Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

2017 American Academy of Nursing Living Legend – Linda R. Cronenwett

Dr. Linda R. Cronenwett is a widely respected leader in advancing inter-professional initiatives to improve healthcare quality and safety. She was instrumental as Chair of the American Nurses Association (ANA) Congress on Nursing Practice and her leadership role on the NIH National Advisory Council for Nursing Research in developing advanced practice nursing and its integration with research. She co-chaired and co-edited the Josiah Macy, Jr. Foundation’s inter-professional work on who will provide primary care and how they will be trained, and she served as President of the Founder’s Committee of Eastern Nursing Research Society (ENRS).

Among her numerous leadership roles, Dr. Cronenwett focused her work on the mission of improving healthcare quality and safety. She co-chaired the Institute of Medicine (IOM) Committee on Identifying and Preventing Medication Errors and served on the board of directors of the Institute for Healthcare Improvement (IHI), on the path toward one of her most recognized accomplishments – launching the national Robert Wood Johnson Foundation (RWJF) initiative “Quality and Safety Education for Nurses” (QSEN), which has been integrated across nursing education programs nationally. QSEN has made its impact on healthcare by influencing national and international revisions in accreditation standards and curricula. Dr. Cronenwett received the American Academy of Nursing (AAN) Presidential Award in 2013 and was named a Living Legend in 2017.

We interviewed Dr. Cronenwett, focusing on her QSEN accomplishments. As Professor and Dean Emeritus of the University of North Carolina – Chapel Hill, and Co-Director Emeritus of the RWJF Executive Nurse Fellows Program, Dr. Cronenwett speaks about leadership as a thought leader using our 3 Questions format!

Veronica D. Feeg, PhD, RN, FAAN

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University of North Carolina – Chapel Hill, and

Question 1. You were one of the founders of the movement to change quality and safety education. Why was that initiative so important and is it still important today?

It certainly is! Colleagues and I began seeking funding for an initiative to change quality and safety education soon after the first Institute of Medicines reports on healthcare errors came out. The magnitude of the problems related to quality and safety were fully at that point in the public consciousness and receiving a lot of attention, and we knew that people were being harmed by medical error with really alarming regularity. Yet, new health professionals were still graduating thinking that the solution for them was just to study hard and be vigilant – that the source of quality was in themselves. In nursing, we even had students who might be expelled from school for a clinical error, rather than learning that all humans make errors and that they needed to know how to learn from errors. They weren’t taught that our job as professionals was to build the systems that would minimize those errors and build the reporting systems that were fair and just that would help us to learn. Almost 80% of the errors involve failures of team communications, and yet, our curricula rarely focused on anything other than nursing team with students really rarely, if ever, having meaningful communications with physicians prior to graduation. And students might have learned about evidence based practice but they rarely knew anything about quality outcomes achieved in the sites where they practiced. And if they did see a gap between best practice and where they were currently practicing, they had little knowledge about what to do to improve quality in that system to close that gap.

So sadly, although there have been great strides in curriculum change in many schools, there is much work that remains yet to do, particularly in the areas of graduate education and in inter-professional education. Also, sadly, the rate of medical error continues to be alarming. We just had a recent study where it’s the third leading cause of death still.

And so, although much more attention is paid to quality and safety metrics in healthcare environments, the methods we’ve used to date to incent quality improvement leave a lot to be desired, in my view, often leading to feelings of burnout among health care professionals. So yes, I think there is much more to do for sure.

Question 2. What were the biggest challenges/barriers/ to achieving the curricular change outcomes that QSEN leaders proposed?

That is a good question. We faced a number of barriers as our project which was called QSEN began. First, nursing and really all other health professions faculty too didn’t fully appreciate that there was a problem in curricula. When asked if they taught quality and safety competencies they uniformly said “yes” because that’s all they did was teach to make their new graduates safe.  It wasn’t until we described the specific knowledge, skills, and attitudes that we knew new graduates needed that they would admit: ”… oh, no, we’re not teaching that!” So, there was work to do to build that burning platform for change.

Second, we were pretty sure that students wouldn’t develop the QSEN competencies unless a large percent of their faculty were reinforcing the learning in every course. So this wasn’t content where the school could assign one person to become an expert, and then that would suffice. They had to teach enough faculty so that these competencies and the knowledge, skills and attitudes undergirded what a student did in simulation labs, in the clinical area, in written assignments, in unfolding case-studies in class and in inter-professional courses.

So, we had to develop many methods to assist broad scale professional development. And we worked on online self-study modules, a website, and a forum – national forum for sharing with each other, we worked on train the trainer conferences, in addition to, it seemed, very many, many, speeches and publications.

Among other barriers, we also faced the reality that we had to develop QSEN competencies among all nurses. And that meant that at the basic practice level, we were concerned with all types of entry-level education programs; and at the advanced practice level, we were likewise concerned with competency development for both masters and doctoral students.

Patients deserve to have all their nursing professionals prepared for work in high-reliability systems of care. So, it really meant we had to change the whole world of nursing education.

Question 3. What advice would you give future nurse leaders who take on the challenge of launching a movement involving changes of this magnitude?

First of all, I think you have to build partnerships. You can’t assume this is a solo activity. You need clinical partners and inter-professional partners at the table with you each step of the way if you are going to make a major change. Nothing kept the school of nursing faculty focused on QSEN sufficiently on this big challenge as well as the constant realities of what clinical partners and patients were needing or expecting from their graduates. They had to be hearing that voice at the table all the way along.

Second, I think, including all the relevant professional organizations at the table as well, we really focused on co-creating the future together – not coming in with the right answer – but co-creating it. And only with that level of involvement do the ultimately acceptable answers evolve. I think you have to plan from the start for how to help each individual faculty member who might listen to a speech and be turned on to the idea how they would make the changes they need to make. So you need to develop strategies to attract people who are innovators and early adopters. You want to have places for them to share and meet each other. But you can’t forget to plan for the needs of the majority, who are happy to help if you make it as easy as possible for them to do so.

And then finally you also need to plan strategies to attract the laggards because in some cases nothing helps achieve that last curricular change more than accreditation requirements or licensure or certification exams. I think you have to not worry about who gets the credit. If you’re going for big change, you need everyone in the profession be a part of it. So you need to let everyone be a part of it and have credit where it’s deserved, and realize that there is more than enough work and more than enough credit to go around.

I guess last I would say you, you have to prepare for the long haul. I’ve had multiple people call me and say: “you know I want to make sure this gets into nursing curricula…could you give me the easy way you got QSEN into curricula?” It’s not just like that. If you really only want to give a few speeches or write a few papers, that is not how major professional change occurs.

So prepare for the long haul, build your partnerships, don’t worry about who gets the credit and just have fun!