QSEN Graduate Competency

Quality and Safety Education for Nurses (QSEN) Graduate Competency. Quality and Safety Education for Nurses (QSEN) (QSEN, 2018) graduate competencies determined by QSEN Institute list evidence-based care as a competency. This QSEN competencies support the need for redesign as evidence in the literature shows simulation as an effective tool to improve care. The QSEN Institute (2018) defines evidence-based practice as integrating the best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. The redesign may have a positive impact on the future patients of the student nurses as the students gain confidence, retain more knowledge and gain competence in the skills practiced.

Process Selection
This process was selected because the students’ clinical experiences are not always optimal in some facilities. For example, a local hospital used as an obstetrics clinical site may have ten deliveries this week and only have one delivery the next. Students are only in the facility ten to twelve hours per week on the days approved by the facility. The level of experience is inconsistent. Increased use of simulation in clinical areas may increase the knowledge of the students.
Rationale/priority/criteria. Most nursing faculty desire the best experience for the assigned students. Students expect the opportunity to see and do as much as possible to gain experience and knowledge. This process is resource intensive, and certainly time intensive. Conducting simulation adequately requires the devotion of many hours. When simulation hours are increased, the simulation must be productive. Faculty cannot decrease on-site clinical and fail students with subpar simulation experiences consisting only of brief discussions of case studies. Simulation experiences need to include hands on teaching and learning to increase learning and retention of knowledge. The Tennessee Board of Nursing (Tn.gov, 2017) has identified this redesign as a need. The board of nursing recognized the need with an increase in the potential use of simulation hours.
Collaboration to Redesign.
A well-defined objective is the key to successful change. In order for the redesign to be effective, stakeholder buy in is imperative. The realization of needed change for this facility came in response to the decrease in available clinical sites. As faculty began to struggle to find clinical placement for the students, collaboration with the Dean of Health Programs, the Assistant Dean of Health Programs, the Director of the Nursing Program and all nursing faculty regarding the need to increase simulation began. In the collaboration meeting, evaluation of the bearing on all stakeholders occurred.
Stakeholder identification. A stakeholder is a person or group that has an investment, share, or interest in something, as a business or industry (Dictionary.com, n.d.). Therefore, the stakeholders in this redesign are nursing students, nursing faculty, nursing program in general, the director of nursing program, the dean of health programs, and the college. The redesign must have a positive influence on the nursing students as well as the nursing program as a whole; therefore, all stakeholders must be included in the collaboration.
Stakeholder collaboration.

The collaboration began with two nursing faculty members discussing the need for increased simulation due to clinical site shortage. These faculty members called a meeting with other faculty members who co-teach the third semester course. The five faculty members agreed there is a need for an increase in the use of simulation in the course due to continued difficulty in finding quality clinical placement for the students. The third semester faculty brought the proposal to the director of the nursing program. The director agreed with the proposal and reported a concern with the statewide curriculum this fall as there was an expectation of increased challenges with clinical placements. These challenges are the result of students having multiple simultaneous clinical placements. The third semester faculty brought the suggestion for increased simulation experiences before the remaining faculty members and the dean of health programs. Some faculty members were hesitant because of fear of change and limited personal experience in

simulation.
Positive experiences experienced by faculty in the room were discussed with remaining faculty members. The next step in collaboration was to discuss the manner in which faculty would go forward with the increase of simulation hours. Topics discussed included whether individual faculty would complete their own simulation or if there was a need for a simulation laboratory coordinator. The increase in simulation experiences would not be required at this time. Simulation experiences would be an optional clinical experience for faculty who desire to reinforce specific skills or for primary hours due to insufficient numbers clinical placement sites.
Process Redesign
As previously noted, the key to success is stakeholder acceptance. The Institute of Medicine (IOM) (2001) reported the creation and maintenance of teams are necessary. The team needs to base their quality improvement work within the team and recognize the contributions of all team members (p. 131). The clinical instructors’ collaborate with the simulation lab coordinator to ensure the specific areas of focused are covered. The IOM identified ten rules for a 21st-century health care system. The rule focused on for this change is Rule 2: customization based on patient needs and values. One of the missions / purposes of the college in this project is to provide safe and effective care for a diverse population. The students’ clinical experiences led to growth in confidence and competence. Customization of clinical experiences is imperative to meet the needs of each student.
Customized. According to the IOM (2001), the customization rule takes into consideration the need for customization based on stakeholders’ needs. In this case, the student’s clinical needs change as a result of specific course outcomes. The students’ clinical experiences must prepare them for the patients for whom they will provide care. For example, the obstetrical clinical at a local hospital often has more labor inductions on Tuesdays. This is a scheduled clinical day for students. Therefore, while the students experience labor and delivery, they often miss the post-partum care experience. In this case, the customization must include additional post-partum based simulation to allow students to enhance post-partum clinical experiences such as focusing on fundal massage, breast care and lactation.
The fishbone diagram “creates a snapshot of the collective knowledge and consensus of a team around a problem” (Brassard and Ritter, 2008, pg.

23). This tool was beneficial in this project as it is visually appealing and organized. The fishbone allows for a broader topic, such as the student benefit to be broken down to allow for identification of substructures. This specific fishbone indicates the benefits of the change project for students, faculty, nursing program, and the college. Wagner, Bear and Sander (2009) concluded that the use of simulation resources reinforced and “helped students build confidence in newly acquired nursing skills” (pg. 467). The literature noted the increase in confidence in students and a subsequent increase in test scores. This includes the combination of traditional curriculum and simulation (Schiavenato, 2009). The benefits are evidence based on the literature review. The challenge is the development of simulation experience and buy in from the nursing faculty. For further detail, refer to Figure

2.