Abstract
Patient safety has been a strategic healthcare priority for at least two decades in almost all countries. Nursing has been perhaps the most notable health profession to strategically establish evidence-based competencies to guide education and practice. The Quality and Safety Education for Nursing (QSEN) framework for pre-licensure and graduate level students established in the United States (US) has been at the forefront of preparing nurses to lead patient safety and quality concerns (Cronenwett et al., 2007, 2009). Efforts to improve quality and safety are spreading globally, as nurses around the world reported in their submissions to this special issue of JRN on patient safety and quality.
QSEN defined six competences declared as essential for all health professions (Institute of Medicine, 2003): patient centred care, teamwork and collaboration, evidence-based practice, quality improvement, safety and informatics. Early definitions encompassed quality and safety into one competency; however, QSEN follows the evidence supporting safety within a new science. Safety is defined as reducing preventable harm by implementing high reliability approaches that standardise processes, establish transparent reporting systems and create Just Cultures as part of the organisation’s safety culture. Quality Improvement as a separate competency may use data from harm events or gaps in care to measure and compare actual care with benchmarks to launch quality improvement teams to improve outcomes. Together, safety and quality are key components of a safety culture that continuously strives to improve outcomes of care.
Papers in this edition represent both competencies and illustrate how nurses are on the front lines of leadership in safety culture. This is particularly evident in two papers, one from Yang et al. reporting on the effect of patient safety culture on nurses’ reporting near misses in addition to reporting harm events; the other, from Mahsoon and Dolansky, examines the role of systems thinking in safety culture and whether it can be used to predict safety competence among nurses in Saudi Arabia. Yang et al. propose that nurses in a supportive work environment are more inclined to report near misses, which can then become learning opportunities to reveal gaps in care, poorly defined processes and lack of resources. Mahsoon and Dolansky also examine safety culture, but from the perspective of systems thinking. Systems thinking is a fundamental concept in continuous quality improvement; standardising processes, redesigning poorly implemented procedures and focusing on unit outcomes demonstrate systems thinking that contributes to safety culture.
Workplace culture was also a factor examined in two other papers on safety culture and quality of care. Kim et al. conducted a cross-sectional analysis using data from the Survey on Patient Safety Culture in a large US healthcare system. Workplace violence contributes to emotional exhaustion, which further diminishes perceptions of safety culture; reporting workplace violence is also tied to an organisation’s commitment to Just Culture. Although Just Culture is a core concept in safety culture, it remains unevenly applied across delivery systems. Safety culture has to be hardwired into the organisation as a core mission and modelled by organisational leadership to reinforce across all units and sub-units. Creating a transparent Just Culture reporting system begins with making sure all staff are educated about Just Culture; quality and safety education were not part of the academic education for most practising health professionals. To address this, Walker et al. reported an Exploratory Factor Analysis of the Just Culture Assessment Tool for Nursing Education to determine students’ knowledge of Just Culture. Findings revealed that students have little experience with reporting errors, whether because of gaps in the curriculum or because some training must come from experience in the job.
Education was in fact a moderator in several papers. Perhaps the most comprehensive is a report of the first Massive Open Online Course (MOOC) course on quality improvement education. Reese et al. reported the evaluation of a MOOC with a global enrolment, timely results to help inform educators redesigning courses for current online teaching imposed by the COVID19 pandemic. A second paper described a Learning Collaborative of faculty and students from seven countries participating in a week-long immersive experience to apply the QSEN competencies in a multi-cultural environment. Sanford et al. reported positive results in achieving five of the competencies; only informatics was not clearly achieved. From global to local, another report on undergraduate students is from Watanabe et al. in Japan. They described learning outcomes from integrating the QSEN competencies in three undergraduate courses; student focus groups indicated at least 75% effectiveness in achieving QSEN competencies.
The final three papers are primarily clinically based. As noted above, nurses are positioned to lead improvements in patient safety and quality yet need leadership and training to have the necessary preparation. den Breejen-de Hooge et al. investigated the role of nurse leadership in quality and safety among 655 nurses in The Netherlands. Results indicate that supportive leaders are a critical key in creating an improvement culture significantly associated with quality of care. They call for more strategic leadership development across all of nursing to foster safety culture.
Closely aligned is the report from Dunning that value congruence correlates with job satisfaction, nurse well-being and patient safety. Lower value congruence was associated to poorer well-being, increased burnout and poor perceived patient safety. This brings to mind Kim and team’s paper presented earlier that links patient safety with workplace violence and emotional exhaustion.
Mentoring is a vital role of leaders. Schuler et al. evaluated a mentoring programme for nurses to develop the QSEN competency evidence-based practice, a cornerstone of clinical decision-making and other measurable parameters. Evidence-based practice requires high-level critical analysis. Having the opportunity to be mentored by experienced nurses can increase nurses’ engagement in delivering care grounded in evidence-based best practices.
Education is the bridge to translate evidence that guides practice. This is illustrated in those papers from clinical settings that illustrate what can happen when committed professionals, prepared with safety and quality competencies, work in cultures of safety guided by supportive leaders.
Ricciardi closes this issue with a view to the future, envisioning what healthcare quality and safety may look like in 2030. The past two decades of progress in improving quality and safety sometimes seems slow, but setting a forthright and bold vision for the future can inspire new achievements in making sure healthcare is safe, reliable, and free from harm.
A lesson learned in the COVID19 pandemic is that collaboration, communication and coordination are necessary to combat a global crisis. While patient safety is not spread in contagious droplets, it is dependent on the spread of evidence from country to country so that we all learn strategies and processes to improve patient care quality and safety. With papers from China, Japan, Ireland, England, Saudi Arabia, US and a multinational education paper, this issue is one of the first international collections to share evidence from such a wide range of cultures on the imperative of patient safety. Together these papers show the importance of nurses using their expertise to transform education, lead clinical improvements and advance policies to build more positive work environments embedded in cultures of safety – we need to build on this collective momentum. Systems are built from the people in them; we each must heed a call to action to ground our work in quality and safety every day for every patient every time.