1. Clinical Nurse Educator Children’s Hospital Colorado
Taking the Plunge: Using the QSEN Framework to Transform Ambulatory Orientation
Laurel More, RN, MS, CPN
Clinical Nurse Educator
Children’s Hospital Colorado
May 2016
This is one story of how QSEN helped to bring about an organized approach to how our nurses in the Ambulatory setting are oriented.

2. Objectives
Discuss how the QSEN framework supports the standardization of competency development in an ambulatory setting
Identify 3 approaches used to support the application of QSEN competencies in the ambulatory setting

3. Background
Ambulatory setting is unique in structure, process and function requiring an integrated team approach
Standardization of practice challenging due to specialization in multiple clinics
Orientation process for ambulatory clinics not well-developed or organized
While QSEN competencies are typically applied to the acute care setting, they can also be applied to other practice areas.
Ambulatory settings tend to be unique their structure, and in how they flow and function and are becoming one of the fastest growing healthcare segments. Ambulatory settings very much rely on a multidisciplinary approach to care so team collaboration is integral to coordinating the care of the patient across the care continuum.
In the setting that I work in, we support 32 clinic specialties which created issues with standardizing practices within our RN staff.
The lack of standardization in the clinics made it very difficult to develop a orientation process for staff hiring into these individual clinics.

4. Background QSEN base competency assessment tool adopted in 2012
Paradigm shift from skills check list to competency based assessment
Ambulatory staff concerned about competencies not being “specific” to the specialty they worked in.
Lack of knowledge/expertise to accurately complete the competency assessment form
The institution had created a comprehensive competency tool for both the RN and Unlicensed Personnel staff that was based on QSEN which was implemented in the ambulatory division in 2012.
This was quite a paradigm shift for the staff. The majority of the staff were only familiar with skills based checklist that were used to determine the competency of new hires to an area. Additionally, most of the staff had never heard of QSEN.
After the roll-out of the QSEN competencies, many of the staff expressed concern about the new competencies. The first issue was that they didn’t understand that competency is more than just validating a skill and secondly, they didn’t know how to align the developed competency statement with the performance of the new hire in their very specialized area. Many times, the staff just signed off the competency tool just so they could get the staff person off orientation.

5. Method Standardized and Aligned Orientation (32 Clinics)
Staff Education
Orientation Framework (QSEN)
On-line Orientation Manual
So armed with the information that there wasn’t a standardized approach to orientation in the Ambulatory Setting, coupled with the concerns of staff accurately completing our new QSEN competency forms, it was imperative to address both issues.
As the Ambulatory Clinical Nurse Educator, this became a high divisional priority project to complete. In contemplating on how to proceed, I identified a three pronged approach that would help support and promote standardization and alignment of our orientation process.
The approach was to:
Develop education for staff related to QSEN
Develop an orientation manual using QSEN as the framework
Publish the orientation on our internal department website.

6. Staff Education Defining Competency and Shifting the Paradigm
Knowledge
Skills
Attitude
While the roll out of the new QSEN competencies was done in 2012, it became apparent that the majority of the RN staff did not understand that competency encompassed more than just being able to perform a skill.
Prior to beginning work on the orientation process in the Ambulatory division, members of the Ambulatory Education Committee were re-educated about how competency encompassed not only skills, but knowledge and attitude/abilities. This helped them in understanding how the institutional competencies were built and set the stage for recommending using QSEN as a framework for building a standardized orientation manual.

7. Development of the Orientation Curriculum
Defining Key Elements of the Competency
Identification of specific resources that supported the competency
A decision was made by the Ambulatory Education Committee, which is made up of clinic RNs and Medical Assistants, to use QSEN as a framework for developing a comprehensive orientation manual that would assist in standardizing orientation for 32 specialty clinics and help in accurately completing competency forms.
Extensive work was done to define the key elements that supported each developed competency statement and to identify specific institutional resources that supported the competency

8. Defining Key Elements of Competency

9. Identifying key elements that support competency statement(s)
The first column is a competency statement taken from the institutional competency assessment tool
The second column represents the work that the Ambulatory Education Committee did to identify key elements that supported the competency statement. The key elements provide standardized guidance for the preceptor/and orientee on what the orientee needs to be able to perform in order to be “deemed” competent.
The key elements align with both institutional standards and the American Academy of Ambulatory Care Nursing Scope and Standards of Practice .

10. This is an example for Teamwork and Collaboration
This is an example for Teamwork and Collaboration. As you can see, it is built to specifically outline what a preceptor needs to be covered with a new hire. Again, this addresses more than just performing a skill

11. Resources

12. Because competency isn’t just about performing a skill, it was important to also provide the resources that support the successful progression to competency.
Resources can include institutional policies and procedures, evidence based tools and information, ancillary department resources and instructional guides.
Hyperlinks are used to take staff directly to the information they need to know. This helps in providing new hires with accurate information rather than risking them learning shortcuts. Again, standardization of practice is what we were going for.

15. Development of an On-Line Orientation Manual

16. We struggled with how we would be able provide a dissemination platform for over 350 staff practicing at multiple locations.
We decided the best approach would be to develop an on-line orientation manual. This also allowed for links to be up-dated in real time as P/Ps changed.
When staff access the manual through our clinical practice tab, they are able to access both the Key Elements document and associated resources.

17. Each QSEN Competency is represented

18. We are continuing to refine several areas of the manual but it has been very well received by the Ambulatory Division and the institution as a whole.
There is some discussion about using this format in other areas besides the ambulatory setting.