Published Back to Strategy Search Strategy Submission Vaccination Think, Pair, Share Activity Author: Brittany Lawson MSN, RN, CMAC Title: Instructor Coauthors: Institution: Lakeview College of Nursing Email: blawson@lakeviewcol.edu Competency Categories: Informatics, Patient-Centered Care Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: Case Studies Learning Objectives: Patient-Centered Care The learner will identify appropriate vaccinations for administration based on individual client data. The learner will select appropriate client education related to the administration of vaccinations. The learner will discuss the benefits and limitations of using the Center for Disease Control and Prevention’s (CDC) website to access information for vaccination schedules and client education. The learner will value the use of evidence-based practice sources of information to assist in the delivery of care. Informatics Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. The learner will identify appropriate vaccinations for administration based on individual client data. The learner will select appropriate client education related to the administration of vaccinations. The learner will discuss the benefits and limitations of using the Center for Disease Control and Prevention’s (CDC) website to access information for vaccination schedules and client education. The learner will value the use of evidence-based practice sources of information to assist in the delivery of care. Strategy Overview: The think, pair, share learning activity allows students to identify appropriate vaccinations by utilizing high-quality sources of information, such as the Centers for Disease Control and Prevention (CDC) website. Four case studies are included within the activity to distribute to students. The case studies provide scenarios of clients in need of a vaccination. By using the CDC website students will get experience in navigating this high-quality source of vaccination scheduling and client education information. Debriefing questions are provided that allow the student to reflect upon the experience. This learning activity can be adapted to the online learning environment. Submitted Materials: 318.-Vaccinations-Think-Pair-Share-Activity.docx - https://drive.google.com/open?id=1spRy67tjrAGCDvpHxjKRiJK1rSfX5TBA&usp=drive_copy Additional Materials: Evaluation Description: The facilitating educator will formatively evaluate the student’s learning throughout the activity and during the debriefing process. Active facilitation of each group’s progress on the case will provide the educator with evaluation data as well. The educator will encourage all students to participate in the debriefing to facilitate learning, reflection, and student evaluation. Students should be provided with feedback throughout the learning activity from the educator and their peers. Alternatively, the debriefing questions can be submitted as a discussion board or written assignment. Many of the students that participated in this activity reported that they preferred this active learning method for immunization schedules and education over a more passive approach (such as lectures or handouts). Students that participated in this activity expressed that this activity helped them develop a greater appreciation for the use of high-quality information sources and their impact on nursing care. Students that participated in this activity expressed an increased level of confidence in identifying appropriate immunizations for clients.

Published Back to Strategy Search Strategy Submission A Novel Format for Student Post Conference and Teaching SBAR Communication Author: Jacqueline G. Ioli MSN, RN, CRNP, PNP-BC Title: Doctoral Student, Widener University Coauthors: Institution: Widener University Email: jgioli@mail.widener.edu Competency Categories: Safety, Teamwork and Collaboration Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Clinical Setting Strategy Type: Case Studies Learning Objectives: After participation in this interactive learning activity, sharing their own work with peers, learns ware able to analyze their roles in QSEN competency 1, Patient Centered Care: a) knowledge of nursing roles in assuring coordination, integration & continuity of care; c) attitudes, values continuous improvement of own communication skills. QSEN competency 5, Safety: c) value own role in preventing errors. Strategy Overview: Based on Vygotsky’s theory of creating frameworks for learning, this PowerPoint teaches the principles of SBAR, guiding student how to sum up their patient’s situation, background, assessment, recommendation for care. In addition, students referenced an image from a website related to their patient. Additional slides asked students to describe the medical diagnosis, safety implications and lesson learned. Students took care to avoid identifying details and excluded patient initials & facility. Patients were described only by age, gender & presenting problem. A recent weather emergency provided an opportunity to trial this tool by using it as a virtual post conference medium. Students completed the PowerPoint and emailed the document to the group. During the weather emergency, students read and commented on peers’ patients from home. The instructor contacted students by phone to review their PowerPoint and engaged the student in discussion. Submitted Materials: 117.QSEN-Exercise.ppt - https://drive.google.com/open?id=1n2JkfiPECmbp6oAtiFaSwpbE23mfGPmG&usp=drive_copy Additional Materials: Evaluation Description: Student comments were positive, “I have learnt a lot of new and helpful information.” Many comments indicated specific clinical thinking about professional issues raised by peers, “I do think the school nurse should implement teaching since childhood is a high risk time for appendicitis.” In addition, students provided positive feedback to each other, “Great job with appendicitis! I liked how you politely put, ‘Patient refused to ambulate.’” Students were challenged by some of the unknowns in their caseload and looked up additional information, “After viewing the PowerPoint I did some research and found that with Non-Hodgkins Lymphoma it often may occur without fever at first. That intrigued me. Also, a biopsy is the definitive diagnosis. I wish we would have been back on the floor to find out what the biopsy revealed.” This faculty member guided the virtual conversation to stress common safety themes applicable to the group of clients under care. In summary, the SBAR template was an efficient and effective method of coping with a weather emergency and teaching safety information. Future groups will develop NCLEX style questions at the knowledge/comprehension level and application/analysis level. The NCLEX style questions together with a survey tool can form the basis of more formalized evaluation of this method.

Published Back to Strategy Search Strategy Submission Clinical Alarm Safety Author: Tammy Spencer MS, RN Title: Senior Instructor Coauthors: Kathy Foss, MS, RN Institution: University of Colorado Denver College of Nursing Email: tammy.spencer@uchsc.edu Competency Categories: Safety Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Clinical Setting Strategy Type: Case Studies Learning Objectives: Delineate general categories of errors and hazards in care. Communicate observations or concerns related to hazards and errors to patients, families and the health care team. Value own role in preventing errors. Describe factors that create a culture of safety. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team. Strategy Overview: Reading for this activity: As a preparation for this learning activity, clinical instructors should read the following article on alarm safety. Some instructors may want to assign this article to students before assigning this learning activity: Phillips, J. (2006) Clinical alarms: complexity and common sense. Critical Care Nursing Clinics of North America. 18: 145-156. Instructor Instructions: This activity involves student data collection of the alarms they hear and see in the clinical setting. It is anticipated that the student collects data on a single pre-determined clinical shift. Data is gathered and shared with the other students in a single post clinical conference. This exercise may be utilized with students as they begin to experience more independent care of their patient in which they are responsible for not only the basic components of patient care, but the recognition, interpretation and response to clinical alarms. Students are also made aware of the culture of alarm response in their unit, as well as how nurses are educated in alarm safety. The accompanying Learning Activity takes the student through an exercise in which data is gathered on the included table regarding the type, source and interpretation of an alarm as well as the action taken when the alarm is activated. The student is challenged to understand the complexity of alarm response as well as the safety implications for patient care. It is the intent of the Learning Activity to provoke discussion around the role and responsibility of the nurse in alarm safety. An evaluation follows this exercise. Students need to complete the evaluation and return it to the clinical instructor. At the end of the rotation, please return the evaluations to the course coordinator. Instructions for the Learning Activity: Alarm Safety Using the attached worksheet, students are to record the auditory and visual alarms encountered in the clinical setting during one clinical shift. The worksheet includes data regarding the type of the alarm, the location of the alarm, the student’s interpretation of the alarm as well as the action taken. Students should include not only alarms that are pertinent to their patient, but any other alarms they encounter or notice related to the patients on their unit. Discussion Questions: Following completion of the Learning Activity, use the following questions as a guide for clinical instructor/student discussion: 1. What are the various influences on clinician responses to alarms? For example: Physical barriers, physical layout of the unit, RN-pt ratio. 2. How, as a student, are you educated about alarms and your response to them? How might education regarding the various patient alarms be an issue associated with alarm response? 3. Who is responsible for alarm response? 4. Based on your observations, why are alarms ignored? 5. Who is responsible for testing and managing alarms on your unit? How are limits set on alarms? 6. What is a nuisance alarm? How did the alarm become a nuisance alarm? What is the danger in classifying an alarm as a nuisance alarm? 7. If asked by a patient about a specific alarm, how would you respond? How does your response play a role in your patient’s perception of their care? 8. What is meant by alarm prioritization? How are alarms prioritized on your unit? Submitted Materials: 97.QSEN_alarm_safety_worksheet.doc - https://drive.google.com/open?id=1YFTvxXzLZd9eH0F9LB_lEiFdFbDR1zmY&usp=drive_copy Additional Materials: Evaluation Description: Student Evaluation: Alarm Safety What did you learn about the impact of alarm safety on patient safety? How is alarm response a nursing/health issue? Who is responsible for responding to alarms? Did you find this learning activity to be useful? Comments: Please return this form to your clinical instructor.

Published Back to Strategy Search Strategy Submission A Criteria for Evaluating Patient Education in the Rural FQHC Setting Author: Alexandra G. Thompson MSN, BSN, BA, FNP-C, APRN, RN Title: Family Nurse Practitioner Coauthors: Nicole R. Powell, DNP, MSN, BSN, FNP-BC, APRN, NP-C, RN-C Institution: MedLink Georgia / Emory University Email: sashathompson@att.net Competency Categories: Evidence-Based Practice, Patient-Centered Care, Quality Improvement Learner Level(s): Advanced Practice Providers, Interprofessional, New Graduates/Transition to Practice Learner Setting(s): Clinical Setting Strategy Type: General Strategy Learning Objectives: Knowledge: Integrate understanding of multiple dimensions of patient-centered care (information, communication, and education; patient/family/community preferences, values) Examine common barriers to the active involvement of patients in their own health care processes Discuss principles of effective communication Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families Describe approaches for changing processes of care Skills: Provides patient-centered care with sensitivity and respect for the diversity of human experience Assess the level of patient’s decisional conflict and provide access to resources Use the criteria for quality improvement efforts Seek information about outcomes of care for populations served in a care setting Identify gaps between local and best practice Design a small test of change in daily work (using an experiential learning method such as Plan-Do-Study-Act) Use measures to evaluate the effect of change Attitudes: Respect and encourage the individual expression of patient values, preferences, and expressed needs Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals Appreciate how unwanted variation affects care Value measurement and its role in good patient care Appreciate the value of what individuals and teams can do to improve care Strategy Overview: While providing care for patients at a rural federally qualified health center (FQHC) in the Southeast, a lack of available education meeting the specific needs of the facility’s patient population was identified. In order to identify the population’s priority needs, local and regional literacy data were reviewed and compared to the available national data to identify facility-specific literacy needs. In addition to consideration of population literacy, contemporary definitions of cultural humility and sensitivity to resource limitations serve as the foundational concepts upon which the criteria were developed. Finally, we sought to enhance access to education for multilingual populations that could be integrated into a high volume, primary care workflow. In order to develop the criteria, we reviewed the evaluation process and guidelines followed by other organizations in the development and distribution of patient education. The criteria were derived from researching several professional organizations and their review processes. Consulted sources include the Agency for Healthcare Research and Quality, the Maine Health health literacy programs, and the Centers for Disease Controls and Prevention Clear Communication Index tool. The recommendation provided to the quality improvement committee at our organization was to utilize the developed criteria to evaluate existing resources as well as updates to patient education. Further, the criteria for submission and review of evidence-based research followed by our specialty practice authorities were reviewed and adapted to the time and practice limitations of the facility’s providers. Quality improvement in the area of patient education serves as the primary purpose of the resulting criteria. Submitted Materials: 300-2-QSEN-Education-Criteria-Sample.pdf - https://drive.google.com/open?id=1YYTPDBdTAQzrb2oH3nATE0glKS2SDDf-&usp=drive_copy 300-3-QSEN-Submission-References.pdf - https://drive.google.com/open?id=1YM5y_AHSID7VLaYKpHjXueqznE6dps8H&usp=drive_copy Additional Materials: Interested parties may contact authors for additional files or patient education examples. We are willing to share the criteria as well as the patient education files that were utilized. Preferred contact via email. Evaluation Description: In order to assess the existing patient education utilized by the providers at the organization, the most commonly used education was identified by a sample survey of approximately fifteen providers and correlated with a list of the most common diagnoses billed within the organization. The developed criteria were used to evaluate the existing patient education for the most common diagnoses. The process showed that none of the existing patient education met the criteria for utilization. The existing patient education lacked transparency regarding source of information, date last reviewed, cultural humility, and known literacy level. As a result, a search for patient education for most utilized diagnoses was undertaken. Additionally, the new patient education needed to be easily accessible in multiple languages to providers working in a high volume, primary care setting. The new patient education was then evaluated with the developed criteria and selected for inclusion in a computer-based file shared with other providers via the organization’s shared drive. Implementation of the new patient education in the clinic setting is currently in progress with patient and provider feedback results pending. The recommended process for implementation includes the following steps: - Survey clinical staff about most used patient education documents - Evaluate the most used patient education documents using the criteria - Acquire new evidence-based patient education documents for existing documents not meeting the criteria - Apply criteria to a selection of patient education documents to be used in the implementation of a pilot program - Disseminate education during a select time period at pilot centers within the organization - Survey patients’ regarding their experience related to receiving the education - Compile data from all pilot centers to present to a Quality Improvement team - Review data with key stakeholders to create a large-scale implementation plan - Establish a committee to continue the process of reviewing and disseminating patient education documents Ideally, three or five people comprise the committee, and ongoing evaluation by the committee may be undertaken using the PDSA model.

Published Back to Strategy Search Strategy Submission Medication Administration Activity (Competency Assessment) Author: Terri Briggs MSN, RN, CNE Title: Sr. Assistant Professor Coauthors: Institution: Mercy College of Nursing and Health Sciences - Southwest Baptist University Email: terri.briggs@mercy.net Competency Categories: Patient-Centered Care, Safety Learner Level(s): Pre-Licensure ADN/Diploma Learner Setting(s): Skills or Simulation Laboratories Strategy Type: General Strategy Learning Objectives: Safely administer medications utilizing clinical reasoning and data assessment along with proper administration techniques. Strategy Overview: This medication activity presents the student with a SBAR report, VS, labs and a MAR with 3-4 medications listed. Students must evaluate client data and identify concerns for medication administration. Students must correctly calculate rate of medication administration and administer medications appropriately. Submitted Materials: Medication-activity-for-SIM-QSEN.pdf - https://drive.google.com/open?id=1-Sd9Xl-5C9jRHgPe5cIzFyKQNhlor5gQ&usp=drive_copy Additional Materials: I have included the directions for students, faculty, rubric for grading, and the medication activity which consists of 4 scenarios. This medication activity is utilized with 4th semester students in their final Nursing Interventions course. Evaluation Description: A goal for this activity was to get students to utilize the Learning Resource Center for skill practice on a more frequent basis. By attaching points to the activity, students are more eager to practice their skills which improves their competency level in the clinical environment. A grading rubric is provided for students and faculty. The students are given the rubric and directions on line prior to the activity. This is a 6 point activity for us. The activity is broken into clinical reasoning and psychomotor skill, with 3 points for reasoning and 3 points for the skill demonstration. The students get 3 points for correctly identifying medications that should be administered based on pt data, withholding meds when parameters are written into the order (eg- SBP below 100mm Hg hold the beta blocker) or identifying if the HCP needs to be contacted regarding medications due to safety concerns. The students receive 3 points for administering the medications utilizing the 7 rights within a 20 minute time frame.

Published Back to Strategy Search Strategy Submission The Med Room: Learning expectations of safe medication preparation and administration Author: Patrick Tuazon BSN(c) Title: Nursing Student Coauthors: Ye Lim Song, BSN(c); Michelle Zhang, BSN(c), Jenny Yuan, BSN(c); Lisa Concilio, RN, MSN-ED, CCRN, PhD(c) Faculty Institution: San Diego State University Email: LConcilio@SDSU.edu Competency Categories: Evidence-Based Practice, Patient-Centered Care, Safety, Teamwork and Collaboration Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Skills or Simulation Laboratories Strategy Type: Online or Web-based Modules Learning Objectives: Describe how to prepare 2 medications for administration using clinical data, an electronic resource, and equipment. Students will describe their direct role and responsibilities while working along-side their preceptor and clinical instructor to apply fundamental skills/knowledge to demonstrate administering or withholding common medications. Apply key concepts from informatics, pharmacology, assessment, and fundamental nursing courses using teamwork and communication skills using the Medication Safety Map and Return Demonstration Summative Performance Evaluation Tool as a guide to clinical decision-making at a beginner’s level. Demonstrate when to incorporate the rights of medication administration by role-playing in the lab prior to entering the clinical setting. Strategy Overview: Intended audience: undergraduate nursing students who have not entered the clinical setting. Crucial conversations and preparation are key to student learning. Working directly with an instructor can produce anxiety and impede learning if expectations are not transparent. Students will be able to observe how to incorporate previously learned knowledge to create clinical reasoning and decision-making. The instructor asks key questions to stimulate reasoning while the student displays preparedness and an intention to be safe and diligent using the rights of medication administration as well as watch 2 RNs verify the correct dosage of insulin ordered. Students will also observe how to draw up insulin; parts of the insulin syringe are discussed as it pertains to safe dose preparation/administration. Submitted Materials: 268Return-Demonstration-Summative-Performance-Evaluation-Rubric.docx - https://drive.google.com/open?id=1qz5k3X-jhSuyckiPsMm9bicc7xurlrHu&usp=drive_copy Additional Materials: The Med Room Video https://drive.google.com/file/d/1NdQlf4Q-5pfLNj4jeAD6fU2fFgmacABL/view?usp=sharing. Medication Administration Safety Map http://qsen.org/medication-administration-map/ Return Demonstration Summative Performance Evaluation Rubric https://drive.google.com/open?id=1zWQrWxWR_GGPC4pXzkvKU5vKyqCKWlRS Evaluation Description: This video demonstrates the process of medication preparation, student/instructor interactions, and displays a student's expected level of preparedness when entering the med room. Role-playing encourages mental preparation and motivates learners. Practice sessions developed the knowledge, skills, and attitude to create responsible, mindful, critical thinkers while working with faculty and hospital staff. Students express fear of working with faculty and thoughts of inadequacy, which were addressed early, allowing students to cognitively reframe stressors when preparing medications. Student performance will be evaluated based on a rubric (see link below) in which learning objectives have been broken down into several expectations. Fulfillment of each task is assessed through points given in accordance with proficiency.

Published Back to Strategy Search Strategy Submission Infusing Quality Improvement into clinical education Author: Donna B. Lupinski MSN, RN Title: Faculty Coauthors: Institution: Lorain County Community College Email: dlupinsk@lorainccc.edu Competency Categories: Quality Improvement, Safety Learner Level(s): Pre-Licensure ADN/Diploma Learner Setting(s): Clinical Setting Strategy Type: Paper Assignments Learning Objectives: 1.Faculty and students will “seek information about quality improvement projects in the care setting” (Knowledge). 2.Students will identify the potential impact of quality improvement measures on patient care (Knowledge). 3.Students will evaluate evidence based practice with observed practice (Skills). 4.Students will gain an appreciation “that continuous quality improvement is an essential part of the daily work of all health professionals” (Attitudes). 5.Students will “value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team” (Attitudes). Strategy Overview: This strategy may be used to educate students on how patient safety may be improved through quality improvement audits and the Plan-Do-Study-Act (PDSA) cycle. The audit subjects were chosen in collaboration with several nurse managers and administrators at clinical facilities utilized by our nursing program. 1) Provide each clinical faculty member the Quality of Care Audit instructor guide (Attachment #1) and a set of audits (Attachment #2): Computer screen; Fall precautions; Hand hygiene; Hourly rounds; IV labeling; and Pain medication reassessment. 2) Have clinical faculty member assign students an audit to complete (Attachment #2). Have students read the directions and perform the audit. 3) Have students discuss their findings and reflections in post conference. Invite the unit manager or charge nurse to participate or provide them a copy of the findings. If the facility allows have the students create a PDSA plan and implement it. Then complete the audit again at a later date and compare the findings to determine if the plan improved care. Submitted Materials: Quality-of-Care-Audit.Instructor-1.docx - https://drive.google.com/open?id=16jeoyQ48KLhaV2Yc168HHqr3Ak_eKdjZ&usp=drive_copy Fall-Precaution_Hourly-rounds.audit_-1.doc - https://drive.google.com/open?id=1ow-pNyzqg8MefXr_QSgQ-CLsrnlZpEua&usp=drive_copy Hand-Hygiene_IV-site.audit_-1.doc - https://drive.google.com/open?id=1odQTD3h1GyshmEGAa-gylrzY_5w_Dyro&usp=drive_copy Pain-medication_Computer-screen.audit_-1.doc - https://drive.google.com/open?id=1pg8PPBrjhnytmNuSPVU4P_0IddTonG2v&usp=drive_copy Additional Materials: Quality of Care Audit-Instructor guide Set of Audit tools-total of 6 Evaluation Description: Students are to discuss audit findings in post conference with clinical group and clinical unit representative if available. Compare if actual practice varies from best practice guidelines or facility policy. Explore possible barriers to implementing best practice or facility policy and if barrier is a personal or systemic barrier. Have students discuss if a practice change is indicated, if indicated have them create a quick change plan using the PDSA cycle format. If facility allows, have students implement their plan and re-evaluate later in clinical rotation. Submit audit form at end of clinical day to instructor for evaluation. If student response on audit form minimal or shows lack of reflection the student is to resubmit the assignment. Results from our assignment: Students performed their assigned audit, wrote a reflection on barriers nurses may have faced in performing the action, and how the results of this activity would affect their personal practice and client care. These reflections were then shared during post conference with the clinical group and an available clinical unit representative. Students were prompted to explore if variation from best practice and facility policy appeared to have a systemic cause rather than placing blame on a singular individual. Students were then asked to decide if a practice change was indicated and to create a quick change plan using the PDSA cycle format. Unfortunately students were not able to implement a PDSA cycle change due to clinical facility preference. Students noted some eye opening behaviors such as: nurses not sanitizing hands prior to or after care of a patient with c-diff; a respiratory therapist who went from room to room to apply treatments without performing hand hygiene; and over 50% of IV sites and tubing not labeled at one institution. Students noticed healthcare workers were more likely to perform an action correctly when they were aware someone was watching. Students compared past and current clinical facility experiences and noted some generalized practices between facilities that seem to help improve consistency of care and infection control practices such as similar yellow color coding practices for fall risk clients. Students indicated the healthcare facility had policies in place and that employees need to follow them more diligently. Students suggested the facility perform more frequent random audits and share the results with staff with a reward system for the unit with best compliance. Students submitted their completed audit forms to be evaluated by the clinical instructor. If student reflection or comparison to evidence based guideline response on the audit form was minimal the student was instructed to resubmit the assignment. Students repeatedly reported that this exercise helped to reinforce the need to habitually perform the action in order to provide best practice care for improved patient outcomes, infection control, and cost effectiveness and to be aware of others and their adherence to or alteration from best practice.

Published Back to Strategy Search Strategy Submission Providing Patient Centered Care Through Teamwork and Collaboration Author: Pamela M. Ironside PhD, RN, FAAN Title: Associate Professor Coauthors: Institution: Indiana University School of Nursing Email: pamirons@iupui.edu Competency Categories: Patient-Centered Care, Teamwork and Collaboration Learner Level(s): New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN, RN to BSN Learner Setting(s): Classroom Strategy Type: General Strategy Learning Objectives: Integrate understanding of multiple dimensions of patient-centered care: Patient/family preferences, values Physical comfort and emotional support Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds Appreciate the role of the nurse in relief of all types and sources of pain or suffering Provide patient-centered care with sensitivity and respect for the diversity of human experience Act with integrity, consistency and respect for differing views Strategy Overview: I have worked in the NICU for a long time and had begun to feel really comfortable with my clinical skills and with the other members of the team. The unit was busy as usual; only two empty spots and we were, of course, hoping they stayed empty. Then the call came from a birthing center in town that they were transferring a fetal demise to us. The lay midwife described the infant as limp and cyanotic, apgar of 1. We admitted the baby and the parents were at the bedside. This infant was the couple’s first baby. The mother carried the infant to full term without complications and had chosen home birth because they wanted to protect their infant from all the “bad bugs” in the hospital. Given what we were seeing, we suspected the infant suffered an anoxic event. Over the next few days these parents kept a vigil at their infant’s side and it was becoming increasingly apparent that a decision about either continuing treatment or withdrawing treatment was rapidly approaching. While we certainly felt sorry for this family, losing a child is never easy, it was difficult to connect with them because we were so busy and they were really different. I mean, they both had dreadlocks, tattoos and multiple piercings—you know, the hippie type. They were Buddhists and no one had any clue what the Buddhist rituals were around death and dying. When I found some time I thought I should probably call somebody, but who? As I approached the patient and mother I was determined to make some kind of connection with this woman so we could start the discussions about withdrawing life support. As I began speaking, you know, the usual, “my name is Kia and I’m going to be taking care of your child today,” the mother looked at me with these huge, glossy eyes and began telling me about how guilty she felt that she had killed her baby. “We thought we were doing what we could to protect our child and we did just the opposite!” She was wracked with grief and clearly in no state to be making important decisions. She told me, “I see people talking to me, but I can’t hear what they are saying. It’s like my whole world has just fallen in on me.” When I left the room, I approached the attending physician to share my concerns about the mother’s ability to participate in these discussions and suggested a care conference for us to discuss the child’s status, the mother’s current state and a possible timeline for making this decision. Her response was, “we don’t usually do that here. We refer patients back to the healthcare facility where the event took place.” You determine the best approach is to convene a care conference so that all interested parties can discuss the situation. Writing assignment: In one page make your case for convening a care conference. read more at Include consideration read more at of the following: What are the 3 most pressing issues facing those providing care for this family? Who read more at would you argue should be involved in this conference and why? Identify the unique perspective (and overlapping contributions or common areas of concern) each would bring to the case. Who would NOT be included in the conference at this point and why? What is the meaning and significance of this to you as the assigned nurse? To the family? After you have made your case consider, “If it were my baby, I would want the nurse to…..” Submitted Materials: Additional Materials: Evaluation Description: Although this is a written assignment, it is very helpful to discuss students’ reflections in a classroom or post-clinical setting. Together with students, you may consider any issues that come up including (but not limited to): How do the characteristics of the parents and their birthing decisions influence students’ thinking about the case conference? How do students anticipate attending to the differences in beliefs, values, religion, etc in light of the gravity of the decisions facing this couple? Where do they seek help for dealing with this situation? Are the routines and timelines for handing such situations adaptable to the parents’ experience of grief? If students argue for urgency, what influences that perspective? If students do not see urgency, what influences that perspective? You can evaluate the written work and/or the students’ participation in discussion. The limit on the length of their written assignment will require students to take and support a particular approach concisely but thoughtfully and will allow you to respond to student work quickly. In most cases, a pass/fail approach to marking would be appropriate. I have found it helpful to return to student responses later in the semester and ask them to reflect on how their perspective of the situation has changed, how they would respond to the situation now, and what questions still remain for them.

Published Back to Strategy Search Strategy Submission Using Process Flow Charts to Improve Clinical Care Author: Leslie W. Hall M.D. Title: Associate Professor of Clinical Internal Medicine Coauthors: Institution: University of Missouri - Columbia Email: HallLW@health.missouri.edu Competency Categories: Quality Improvement Learner Level(s): Graduate Students, New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN, RN to BSN Learner Setting(s): Classroom Strategy Type: Online or Web-based Modules Learning Objectives: At the completion of this session, the learner will: Demonstrate an understanding of how information regarding a care process can be organized into a process flow chart Understand how the process flow chart may help to identify unwanted variation in a clinical process Understand how the process flow chart may be utilized to identify high impact areas for instituting change in a clinical process Strategy Overview: This relatively simple exercise provides an opportunity for nursing students to examine a common clinical care process (administration of inpatient antibiotics) that is not occurring efficiently and examine what some of the root causes might be that are causing the delays. The concept of a process flow chart is introduced as a tool to identify high impact areas that might be high leverage areas for change. The chart is also introduced as a tool that can be used to identify practice variations. The importance of this exercise is to introduce the idea that an inefficient process can be reduced to a series of clinical steps, rather than viewing it as dysfunctional individuals (which usually leads to feelings or statements of blame). Identification of the high impact change areas can allow interventions to be appropriately focused where the greatest benefit will accrue. Submitted Materials: Additional Materials: Evaluation Description: This teaching exercise has been used in a variety of small group learning environments, with positive feedback from learners. Although it has not been utilized by the author in independent study or as part of a computer-based module, the content is probably amenable to delivery by these methods as well.

Published Back to Strategy Search Strategy Submission Strategies to Decrease Student Anxiety and Improve Patient Safety in a Critical Care Clinical Setting Author: Julie Hopkins DNP, RN, PHNA-BC Title: Instructor Coauthors: Institution: Frances Payne Bolton School of Nursing, Case Western Reserve University Email: jlh208@case.edu Competency Categories: Patient-Centered Care, Safety Learner Level(s): Pre-Licensure BSN Learner Setting(s): Clinical Setting Strategy Type: General Strategy Learning Objectives: Through participation in this clinical exercise the student will: 1. Discuss the impact of student anxiety on patient safety in a critical care clinical setting. 2. State the effect reflective journaling has on decreasing anxiety. 3. Review previously learned skills in a lab setting during critical care clinical orientation as a means of decreasing anxiety in practice. 4. Demonstrate the effect student anxiety has on communication with patients and the care team. 5. Analyze the relationship between student anxiety and the provision of patient-centered care. Strategy Overview: The start of a critical care clinical rotation can be an exciting time for many nursing students. For some, however, the prospect of caring for critically ill patients in an intensive care unit (ICU) can be overwhelming. While some apprehension is to be expected, excessive anxiety can impede students’ ability to think clearly, therefore increasing the risk of errors and ultimately jeopardizing patient safety. Too much anxiety may also negatively impact students’ interactions with their patients, compromising communication and affecting the provision of patient-centered care. In an effort to decrease students’ anxiety and increase their comfort level in caring for critically ill patients, an orientation day “skills fair” along with reflective journaling will be introduced in this junior level BSN critical care course. Prior to the start of the course, students will be asked to reflect on their preconceptions of critical care clinical and identify any fears or anxieties they may have regarding caring for critically ill patients. A brief questionnaire will be posted on the course Canvas site one week prior to the start of the clinical rotation. Questions will include “What are your perceptions of the critical care clinical rotation?” “Do you have any fears of caring for ICU patients? If so, discuss them.” The students will upload their responses to the Canvas site prior to the first day of clinical. The content of this reflection will not be graded. Students will simply earn credit for submitting the assignment on time. On the first clinical day, each instructor will have their group engage in a roundtable discussion where students will be able to share their thoughts, feelings, and concerns regarding caring for critically ill patients. Students will not be mandated to share what they wrote in their pre-clinical assignment, but faculty will promote an environment where students feel safe to discuss their feelings. Students’ fears and apprehensions will be acknowledged. Instructors will stress to the group that the focus of this clinical rotation is not only hands-on patient care and clinical skill development, but also confidence building, patient safety, communication, and the provision of patient-centered care. Following this discussion and a tour of the ICU, students will reconvene in the school’s nursing lab for a “skills fair.” The following clinical skills were chosen to review: 1) Administering medications via a gastric tube 2) Inserting an indwelling Foley catheter 3) Inserting an intravenous (IV) line, administering medications by IV bolus, and administering medications by IV piggyback 4) Suctioning a tracheostomy and providing care of a tracheostomy 5) Medication math calculations These skills were chosen because of the high likelihood of having the opportunity to perform them in an ICU setting. Students enrolled in this course have tested out on these skills in their prior medical-surgical rotation. However, they likely had little opportunity to perform the skills in the clinical setting. The goal for the skills fair is to refresh students’ memory on correct technique and procedure, increase their confidence, and decrease their anxiety prior to the start of the ICU clinical rotation. Refining their skills, decreasing their anxiety, and improving their confidence will ultimately improve patient safety in the clinical setting. During the skills session, students will break into small groups and move through the five stations at 20-minute intervals. A clinical instructor will be at each station and will demonstrate the skill for students, then allow each student time to practice. If additional time is needed on a skill, students may return to repeat it after cycling through each station. Instructors will provide feedback and assistance, but students will not be tested or graded on each skill. The goal is to provide a low-stress environment for students to gain confidence prior to working with critically ill patients. Reflective Journaling Students will also complete one structured reflective journal during the seven-week clinical rotation. Reflection will allow the students to explore their thoughts and feelings related to the clinical experience. It will also help students understand their stress and anxiety, and the impact these factors have on patient safety and the provision of patient-centered care. Open-ended questions include “Identify and describe aspects of your clinical day which may have caused you to feel anxious.” “Describe how you communicated your feelings of anxiety to your clinical instructor and/or assigned nurse. How did communication with members of the health care team impact your anxiety level?” “What aspects of patient safety were your focus today?” “Evaluate your performance of patient care today. Include what you learned and where you feel you could improve, particularly in regard to patient safety.” A deadline for submitting this reflective assignment to the course Canvas site will be given to students at the beginning of the course. Finally, students will also complete a post-course reflection of this experience. The same questions posed at the beginning of the course will be revisited at this time. The questions will be posted on the course Canvas site and will include “Reflect on your fears and concerns prior to the start of the course. Based on your experiences during this rotation, what are your current perceptions of caring for critically ill patients?” “Reflect on your experiences from this clinical rotation. Did your anxiety level change throughout the rotation?” This post-course reflection is not graded, but credit is awarded for submitting it on time. Submitted Materials: 234-Revised-Critical-reflection-rubric.docx - https://drive.google.com/open?id=1qBXae3Lphj-F1jxqhQdyuJXloQESkv3b&usp=drive_copy Reflective-Journal-template-updated-1.docx - https://drive.google.com/open?id=16vB8834H6Il-e7ntgShUPD3yfybRi7L7&usp=drive_copy Additional Materials: See the attached files: 1. Reflective journal template 2. Critical reflection rubric Evaluation Description: One of the most helpful aspects of journaling is having the opportunity to reflect on an experience and think about how to improve upon a similar situation in the future. Through journaling, students have a written memoir of an experience. They can reflect on this, and think about how they overcame this particular difficulty. In this way, it encourages refinement of action (Miller, 2017). The students’ structured reflective journal will be scored based on content, quality of writing, and timeliness of submission. The true measure of success with the assignment, however, is a noted decrease in anxiety level for the student in caring for critically ill patients. For this reason, the focus of their journaling should not be on “hands on skills” performed, but on their own personal reflection of their feelings toward their patient assignment, and how those feelings impacted patient safety, communication with the patient and interprofessional team, and their provision of patient-centered care. Their ability to be able to make connections between their attitudes and fears and their overall performance will lead them to professional growth. The goal is for students to continue their practice of reflective journaling in future courses. Ideally, they may not only identify connections between student anxiety and patient safety, but also recognize their strengths and weaknesses which impact communication, safety, and the provision of patient-centered care. References Ganzer, C. A., & Zauderer, C. (2013). Structured learning and self-reflection: Strategies to decrease anxiety in the psychiatric mental health clinical nursing experience. Nursing Education Perspectives, 34(4), 244-247. Miller, L. B. (2017). Review of journaling as a teaching and learning strategy. Teaching and Learning in Nursing, 12, 39-42. Zhao, F.-F., Lei, X.-L., He, W., Gu, Y.-H., & Li, D.-W. (2015). The study of perceived stress, coping strategy and self-efficacy of Chinese undergraduate nursing students in clinical practice. International Journal of Nursing Practice, 21(4), 401–409.

Published Back to Strategy Search Strategy Submission Clinical Evaluation Tools embodying AACN BSN essentials and 6 QSEN KSAs Author: Linda Flores MSN-Educator; CEN, RN Title: Assistant Professor Coauthors: Patricia Shakhshir, PhD, CNS, RN-BC, Mary Lopez, PhD, RN Institution: Western University of Health Sciences College of Graduate Nursing Email: lflores@westernu.edu Competency Categories: Evidence-Based Practice, Safety Learner Level(s): Pre-Licensure BSN Learner Setting(s): Clinical Setting Strategy Type: General Strategy Learning Objectives: 1) Utilize Clinical Evaluation Tools containing observable scaffolded competencies embodying the American Association of Colleges of Nursing BSN essentials and 6 QSEN knowledge, skills, and attitudes (KSA): Safety, evidenced based practice, patient centered care, team work/ collaboration, informatics, and quality improvement. The added core of professionalism embodies the spirit of the school’s clinical handbook and hospital’s mission statements. Tools range from semester I-IV, Fundamentals, Medical Surgical Nursing; Advance Medical Surgical Nursing; Pediatrics, and Community Health. (Obstetrical Nursing and Psychiatric Nursing pending). 2) Provide a numeric grade--The tool utilizes a numeric system 0-4 for each of the 6 QSEN competencies KSAs totaling 100 points for a "grade" in clinical (instead of pass/fail). 3) Document reflection of values and attitudes in the clinical setting with the use of exemplars (narrative pedagogy). Strategy Overview: 1) Students utilize the clinical evaluation tool to self-grade at midterm and final week. Clinical faculty agreement or recommend changes both at midterm and final week. 2) At Mid-term, a numeric value of 2 is acceptable since continued growth is expected until completion of clinical hours. a. When a QSEN competency KSA falls “below expectations,” a score of 2 out of 4; a remediation plan for competency I-VI and KSA a-f will be documented on the Performance Improvement Form. Agreement from student, clinical faculty, lead faculty, and director(s) signatures required. b. When remediation requirements meet time frames & criteria, the grade for the specific competency and KSA increases to “met” at 3 out of 4. 3) Early identification of areas falling below expectations and a clear action plan with time frames for student success facilitate clear communication and documentation of efforts. 4) Narrative Pedagogy (exemplar) required for a score of 4 documents personal knowledge application of skills and attitude changes while providing quality safe care for the sick client. One clinical exemplar may embody several competencies I-VI and KSAs a-f. Submitted Materials: Clinical-evaluation-tool-guidelines-WUHS-2014-1.doc - https://drive.google.com/open?id=15rm2JY7NInYRf-N95pkFkn-FnaclTkrl&usp=drive_copy Level-I-CGN6411-Clinical-Eval-Tool-1.pdf - https://drive.google.com/open?id=1U4CPUXy4TUvNjBsrN2QScqimKeVpQVhJ&usp=drive_copy Level-II-CGN6502-Clinical-Eval-Tool-A-1.pdf - https://drive.google.com/open?id=17UT2P0DLDf7_zQ7RcxcITupAnUku5Kjs&usp=drive_copy Level-III-CGN-6711-OB-Clinical-Performance-Evaluation-Tool-1.pdf - https://drive.google.com/open?id=1UiErlcZBrWq93B9soclc9QGSBjK25SRF&usp=drive_copy Level-IV-CGN-6902-Community-Health-Tool-A-1.pdf - https://drive.google.com/open?id=1UwA7OoK4dKLyxYSPSovEjWkcEbOxYPP1&usp=drive_copy Additional Materials: Level IV Community Health Clinical Evaluation tool available per request to Linda Flores lflores@westernu.edu Audio Power Point Presentation (18 minutes) explaining the quality improvement group activities (Level III) in post conference or debriefing available, please contact Linda Flores. Level IV Psychiatric Nursing tool in progress. OB and Community clinical evaluation tools will be available upon request. Teaching strategy enhancement from the version presented at QSEN 2012 by Nicholls State presenters: Eymard, A., Davis, A., & Lyons, R. (2012). Progressive clinical performance evaluation tools incorporating the QSEN competencies. Podium presentation at the Innovation to Transformation: 2012 QSEN National Forum, Tucson, Arizona. Evaluation Description: Since utilizing these tools, clinical grades range from 77% (passing) to 100% (above expectations). Those students achieving higher than 77% wrote clinical exemplars capturing their previous misconceptions and changes in attitudes or values; desiring methods for changing the system (blameless communication); creating opportunities for patient centered pain management or goals; and lastly reporting off during interdisciplinary rounds at bedside to advocate for the patient or family. Post conference discussion contain aspects of the tool such as quality improvement and safety. Embedded within the tool are post conference exercises such as root cause analysis of a “work around” of an active or latent safety failure. The critical care semester clinical evaluation tool (Level III) also highlights the hospital report card so that early introduction of measurable nurse sensitive indicators become part of their language, values, and evidenced based practice. Another activity embedded within the tool is the identification of the “sacred cow” or traditional “way of doing” thing. An audio PPP or 1:1 meeting with adjunct clinical faculty enhances their ability to decipher use of the clinical evaluation tool. Weekly e-mails from the lead course faculty member connects weekly course content to clinical assignments and aspects of the tool. Early identification of several students who did not meet performance improvement criteria at Midterm help all parties develop a plan for clinical progression. Several solutions included switching medical surgical units, additional clinical/ lab hours, and case study worksheets. The student, clinical faculty, lead course faculty, and director of the program agree upon solutions that consider the student’s ability, clinical site, patient, and course objectives. Outcome based competencies: Our clinical unit nurse educators also provided input such as customer service criteria. While the acronyms vary, the concept consistently contained themes such as immediate trouble shooting, acknowledgment, prevention, and service. The relationship with clinical site nurse educators will be integral for the future. When active or latent safety infractions occur on the unit, a post conference debriefing included a root cause analysis (level III clinical evaluation tool, Quality Improvement competency). Under the guidance of the clinical faculty, an option includes a plan, do, study, act proposal to bring to the unit nurse educator (to achieve a score of “4” above expectations). Without a “just culture” environment, the students might not feel safe to bring forth their quality improvement suggestions. The group exercise facilitates team work and collaboration. A score of 4 requires a clinical exemplar as recommended by Drs. Benner, Sutphen, Leonard, and Day's (2010) Educating Nurses: Call for Radical Transformation suggestion of critical reflection for finding new meaning within context of practice. Use of exemplars create connections between their knowledge integrated from the classroom into the clinical practice and the humanistic science of caring. One exemplar may capture several QSEN KSA areas as “exceeds” semester expectations. Usually 2-4 exemplars total document their development of attitude and values while providing safe, evidence based, patient centered care. Post conference debriefings facilitate student recognition of their success.

Published Back to Strategy Search Strategy Submission Use of Institute for Healthcare Improvement (IHI) Open School Courses in a Prelicensure Nursing Program Author: Colleen A. Hayes MHS, RN Title: Assistant Professor of Nursing Coauthors: Institution: Western Carolina University Email: cahayes@wcu.edu Competency Categories: Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration Learner Level(s): Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: Online or Web-based Modules Learning Objectives: 1. Value seeing health care situations “through patients’ eyes.” Respect and encourage individual expression of patient values, preferences and expressed needs. [patient centered care] 2. Acknowledge own potential to contribute to effective team functioning. Appreciate importance of intra- and inter-professional collaboration. [teamwork and collaboration] 3. Discuss effective strategies for communicating and resolving conflict. [teamwork and collaboration] 4. Choose communication styles that diminish the risks associated with authority gradients among team members. [teamwork and communication] 5. Value the influence of system solutions in achieving effective team functioning. [teamwork and communication] 6. Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families. [quality improvement] 7. Use tools (such as flow charts, cause-effect diagrams) to make processes of care explicit. [quality improvement] 8. Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as, work-arounds (shortcuts or breaks in standard processes) and dangerous abbreviations) [safety] 9. Delineate general categories of errors and hazards in care. Describe factors that create a culture of safety (such as, open communication strategies and organizational error reporting systems) [safety] Strategy Overview: Several Institute for Healthcare Improvement (IHI) Open School courses are completed by students in a leadership and management course during the last semester of a traditional and accelerated BSN program. Students independently complete IHI courses in patient safety and leadership, including: Introduction to Patient Safety, Fundamentals of Patient Safety, Human Factors and Safety and Communicating with Patients after Adverse Events, and Leadership (L101) So You Want to be a Leader in Healthcare throughout the semester. Content from the courses are incorporated into class activities and discussions, written assignments and course test questions. Learning Strategies related to IHI Open School Courses on Patient Safety: 1) One activity competed in class after students complete the patient safety courses is to have students write on post it notes to place on posters in the classroom. One poster is dedicated to what students learned by completing the IHI Patient Safety Courses, and the other poster is for students to add "how they felt" after completing these courses. To initiate discussion in the class, each student is asked to complete at least two post it notes (they may complete more) related to the IHI Patient Safety Open School courses. On one post it note students write at least one thing they learned by completed the Open School course, and one post it note on how completing the courses made them feel. The post it notes are placed on poster paper in the room. The instructor summarizes some of the most common responses on each poster, and facilitates discussion on common topics. Some common learning points identified by students are: “just culture”, causes of errors – human and system factors, how common errors are in healthcare, etc. Frequently students identify “how they feel” after the modules as: “afraid I will make an error that hurts someone”, “heartbroken for families that have been effected by errors.” Adequate class time for discussion is needed to process learning points and student fears and anxiety related to patient safety. 2) A cause and effect (fishbone) diagram is used in class after the patient safety modules are completed, to outline the causes of one scenario/situation presented in the IHI course. An airline crash scenario video in one of the modules is used to identify contributing factors of the crash, including communication, hierarchy/organizational culture, environmental factors, fatigue, stress. Students are then asked to describe an error or near miss they may have witnesses in the clinical environment, and discuss similar/contrasting factors leading to the error or near miss. 3) The students complete a patient interview assignment (attached) to gain understanding of a patient's perspective of a healthcare experience based on the IOM 6 Domains. During the course content and lecture period on patient centered care, the students discuss findings from their patient interviews. Data from patient interviews is compiled during class, including the types of care units, clinics where the patient experienced care, and themes of what constituted "good" or "bad" nursing care as perceived by patients and families. A review and discussion of learning from the IHI course related to completing a patient apology (IHI Course PS 105) is also completed during this class period. Students are divided into small groups with at least one student with a patient story with an untoward outcome or dissatisfaction with care. In small groups the students construct a patient (or family) apology based on the individual circumstances of the patient story and using principles of delivering an effective apology. Each small group then presents a brief summary of the patient experience, and delivers an apology to the patient or family member. The remainder of the class listens and critiques the apology. 4) Students also complete a paper (assignment attached) after completing the IHI leadership course. The IHI leadership course addresses being a leader in a system, and taking a leadership stance in difficult situations, no matter the official role or title. The course also addresses inter-professional communication and relationships. The purpose of the assignment based on the IHI course, is to have the student describe a past experience or situation in a job or school situation, and analyze how they could have handled the situation differently based on concepts learned in the IHI leadership course. Submitted Materials: Additional Materials: Evaluation Description: Evaluation Methods: 1. Course exams include specific questions related to IHI courses. 2. Patient Interview Assignment (attached) 3. Leadership Assignment (attached) 4. Class discussions and participation in activities Assessments: End of course evaluations indicate that students find the IHI courses relevant, interesting and add value to the nursing leadership course. The IHI "So You Want to be a Leader" Course (LD 100) has been mentioned most often by students as the most helpful, well presented and important IHI course they completed. The unfolding case study very clearly demonstrated how to approach an issue and address it as a "leader" in a health care situation. Students scored well on exam questions related to content covered in the IHI courses - scoring higher on those content areas than those presented through other methods (readings in the text, presentations in class) in the course. Each assignment included a section on learning points from the assignment. Comments added by students showed changes in attitudes and values related to patient safety and leadership.