Published Back to Strategy Search Strategy Submission OB Case Studies for Application of QSEN Safety Competencies: Examination of the Concept of a ‘Just Culture’ through Root Cause Analysis Author: Sue Mahley MN, RN, WHNP-BC, CNE Title: Assistant Professor of Nursing Coauthors: Institution: Research College of Nursing Email: sue.mahley@researchcollege.edu Competency Categories: Safety Learner Level(s): Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: Case Studies Learning Objectives: Following implementation of this strategy, the student nurse will: Describe factors that create a culture of safety (such as open communication strategies and organizational error reporting systems). Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as root cause analysis). Participate appropriately in analyzing errors and designing system improvements. Engage in root cause analysis rather than blaming when errors or near misses occur. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team. Value own role in preventing errors. Strategy Overview: Background of Strategy: Considering the high risk stakes and high costs of obstetrical care and that many deaths attributable to human error may be potentially preventable, the Maternity Nursing classroom or clinical sitting (clinical conference) provide a forum that is ripe for application of the QSEN Safety Competencies. This strategy focuses on promoting a culture of safety and the role of root cause analysis. Implementation of Strategy: To challenge senior nursing students in their Maternity Nursing Course to embrace the concept of just culture, an obstetric case study is presented in which patient safety is jeopardized. (Three sample case studies are provided in the attachments.)Students are divided into teams to review the timeline of events of the same case study. As the investigative team, students must decide on clear roles and methodologies in the analysis of findings and identification of root cause (of the patient safety problem). A root cause analysis flow-sheet is provided to the teams for a systematic approach. Determination of root cause is followed by devising a plan for corrective action. Students utilize a just culture algorithm to ensure that appropriate corrective actions are implemented. Facilitation of effective channels of communication is reflected in their plans. Use of course textbooks and electronic resources are encouraged in order to research system policies and standards of practice (such as AWHONN and ACOG). System weaknesses are evaluated in relation to individual healthcare provider performance. Students gain not only an understanding of maternity care risks but also of health care system policies and practices. The concept of a ‘just culture’ is brought to life through student participation resulting in increased awareness, understanding and appreciation of the complexities of the health care system. Groups share their findings with all participants at the culmination of the activity. Submitted Materials: Additional Materials: Evaluation Description: A survey was used to evaluate student response to this teaching strategy. By self-report, students in the first participating class (n=50) ‘agreed’ to ‘strongly agreed’ to an increased understanding of root cause analysis (92%) as well as increased awareness and appreciation of the complexities of the health care system when patient safety is jeopardized (95%). A sample of the survey is attached. In order to measure knowledge gained, a pre and post activity quiz was devised to assess student understanding of ‘just culture’ and root cause analysis. A sample of the quiz is attached.

Published Back to Strategy Search Strategy Submission Collaborative Exams to Promote Learning Through Teamwork and Collaboration Author: Katie Morales PhD, RN, CNE Title: Assistant Professor Coauthors: Institution: Berry College Email: KMorales@Berry.Edu Competency Categories: Teamwork and Collaboration Learner Level(s): Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: General Strategy Learning Objectives: The objective for this learning activity was to assess and promote learning individually and through teamwork and collaboration. Teamwork and Collaboration: Knowledge: Describe impact of own communication style on others. Discuss effective strategies for communicating and resolving conflict. Describe own strengths, limitations, and values in functioning as a member of a team. Skill: Solicit input from other team members to improve individual, as well as team, performance. Learning Objectives: 1) Assess and promote learning through teamwork and collaboration. Teamwork and Collaboration: Knowledge: Describe impact of own communication style on others. Discuss effective strategies for communicating and resolving conflict. Describe own strengths, limitations, and values in functioning as a member of a team. Skill: Solicit input from other team members to improve individual, as well as team, performance. Initiate actions to resolve conflict. Strategy Overview: This teaching strategy involves collaborative exams to promote learning through teamwork and collaboration. Collaborative exams are an evidence-based practice to help nursing students develop and practice team work and collaboration skills (Improved Class Preparation and Learning Through Immediate Feedback in Group Testing for Undergraduate Nursing Students by Peck, Stehle Werner, and Raleigh [2013]). Collaborative exams incorporate several learning theories (cognitive-developmental behavioral learning, social interdependence, and constructivism). The collaborative exam provides active and collaborative learning, immediate feedback, and structure which appeal to millennial learners. Collaborative exams are an interactive learning strategy allowing students to work together and answer exam questions. The items on the individual exams are developed each semester based on course objectives by the faculty members. Items may be original or from a test bank of previously used items. Test bank items are edited based on past exam analysis. All course faculty should edit course exams for content, clarity, and adherence with course objectives. The exam items and answer options are randomized on both the individual and collaborative exams to reduce the possibility of unplanned collaboration. To prepare the collaborative exam, the faculty simply copy the individual exam as a collaborative exam. Following a test-retest strategy, students take the individual exam again as a member of a small group immediately following the individual exam. In the initial cohort, when offered the opportunity to participate in the collaborative exam, all students elected to participate. Because the collaborative exam promoted group interaction and interpersonal skills, the collaborative exam was adopted in the course and used with all following cohorts since implementation. If a student misses a course exam, he/she must notify the course faculty prior to the exam and have an excused absence for the exam period. If excused, he/she may be given an alternate exam in an alternative format. If a student misses a course exam, he/she forfeits the collaborative exam and, subsequently, the collaborative points. Furthermore, to ensure success in the course and on National Council Licensure Exam (NCLEX-RN® exam), students scoring below 80 on any individual exam are given a remediation plan regardless of their collaborative scores. All individual post-exam remediation assignments must be completed prior to the next exam or three points will be deducted retroactively from the student’s grade on the individual exam which required remediation. Procedure Upon completion of the individual exam, students remain quietly (without electronics) in the exam room for the collaborative exam to begin. Collaborative exams occur after each exam. The final exam is not included as it is comprehensive. Students are placed in groups of 4-5. Student placement has included random assignment, assignment based on individual scores, or in learning groups used across the curriculum for the semester. All assignment options have worked well. Students have not reported being assigned groups rather than being allowed to choose their groups as an issue. One person per collaborative group logs into a copy of the individual exam. No other additional group members log into the exam. The team leader submits one exam for the group. As a result, students must reach consensus on the best answer. The collaborative exam allows the faculty to assess and promote learning. To assess learning, collaborative exams are scored in the same manner as the individual exams on a scale of 0-100. To incentivize the students and avoid grade inflation, points are awarded to each student’s individual exam score based on the following: Collaborative score of A (90-100) = 2 points Collaborative score of B (80-89) = 1 point Collaborative score of less than 80 = 0 points Upon completion, the items the group missed on the collaborative exam are displayed. As group members view and discuss the rationales, no other exam reviews are conducted in these courses. Discussion fosters learning among the groups. Students debate, integrate and synthesize course material while it is still foremost in their minds. The collaborative exam allows students to actively engage with the content and one another and obtain instant feedback to correct misconceptions. Immediate feedback is more effective than traditional testing to enhance learning (Peck, Stehle Werner, & Raleigh, 2013). Test-retest methods provide immediate answers to lingering questions, correct misconceptions, and promote retention of knowledge (Hann, Roberts, & Hurley, 2016). Students commented knowing the correct answers immediately was more effective than trying to recall and look up the items after class. Furthermore, immediate feedback from collaborative testing may improve final exam scores. Group collaboration increases learning and enhances critical thinking. Students work together, use active problem solving, and defend their positions. Students improve their analytical skills and critically evaluate the answer options based on group ideas and opinions. Students teach one another as they collaborate and reach consensus on the best answer. Consistent peer to peer deliberate practice may improve retention of student learning (Johnson, 2016). Students develop knowledge and skills for team work and collaboration during the collaborative exam. The students describe the impact of their own communication style on others as they solicit input to improve individual and group performance. The collaborative exam promotes effective communication and conflict resolution. Students were able to speak freely and reported verbal and non-verbal behaviors were appropriate and respectful. Although the author was prepared to initiate actions to resolve conflict, this was never necessary. Debriefing included the lively group discussion and debate regarding each question. Faculty reported fewer negative and argumentative behaviors following the collaborative exams. This learning strategy integrates the QSEN competency of teamwork and collaboration as students identify their own strengths limitations, and values when functioning as a team member. Students assess their personal learning through the collaborative exam. A top performing student learned she had to be more assertive while some lower performing students learned they had misplaced confidence in their knowledge. Additionally, students are offered the Loma Linda (2006) Learning Assistance Program Objective Analysis Worksheet to identify areas of strengths and weaknesses following each exam. In conclusion, the collaborative exam can be easily adapted to any learning setting to promote learning and team work, decrease test anxiety, and motivate students (Hann, Roberts, & Hurley, 2016). The faculty benefit from hearing the group discussion and seeing enthusiasm replace the typical post-test anxiety. Submitted Materials: 227Collaborative-Exam-Evaluation-.docx - https://drive.google.com/open?id=1qHP8vAqFWdtE7146pm2trtc34o-GIJbF&usp=drive_copy Additional Materials: Collaborative Exam Evaluation Selected References Hann, K., Roberts, T., & Hurley, S. (2016). Collaborative testing as NCLEX enrichment. Nurse Educator,00(0), 1-4. Doi: 10.1097/NNE.0000000000000241 Johnson, C.E. (2016). The effect of deliberate practice combined with high-fidelity simulation scenarios on psychomotor skill competency and retention in prelicensure nursing education: A mixed methods study. Retrieved from ProQuest Dissertations and Theses database. (Mercer University No. 10302144). Peck, S., Stehle Werner, J.L., & Raleigh, D.M. (2013). Improved class preparation and learning through immediate feedback in group testing for undergraduate nursing students. Nursing Education Perspectives, 34(6), 400-404. Doi: 10.5480/11-507 Evaluation Description: Informal student and faculty feedback have been obtained over the three-year period of collaborative exam implementation. The areas explored informally have been included on the Collaborative Exam Evaluation template for student and faculty use.

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 Health Literacy Learning Activity 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: Patient-Centered Care Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Classroom, Clinical Setting Strategy Type: Case Studies Learning Objectives: Provide patient-centered care with sensitivity and respect for the diversity of human experience. Value seeing health care situations “through patients’eyes.” Examine common barriers to active involvement of patients in their own health care processes. Describe strategies to empower patients or families in all aspects of the health care process. Recognize the boundaries of therapeutic relationships. Strategy Overview: This learning activity works well with any level pre-licensure student, and is an excellent activity for a post clinical conference. The students will need to complete the following reading before this learning activity: Center on an Aging Society (1999) Low health literacy skills increase annual health care expenditures by $73 billion. Washington D.C.: Georgetown University. Accessed on the web 10/6/08 at: http://ihcrp.georgetown.edu/agingsociety/pubhtml/healthlit.html Center for Medicare Education.(2000).Considering health literacy. Issue Brief Vol. 1 No.6. Institute for Healthcare Advancement. (2008). Easy to use California advance health care directive. (pdf attached) Downloaded from the web on 10/6/08 at: http://www.iha4health.org/index.cfm/MenuItemID/266/MenuSubID/195.htm Instructions for the Instructor: This activity is to be done as a single post clinical conference experience ideally by the mid-term point in the rotation. The students will divide into pairs and perform the role of nurse or patient in a learning activity designed to illustrate the experience of having limited language skills similar to those experienced in situations of low health literacy. The role descriptions for the nurse and patient are attached as separate files. Following the Learning Activity: In Another’s Shoes, discuss the questions listed below. As part of this activity, share your own examples of forms, literature, etc. used in your organization that are written in an easy to read and easy to understand format. An evaluation follows this exercise. Students need to complete the evaluation and return it to you. At the end of the rotation, please return the learning activities evaluations to the course coordinator. Instructions for the Learning Activity: Divide students into pairs. Each student chooses one role (For example: Student A is the Nurse, Student B is the Patient) The student does not look at his/her partner’s instructions. Instruct the student to read the entire role sheet prior to starting the activity. Non-verbal communication can be used in this exercise. Students should role play for 2 – 3 minutes. Submitted Materials: 98.health-literacy-learing-activity-Evaluation.doc - https://drive.google.com/open?id=1YFTvxXzLZd9eH0F9LB_lEiFdFbDR1zmY&usp=drive_copy 98.QSEN_Learning_Activity_7_role_playing_instructions.doc - https://drive.google.com/open?id=1YFTvxXzLZd9eH0F9LB_lEiFdFbDR1zmY&usp=drive_copy Additional Materials: Evaluation Description: Following completion of the Learning Activity , use the following questions* as a guide for clinical instructor/student discussion: Tell about your experience in your role as nurse or patient. How does this exercise correlate to the frustrations experienced by nurses trying to provide health care information to clients who have low health literacy skills or limited ESL skills? How does this exercise correlate to the frustrations experienced by patients trying to assimilate healthcare information without relying on printed materials? What other factors might play a role in a patient’s understanding of health information? (For example: Medications that cause memory loss, sleep deprivation) What is health literacy? How can nurses assess illiteracy and adapt approaches to patient teaching? How does low health literacy skills impact patient outcomes? What resources are available on your unit or in your organization to assist patients with low health literacy skills? Why is it important to assess patient literacy? How does health literacy play a role in patient safety? * Reference: Young, J. & Ironside, P. Patient Teaching and Safety: Exploring Health Literacy. www.qsen.org An evaluation tool was used to collect student attitudes and feedback (attached document).

Published Back to Strategy Search Strategy Submission Reframing Constructive Criticism Using Reflection Based on QSEN Competencies Author: Gerry Altmiller EdD, MSN, APRN Title: Assistant Professor Coauthors: Institution: La Salle University Email: Altmiller@lasalle.edu Competency Categories: Safety, Teamwork and Collaboration Learner Level(s): Faculty Development Strategies, Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Clinical Setting Strategy Type: General Strategy Learning Objectives: Appreciate the importance of intra- and inter-professional collaboration Contribute to resolution of conflict and disagreement Appreciate the cognitive and physical limits of human performance Strategy Overview: Constructive criticism has been identified as a triggering event for incivility in nursing education. As part of professional development, it is essential that faculty create strategies to deliver constructive criticism without injuring with the faculty student relationship. This tool, while not all inclusive, provides examples of how constructive criticism can be reframed. Using the QSEN competencies, particularly the attitudes, as a guide, instructors can reframe their discussions with students regarding poor performance. With the instructor’s assistance, students can reflect on their performance and extract a realistic appraisal of the level of safe practice they have demonstrated, viewing it from the patient perspective. Such processes of reflection may help the student arrive at the conclusions that frequently are now communicated directly by the faculty member and so frequently serve as the triggering event for incivility in the faculty student relationship. Submitted Materials: 108.QSEN-Constructive-Criticism-Tool.doc - https://drive.google.com/open?id=1n2JkfiPECmbp6oAtiFaSwpbE23mfGPmG&usp=drive_copy Additional Materials: Evaluation Description: This tool was created to serve as an example of how direct constructive criticism of poor student performance can be reframed using the QSEN competencies. It has not been formally evaluated but has been offered as a strategy to reduce incivility in nursing education by improving communication techniques between faculty and students. Faculty can determine if it increases comfort level in situations of duress where student performance necessitates constructive criticism.

Published Back to Strategy Search Strategy Submission Quality-Safety Project Poster Author: Elizabeth Murray PhD, RN, CNE Title: Assistant Professor Coauthors: Institution: Florida Gulf Coast University School of Nursing Email: emurray@fgcu.edu Competency Categories: Quality Improvement, Safety, Teamwork and Collaboration Learner Level(s): Pre-Licensure BSN Learner Setting(s): Classroom, Clinical Setting Strategy Type: Independent Study Learning Objectives: Upon completion of this activity, students will: 1.Examine how the safety, quality, and cost-effectiveness of health care can be improved through the active involvement of patients and families. 2.Collaborate with team members to analyze quality and safety problems/issues in the clinical environment. 3.Use quality improvement tools to analyze processes of care, adverse events and medical errors, and improve care. 4.Participate appropriately in analyzing errors and designing system improvements. 5.Value the need for continuous improvement in clinical practice based on new knowledge. 6.Demonstrate commitment to team goals. 7.Demonstrate awareness of own strengths and limitations as a team member. Strategy Overview: The Quality-Safety Project Poster is an activity designed to expose students to the following processes: 1) identifying a quality-safety problem in the clinical arena; 2) using quality tools to analyze issues; and 3) determining an action plan to address the issues/problems. Students collaborate with team members and present Quality-Safety posters to the entire School of Nursing faculty and student body at the end of each semester. Around the fourth week of the semester, students discuss the quality movement, adverse events and medical errors, the IOM Six Aims, and QSEN competencies in class. Then students form a team of three to work together on a quality-safety project during the remainder of the semester. Students are given 10-20 minutes at the beginning of each class to meet and discuss their projects. The faculty is available during this time and meets with each team to address any questions and provide guidance. Following is an overview of the strategy (see submitted materials for specific student guidelines): • In-class Preparation for the Project: Students view the Lewis Blackman story available at http://qsen.org/faculty-resources/videos/the-lewis-blackman-story/ and review various quality improvement strategies that could be used to improve care such as root cause analysis and plan-do-study-act. In their teams, students work on a fishbone diagram related to the Lewis Blackman story. Teams compare and contrast their fishbone diagrams with other teams. • Students Identify a Clinical Problem/Issue for Team QI Project - students can select: o A clinical problem/issue identified during clinical practice. Examples include problems or issues related to staffing, patient safety, nurse safety, failure to meet practice standards, communication, etc…. o An adverse event or medical error identified during clinical practice. Examples include errors related to medication administration, standards of practice, procedures, near misses, etc…. • Each Team Completes a Fishbone Cause and Effect Diagram for the Specific Problem/Issue Identified • Teams Explore the Problem/Issue in Terms of National Quality and Safety Initiatives: Link the identified problem/issue to national quality or safety indicators from at least one of the following Organizations. Teams are encouraged to link to more than one: o The Joint Commission (TJC) o National Patient Safety Goals (NPSG) o National Quality Forum (NQF) o Agency for Healthcare Research and Quality (AHRQ) o Institute for Healthcare Improvement (IHI) o Institute for Safe Medication Practices (ISMP) o Healthy People 2020 o Others • Teams Explore the Problem/Issue in Terms of: o ANA Scope and Standards of Practice (2015) o ANA Code of Ethics with Interpretive Statements (2015) o Nursing Sensitive Indicators o Relevant state nurse practice acts, regulations, standards of nursing practice, nurse safety, patient safety, etc…. • Teams Explore the Problem/Issue in Terms of the Relevant QSEN Core Competencies • Teams Must Develop a Plan for Improvement Using the following QI Tools: o Plan-Do-Study-Act (PDSA) o Root Cause Analysis (RCA) using Fishbone Students present a poster at the end of the semester. All students in the class must visit other team posters and complete an evaluation form. Most faculty attend the poster session, ask students questions about their projects, and complete an evaluation form. Students from on-campus nursing classes are released at intervals to visit the posters. To ensure students being released from class attend the poster session, they are issued cards in class and must obtain stamps from the poster presenters. Submitted Materials: 174.-HO1.Guidelines-1-1.docx - https://drive.google.com/open?id=1E6e1SKLXxKFKFyGQMZqQ9TTfRS5nufUi&usp=drive_copy 174.-HO2.-Self-and-Peer-Assessment-1-1.docx - https://drive.google.com/open?id=1E4a3JVgqAf_6ybmBMChM7bmFJ1nuBxGk&usp=drive_copy 174.-HO3.-Faculty-Student-Evaluations-1-1-1.docx - https://drive.google.com/open?id=1Dop69c9H97bCR9UBZIczPHBh4xQ9GXmH&usp=drive_copy 174.-HO4.-Faculty-Evaluation-Form-1-1.docx - https://drive.google.com/open?id=1DfJ-TKWbOes4OmykX0HrfVg_rIRu5_Or&usp=drive_copy Additional Materials: Evaluation Description: Students are formally evaluated on their projects by course faculty as well as by faculty attending the poster session. During the poster session, students are observed by faculty answering questions and presenting their posters to others. Students are required to visit other team posters and complete an evaluation using the same evaluation criteria that faculty use. In addition, students are required to complete a self-evaluation and a peer assessment related to teamwork and collaboration.

Published Back to Strategy Search Strategy Submission Senior Nursing Student Capstone Clinical Integration Paper: Incorporating Quality and Safety Competencies Author: Susan DeSanto-Madeya RN, DNS Title: Assistant Professor Coauthors: JoAnn Mulready-Shick, EdD, RN, CNE Undergraduate Nursing Program Director Institution: College of Nursing and Health Sciences University of Massachusetts Boston Email: joann.mulreadyshick@umb.edu Competency Categories: Evidence-Based Practice, Informatics, Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration Learner Level(s): Pre-Licensure BSN, RN to BSN Learner Setting(s): Clinical Setting Strategy Type: Paper Assignments Learning Objectives: Learning Objectives: In writing this 10-12 page clinical integration paper, the senior nursing student will: Describe a nursing or patient care concern, issue, or problem encountered during the senior level clinical experience. Identify one or more of the QSEN competencies referring to the specific knowledge, skills, or attitudes and behaviors for that particular competency (ies) as outlined in the Cronenwett et al (2007) article. Analyze the significance of the concern for nursing practice in relation to the one or more QSEN competencies. (From different perspectives, what and why is it important to explore this concern or issue?) Complete a review of the literature related to the nursing or patient care concern and the associated QSEN competency. Provide a case exemplar from your clinical experience that exemplifies the nursing or patient care concern and its related QSEN competency(ies). Synthesize the nursing implications from recent literature to the specific concern or issue and include implications for these three areas: - P ractice- What did you determine was the best or preferred nursing practice for this concern, providing rationales and evidence? - Education- What are the current guidelines for educating staff about patient care or nursing practice related to this concern or issue, providing rationales and evidence? - Research- What are the priorities for further study, from a nursing clinical or professional perspective? Strategy Overview: Each student will write a paper relating a nursing care concern, issue, or problem, encountered during the senior clinical experience, to a particular QSEN competency (ies). The paper must include a selected case or exemplar that illustrates the clinical concern or issue. Implementation: Length of paper 10-12 pages, excluding title page and reference page. APA format, including headings and correct citations in farmacieproprie body of paper. The paper is due _______ in your student portfolio. Stages and processes for paper completion: 1. Identification of nursing or patient care concern or issue- Submit a typed paragraph describing the issue and related QSEN competency. Include annotated bibliography of 3 nursing and/or health care research articles. Submit by end of first month. Date due: Write a draft of the paper. Submit to clinical faculty by end of second month. Date due: Complete the Final paper, incorporating revisions from draft. Date due: Present your paper to clinical group classmates -either oral presentation and/or poster. Consider future submission to nursing conference or publication. Presentation due:_______ Submitted Materials: Additional Materials: Evaluation Description: Grading Criteria: This paper is a senior course requirement. Students must receive a 80% or better on this senior capstone clinical integration paper to pass this course. Introduction of the nursing or patient care concern, issue, or problem. Identification of its significance. Identification of related QSEN competency. 25 points Review of the literature- currency, inclusion of both the nursing or patient care concern and QSEN competency literature, use and scope of professional nursing and health care literature. 25 points Case study or exemplar illustrating the patient care or nursing issue or concern. 20 points Synthesis of nursing implications for practice, education, and research. 25 points Writing style, grammar, spelling, punctuation, and APA format. 5 points

Published Back to Strategy Search Strategy Submission "What Would You Do Walk-Through" Author: Sarita James PhD, RN-BC, CNE Title: Associate Professor Coauthors: Institution: Louisiana State University at Alexandria Email: sjames@lsua.edu Competency Categories: Patient-Centered Care, Safety, Teamwork and Collaboration Learner Level(s): New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Skills or Simulation Laboratories Strategy Type: General Strategy Learning Objectives: 1. Apply critical thinking and clinical judgment to identify priority patient-centered nursing intervention in the care of maternal-newborn patients. 2. Apply evidence-based practice in the demonstration of a basic assessment. 3. Demonstrate professional behaviors when prioritizing and managing safe care for a maternal-newborn patient. 4. Demonstrate effective use of technology and standardized practices that support safety and quality patient care. 5. Uses effective verbal communication with team members to help the patient achieve health care goals. Strategy Overview: Prioritization/Delegation Scenarios Maternal-Newborn Care “What would you do Walk -Through” Process: Students will approach five client beds each client within the simulation lab. Each client’s name is clearly designated at the head of the bed. Each client has orders, armbands, Kardex, report off sheet or an actual “report off” nurse, and explanation of the scenario. Students are to review each scenario as a clinical group, collaborate with clinical group, and after review of each patient, determine priorities and/or delegations of care. Students will be informed of the correct priorities at debriefing. Submitted Materials: Sim-Evaluation-and-Debriefing_Maternal-Newborn1-1.docx - https://drive.google.com/open?id=18-txd2rrBzGhdKQJjVLJeGavzEoo3nAD&usp=drive_copy Situational-Scenarios-for-Decision-and-Delegation-1-1.docx - https://drive.google.com/open?id=18at_pdQ3caNJojeil3kizo662XtcSPM9&usp=drive_copy Additional Materials: Description of the scenarios is attached here as well as the evaluation form. The actual chart, or scenario materials for each client are available by emailing sjames@lsua.edu . All documents are modifiable as the focus is to create an environment to assist students to prioritize patient care and use delegation skills where appropriate to help them prepare for entry into practice. Evaluation Description: Students participate with the simulation facilitator (faculty member) for a one-hour debriefing of the experience to identify their strengths/weaknesses, what went well, what could have been improved. Students are given an evaluation form to anonymously evaluate the experience and provide feedback.

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.