curriculum

12. Literature Review Murray et al. (2010) at the University of Wisconsin incorporated a clinical project component to the classroom content for senior nursing students. Recommendations included having guest speakers present to class about QI projects, focusing upon the process of learning the QI process rather than the outcome of the projects, and assigning students to teams rather than allowing them to self select. Berwick (2011) discussed the importance of preparing nurses with a knowledge of systems and become actively involved in multidisciplinary QI projects as students.

13. Literature review, con’t. Sherwood (2011) reported the work of an extensive nationwide study to identify curricular placement of QSEN competencies. Results included placing KSA competencies for teamwork, quality improvement, and collaboration in the intermediate level, with a greater emphasis upon the advanced stages within curricula. Armstrong et al. (2012) recommended that if students work with clinical managers to choose QI projects this would contribute to the sustainability of the project. They also recommended a combination of class and clinical components to the QI content.

14. Literature review, con’t. Dolansky & Moore (2013) called for a focus upon systems thinking for nursing education competencies. Dotson, B. & Lewis, L. (2013) conducted a cooperative learning experience in which the senior associate degree nursing students worked in groups with geriatric medicine fellows on quality improvement projects. They discovered that the projects needed to be expanded across two semesters, and recommended that students be allowed to choose their topics. The groups in this study were very large (2 cohorts of 29 and 36 students in only 2 clinical sites), thus posing a challenge to the faculty when working with students and in evaluation. Seibert (2014) reported the implementation of a series of practice based activities to assist nursing students to integrate concepts such as quality improvement, communication, change theory, and systems theory. Students assessed barriers to patient centered care, with the emphasis upon written assignments.

15. Framework Knowledge – Patient centered care – Teamwork and collaboration Skills – Patient centered care – Quality improvement – Safety Attitudes – Teamwork and collaboration – Safety

16. Knowledge Knowledge-Patient Centered Care: 1. Examine how the safety, quality and cost effectiveness of health care can be improved through the active involvement of patients and families. 2. Examine common barriers to active involvement of patients in their own health care processes. 3. Describe strategies to empower patients or families in all aspects of the health care process. Knowledge-Teamwork and collaboration: 1. Describe scopes of practice and roles of health care team members. 2. Describe strategies for identifying and managing overlaps in team member roles and accountabilities. 3. Recognize contributions of other individuals and groups in helping patient/family achieve health goals.

17. Skills Skills-Patient Centered Care: 1. How does the organization provide patient-centered care with sensitivity and respect for the diversity of human experience? 2. Assess own level of communication skill in encounters with health care providers, patients and families. Skills-Quality Improvement: 1. Seek information about outcomes of care for populations served in care setting. 2. Seek information about quality improvement projects in the care setting. Skills-Safety: 1. Communicate observations or concerns related to hazards and errors to patients, families and the health care team.

18. Attitudes Attitudes-Teamwork and Collaboration: 1. Value teamwork and the relationships upon which it is based. 2. Value different styles of communication used by patients, families and health care providers. Attitudes-Safety: 1. Value own role in preventing errors. 2. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team.

19. Problem statement

20. Project Design Placement Fall requirements Spring requirements

21. Fall Rubric Conduct a health care system assessment in your assigned organization during your NUR 212 focused client care experience using the following topics as your guide. Address each item and provide the information obtained during your observations in long term care. Organize your paper around the three main topics of knowledge, skills, and attitudes. 1. Knowledge Patient centered care Teamwork and collaboration 2. Skills Patient centered care Quality improvement Safety 3. Attitudes Teamwork and collaboration Safety

22. Fall Rubric, con’t. Within each topic, provide at least one example observed for each item. 40 points Discuss opportunities that exist for enhancement of client care and/or the health care system/s. 40 points Identify the observed members of the health care team’s roles in which they provide care. 20 points

23. Spring Rubric Form a team with 2-3 others who went to the same facility as you. Share your quality improvement assessment findings with your team. Working together with your team, choose one opportunity that has the most potential for enhancing the quality of patient care or the health system in which you attended. Together with your team, propose one change or health care system enhancement to address this finding. Make sure that your change is both realistic and attainable. Research the literature for best evidence to support your concern and suggestion for change. Create a presentation of your findings with proposed change that you will present to the class and the facility. This presentation may take the form of a poster, a power point of no more than 8 slides (including title), or an oral presentation. If you choose an oral presentation, you should provide hand-outs, pamphlets, brochures, illustrations, or some kind of visual for your audience. Provide copies of your reference page for your audience. For your presentation, you and your team members will include the following: 1. Opportunity observed for quality improvement-25 points 2. Applied evidence based theory or best evidence available-10 points 3. Proposed change to enhance quality and/or safety of health care—30 points 4. Minimum of 3 current references to support suggested change/enhancement—10 points 5. Timeline for implementation—10 points 6. Measurable goal with method for evaluating change—10 points 7. All team members participate in presentation and are audible to audience—5 points

25. Results Simple elegant projects evolved from the fall observations. For instance, one group began with a focus upon decreasing falls. They ended by showing how to implement a 10 minute exercise program for residents three times per week, and demonstrated through the literature that this is an effective intervention to decrease falls by strengthening skeletal muscle.

28. Results, con’t. Another group started with “decrease medication errors” and ended with “decreasing interruptions during medication administration”.

31. Results, con’t. As a third example, a group in a different facility proposed visual identifiers for residents to help prevent falls.

36. Evaluation Students’ struggles Comments from community stakeholders Did it meet our stated goals? Our hopes? Our dreams?

37. Knowledge and Wisdom “Knowledge is knowing that a tomato is a fruit. Wisdom is knowing not to put it in a fruit salad.”...Miles Kington

38. Recommendations Early preparation of students Plan in advance with health care facilities Use same agencies for both semesters for clinical sites to provide continued contact by students with the environment. Collect data pre- and post- project about students’ knowledge and affective learning Publish findings and generate further innovations

39. Parting thoughts “Be a yardstick of quality. Some people aren’t used to an environment where excellence Is expected.“...Steve Jobs

40. “Quality is remembered long after the price is forgotten...”...Gucci $$$

41. “Quality means doing it right when no one is looking.”...Henry Ford ✔ ✔ ✔ ✔ ✔ ✔

42. And finally...

43. References Armstrong, G., Headrick, L., Madigosky, W., & Ogrinc, G.. (2012). Designing education to improve care. Joint Commission journal on quality and patient safety / Joint Commission Resources, 38(1), 5- 14. Bednash, G. P., Cronenwett, L., & Dolansky, M. A. (2013, March/April). QSEN transforming education. Journal of Professional Nursing, 29(2), 66-67. Berwick, D. M., & Bisognano, M.. (2011). [Commentary on] Preparing nurses for participation in and leadership of continual improvement. Journal of Nursing Education, 50(6), 322-327. Cronenwett. L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122-131. Dolansky, M. & Moore, S. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. Online Journal of Nursing, 10913734, Sept2013 18(3). Dotson, B. & Lewis, L. (2013) Teaching the quality improvement process to nursing students. Journal of Nursing Education, 52(7): 398—400. Headrick L., Barton, A., Ongrinc, G., Strang, C., Aboumatar, H., Aud, M., Haidet, P., Lindell, D., Madigosky, W. & Patterson, J. (2012) Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning. Health Affairs 31(12), 2669-2680. Murray, M. E., Douglas, S., Girdley, D., & Jarzemsky, P.. (2010). Teaching quality improvement. Journal of Nursing Education, 49(8), 466-469. National League for Nursing, (2014). Biennial Survey of Schools of Nursing, 2014. Seibert, S. A.. (2014). Safety consciousness: assignments that expand focus beyond the bedside. Nurse education today, 34(2), 233-236. Sherwood, G.. (2011). Integrating quality and safety science in nursing education and practice. Journal of Research in Nursing, 16(3), 226-240.