Integrating QSEN and ACES: An NLN Simulation Leader Project

Publication: Nursing Education Perspectives
Author: Forneris, Susan G
Date published: May 1, 2012

CARING FOR THE SPECIAL NEEDS OF THE AGING ADULT IS AN INCREASINGLY IMPORTANT FOCUS IN NURSING EDUCATION. Knowledge continues to evolve, creating exciting learning opportunities for nursing students and challenges for nurse educators. one such challenge is to use simulation to operationalize knowledge around safe care of the aging adult.

the 2010-2011 national League for nursing (nLn) Simulation Leader Curriculum integration team - nurse educators selected to participate in a yearlong simulation leadership development program - examined key issues in the design, development, use, and integration of simulation in nursing education. the group noted that resources to guide faculty on how to tailor simulation to incorporate competencies around quality and safety in care of the aging are not easily accessible. this article provides an overview of the resources developed by the team for SirC, the nLn Simulation innovation resource Center. it is intended as a guide to incorporate concepts of quality and safety education for nurses into an unfolding simulation focused on care of the aging adult.

Background Quality and Safety Education for nurses (QSEn) addresses the nursing competencies needed to assure the quality and safety of patient care. adapted from the institute of Medicine (ioM) competencies for nursing (2003), QSEn outlines essential features of competent nursing practice (nursing competencies) to improve patient safety and quality in health care settings. the six QSEn competencies are: patient-Centered Care, teamwork and Collaboration, Evidence-Based practice, Quality improvement, Safety, and informatics (Cronenwett et al., 2007). Subsets of each QSEn competency include knowledge, skills, and attitudes achievable during the educational process. results of the QSEn national delphi Study (Barton, armstrong, preheim, Gelmon, & andrus, 2009) led to the leveling of QSEn competencies into beginner, intermediate, and advanced learning objectives for integration across a nursing curriculum.

The use of an unfolding case study correlates well with a leveled approach in the teaching of quality and safety for care of the older adult. unfolding case studies expose students to multiple aspects of a clinical situation and promote problem solving using an experiential learning method (page, Kowlowitz, & alden, 2010). the curriculum integration team determined that a scenario that unfolded over time would be an ideal simulation exemplar to demonstrate the integration of beginner, intermediate, and advance level QSEn competencies in care of the aging adult client.

The NLN, in partnership with the Community College of philadelphia and with funding from the John a. Hartford Foundation, Laerdal Medical, and the independence Foundation, developed the aCES (advancing Care Excellence for Seniors) project to teach nursing students how to care for the older adults. the aCES project features four cases that unfold over time, take place in a variety of health care settings, and require complex decisionmaking. the team determined that blending QSEn with aCES was a natural choice for the focus of the project.

Millie Larsen (reese, 2010), one of four aCES cases, includes a web-based text document with links to audio files and other supportive information. aCES provides teaching tools, evidence-based resources, and, importantly, a framework for incorporating the complexities of caring for the aging adult. permission was granted by the nLn to utilize the aCES scenario featuring Millie for inclusion in the curriculum integration project.

Millie Larsen's case unfolds in three scenarios, with settings in an outpatient clinic and in an acute care hospital. it concludes with conflict regarding discharge from the inpatient setting. the scenarios reveal a compelling story illustrating the interaction of the multiple factors that affect a geriatric client's health. table 1 illustrates how the simulation leader project integrated the QSEn competencies by level into Millie's unfolding health care encounters. the beginner competencies are integrated into Millie's initial admission simulation; the intermediate and advanced competencies are integrated into Millie's hospital stay and discharge simulations, respectively.

Beginner QSEN Competencies the task of incorporating QSEn competencies into an existing curricular framework is daunting. However, it is possible to take an existing learning activity, identify the appropriate knowledge, skills, and attitudes (KSas), and easily adapt it to the QSEn model.

using the Millie Larsen unfolding case scenario, the Simulation Leadership team examined each part of the case to identify existing or potential beginning level competencies. Scenario 1 was examined without changes to the original aCES Simulation design template, demonstrating how an existing simulation can be utilized without modification. Scenarios 2 and 3 were adapted, with simple variations, to incorporate more competencies or concentrate on a specific domain. Furthermore, the scenarios were delineated for progression from simple to complex KSas, as developed by the national delphi study (Barton et al., 2009).

the QSEn competency focused on patient-Centered Care is a foundational concept essential for beginning nursing students. Millie's introductory monologue and Scenario 1 are easily utilized for an introductory nursing course, and the competencies are identified without difficulty. table 2 illustrates beginner-level patient- Centered Care KSas for demonstration in Millie's outpatient simulation (Scenario 1).

Intermediate QSEN Competencies Millie Larsen's situation unfolds further in simulation scenario 2 with her admission to an acute care facility. this scenario was adapted to introduce several intermediate QSEn level concerns that the student must address (e.g., Millie's fall; a medication near-miss surrounding an unclear change in medication dosing; an outside phone call inquiry about Millie's condition; her upcoming discharge needs; and the conflict between Millie and her daughter about discharge placement). these concerns involve collaborative work with interdisciplinary health care teams to help Millie and her daughter achieve the health goals. With the adaptations made by the project team to Millie's scenario 2, beginning level QSEn KSas are reiterated and expanded, while higher level KSas are introduced.

the KSa defined for the Safety competency are addressed through Millie's fall. in this scenario, it is noted that a fall-risk assessment was not completed. Millie's fall shows the importance of such KSas as using effective strategies to reduce risk of patient harm and communicating concerns regarding safety issues.

patient-Centered Care is emphasized in the second scenario with the recognition of conflict between Millie and her daughter regarding where Millie will live following discharge. respecting the patient's wishes and supporting the daughter's involvement in her mother's care are nursing actions that surpass basic respect and sensitivity. these topics require thoughtful communication and conflict resolution skills. Legal and ethical issues are also an intermediate level KSa; a phone inquiry by a church member about Millie's condition illustrates compliance with Hippa regulations. the teamwork and Collaboration competency is emphasized when physical therapy and occupational therapy expertise are sought to address Millie's mobility and activities of daily living.

Advanced QSEN the third scenario was adapted to integrate advanced QSEn competencies. Competencies targeted at the advanced level include patient-Centered Care, Quality improvement, Safety, informatics, and teamwork and Collaboration. Scenario 3 adaptations incorporate polypharmacy, an interdisciplinary team discharge planning meeting, and a root cause analysis related to Millie's fall.

The integration of polypharmacy in this scenario addresses Safety and patient-Centered Care. to increase the complexity of the scenario by creating the likelihood of an adverse drug interaction, two drugs were added to Millie's medication list for discharge: zolpidem (ambien) 10 mg and tramadol (ultram) 50 mg. this combination of drugs and dosages creates a life-threatening situation for an aging adult.

The complex interaction between the myriad of factors that affect the geriatric patient's health and well-being is illustrated in the discharge planning conflicts that evolve in this scenario. not only is there concern over the amount of medications that Millie will be taking, her daughter is also concerned over the financial demands for her care, her recent confusion, and the fall she experienced while in the hospital. Millie and her daughter are at odds regarding future living arrangements. Students should recognize the complexity of this situation and recommend and conduct an interdisciplinary team discharge meeting (addressing the competency of teamwork and Collaboration).

The Center for disease Control and prevention (CdC, 2011) estimates that one in every three adults who are 65 or older will experience a fall, and of those who fall, 20 percent to 30 percent will experience moderate to severe injuries. addressing the underlying cause and prevention of future falls through a root cause analysis (rCa) focuses on the Safety and Quality improvement competencies. Guidelines to systematically conduct an rCa utilizing a fishbone diagram are provided. Conducting an rCa involves systematically examining the incident and identifying potential human factors and system failures that contributed to the fall. once the underlying factor is discovered, students are encouraged to brainstorm interventions aimed at improving quality and preventing recurrence of the incident.

Conclusion this overview illustrates how an aCES scenario is adapted to incorporate the QSEn competencies. Samples of the QSEn competencies and KSas are illustrated. depending on the quality and safety learning objectives, different competencies and KSas can be incorporated and simulations can be adapted accordingly. debriefing following the simulation is essential to student learning; it also can be tailored to incorporate guided questions that focus on uncovering the quality and safety knowledge that guided student thinking.

utilizing the collective wisdom of educators and clinicians, we are challenged to set aside traditional models of education. this is especially significant for care of the aging adult. today's nurse educators need to operationalize nursing competencies in education through thoughtful teaching strategies that "deepen the values and attitudes required for quality and safety work" (Cronenwett et al., 2007, p. 130). Simulation is a thoughtful approach to stimulate student thinking and demonstrate the complexities of care for the aging adult.

the adoption of simulation across nursing curricula presents a complex challenge for nurse educators (Starkweather & Kardong-Edgren, 2008). Faculty interested in learning strategies for successful integration of simulation into nursing curricula are encouraged to review the online courses "Curriculum integration" and "Faculty development," located on the nLn Simulation innovation resources Center (SirC) website. Visit


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Author affiliation:

About the Authors The authors are members of the 2010 NLN Simulation Leader Curriculum Integration Team. Susan G. Forneris, PhD, RN, CNE, is an associate professor at St. Catherine University, Department of Nursing, St. Paul, Minnesota. JoAnn G. Crownover, MSN, RN, CNE, is assistant professor at Colorado State University Pueblo. Laurie Dorsey, MSN, RN, is professor of nursing, Ivy Tech Community College: Southeast Region, Madison, Indiana. Nancy Leahy, MS, RN, is associate professor at John Tyler Community College, Midlothian, Virginia. Nancy A. Maas, MSN, RN, FNP-BC, is assistant professor, Northern Michigan University, Practical Nursing, Marquette. Lorrie Wong, PhD, RN, is director of simulation learning, University of Hawaii School of Nursing and Dental Hygiene, Honolulu. Anne Zabriskie, MS, RN, CNE, is coordinator, simulation learning at the University of North Carolina-Wilmington. Jean Ellen Zavertnik, MN, RN, ACNSBC, is assistant clinical professor, Virginia Commonwealth University, Adult Health Nursing Systems, Richmond. The authors are grateful to Dr. Pamela Jeffries and Dr. Mary Anne Rizzolo, both recognized leaders in simulation, for their mentoring in the development of this NLN Simulation Leader initiative and the corresponding publication. For more information, contact Dr. Forneris at

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