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After reviewing the 2012 QSEN Graduate Competencies, identify a quality/safety issue that you have seen in your practice or clinical setting.
Explain to your classmates the issue you have identified and the reasons why it is an issue. Include the potential negative outcomes that can arise if the issue is not resolved.

For example, you notice the provider is not following the American Cancer Society’s recommendation for cervical cancer screening. This issue in quality competency can lead to under-testing, over-testing, increased cost, and increased potential for surgical procedures. These factors can have negative consequences, such as higher risk for preterm labor, or infertility.

As you create your post, review the knowledge, skills and attitudes of the relevant competency regarding the quality/safety issue you have identified.

with refrences


Graduate-Level QSEN Competencies

Knowledge, Skills and Attitudes
September 24, 2012

The Robert Wood Johnson Foundation (RWJF) has made significant and ongoing contributions to ensure that
nursing professionals are provided the knowledge and tools needed to deliver high quality, safe, effective, and
patient-centered care. Much of this work has focused on nurses in entry-level roles. Beginning with Phase I,
the Quality and Safety Education in Nursing (QSEN) project, led by Dr. Linda Cronenwett, identified the
knowledge, skills, and attitudes (KSAs) that nurses must possess to deliver safe, effective care (Smith,
Cronenwett, & Sherwood, 2007). This phase met the challenge of preparing future nurses to continuously
improve the quality and safety of the healthcare systems within which they work. In Phase II, QSEN faculty,
a National Advisory Board, and 17 leaders from 11 professional organizations representing advanced nursing
practice defined graduate-level quality and safety competencies for nursing education and proposed targets
for the KSAs for each competency (Cronenwett et al., 2009). Additionally, in QSEN Phase III, RWJF funded
significant work at the American Association of Colleges of Nursing (AACN). This work developed the
capacity of faculty engaged in pre-licensure nursing education of all types to mentor their colleague faculty
members in the integration of the evidence-based content that will educate entry-level students about the six
QSEN competencies.
The growing focus on ensuring and measuring quality and efficiency of healthcare outcomes necessitates
markedly transformed graduate-level nursing education. In keeping with the Institute of Medicine’s report on
the Future of Nursing (2011), graduate nurses will be the future leaders in practice, administration, education,
and research. Due to healthcare reform, multiple changes in the delivery of care, and the number of
Americans with access to this care, the need for highly educated nurses will expand dramatically. It is
essential that these nurses understand, provide leadership by example, and promote the importance of
providing quality health care and outcome measurement.
In February 2012, RWJF engaged AACN in an effort to expand the reach of the national QSEN initiative in
graduate education programs. Building on work completed by AACN at the undergraduate level and also in
Phase II of the earlier QSEN initiative, this new project was launched to provide educational resources and
training to enhance the ability of faculty in master’s and doctoral nursing programs to teach quality and safety
competencies. During this phase of QSEN, AACN collaborated with expert consultants and stakeholders to
achieve four primary goals, specifically:

• Update and reach consensus on the quality and safety competencies that must be accomplished in a
graduate nursing program;

• Create learning resources, modules, and interactive case studies to help prepare graduates with the
competencies needed to provide quality and safe care across all settings;

• Host workshops to train faculty from over half of the nation’s graduate-level nursing programs and
their clinical partners to facilitate the implementation of the consensus-based competencies; and

• Develop a Web-based learning program, a speakers’ bureau, an online collaboration community, and
content-specific teaching materials for graduate-level faculty and their clinical partners.

In order to accomplish the first goal, AACN convened a panel of experts in the field of quality and safety
education and graduate-level practice as well as representatives of key stakeholder organizations. This
advisory group reviewed the existing QSEN graduate competencies, as well as AACN’s recently revised
Essentials of Master’s Education in Nursing (2011), to determine the competencies that graduate-prepared
nurses must possess to meet contemporary care standards.
The KSAs on pages 5-18 represent the advisory group’s consensus on the graduate-level quality and safety
competencies that are relevant to the existing standards for all graduate nursing education. Sections in bold
represent content from the 2009 Nursing Outlook article by Dr. Cronenwett and colleagues; the non-bolded
sections are the revisions recommended by the advisory group.



Definitions of QSEN Competencies

Quality Improvement (QI): Use data to monitor the outcomes of care processes and use
improvement methods to design and test changes to continuously improve the quality and safety
of healthcare systems.

Safety: Minimize risk of harm to patients and providers through both system effectiveness and
individual performance.

Teamwork and Collaboration: Function effectively within nursing and interprofessional teams,
fostering open communication, mutual respect, and shared decision-making to achieve quality
patient care.

Patient-centered Care: Recognize the patient or designee as the source of control and full
partner in providing compassionate and coordinated care based on respect for patient’s
preferences, values, and needs.

Evidence-Based Practice (EBP): Integrate best current evidence with clinical expertise and
patient/family preferences and values for delivery of optimal health care.

Informatics: Use information and technology to communicate, manage knowledge, mitigate
error, and support decision making.


Graduate-Level QSEN Competencies

Knowledge Skills Attitudes
Describe strategies
for improving
outcomes at all
points of care

Translate aims for
quality improvement

Align the aims,
measures, and changes
involved in improving

Commit to concepts of transparency,
managing variability measurement and

Describe nationally
accepted quality
measures and
benchmarks in the
practice setting

Use a variety of
sources of information
to review outcomes,
compare benchmarks
of care, and identify
potential areas for
improvement (e.g.,
National Database of
Nursing Quality
Indicators; Hospital
Compare; Center for
Medicare/ Medicaid
Services (CMS)
indicators, Joint
Commission: ORYX,
National Public Health
Performance Standards
and others)

Participate in analysis
of databases as sources
of information for
improving patient care

Use quality indicators
and benchmarks for
improving system
processes and outcomes

Commit to achieving the highest level of
processes and outcomes of care

Inspire others to achieve benchmark

Model behaviors reflective of a
commitment to high quality outcomes

Evaluate the
relevance of quality
indicators and their

Identify useful measures
that can be acted on to
improve outcomes and

Value the importance of the use of data
in quality improvement


Explain variance
and its common
causes in patient
care process and
outcomes including

Select and use quality
improvement tools
(e.g., run charts,
control charts, root
cause analysis, flow
diagrams and GANTT
charts) to achieve best
possible outcomes

Commit to reducing unwarranted
variation in care

Analyze ethical
issues associated
with continuous

Participate in the
design and monitoring
of ethical oversight of
continuous quality
improvement projects

confidentiality of any
patient information
used in quality
improvement efforts

Value ethical conduct in quality
improvement efforts

Value the roles of others, such as IRBs,
in assessing ethical and patient
rights/informed decision making

Analyze the impact
of context such as
access, cost,
workforce, team
functioning, or
engagement on

Lead improvement
efforts, taking into
account context and best
practices based on

Demonstrate commitment to process

Value context (e.g., work environment,
team functioning, social determinants)
as an important contributor in quality

principles of

Apply change
management principles
by using data to
improve patient and
systems outcomes

Appreciate that all improvement is

Demonstrate leadership in affecting the
necessary change

Evaluate the effect
of planned change
on outcomes

Design, implement,
and evaluate small
tests of change in daily
work (e.g., using an
experiential learning
method such as Plan-

Value planned change

Analyze the impact
of linking payment
to quality

Use benchmarks that
carry financial penalties
(e.g., serious reportable

Consistent with the National Quality
Strategy, commit to achieving the
highest quality of care in the practice


improvement events) to improve care setting (e.g., National Strategy’s aims of
Better Care, Healthy People, and
Affordable Care)

Describe the intent
and outcomes of
public reporting

Use public reporting
information to advance
quality improvement

Appreciate that consumers will be more
empowered to make decisions based on
quality information

Value community engagement in quality
improvement decision making

Knowledge Skills Attitudes
Analyze factors that
create a culture of safety
and a “just culture”

Use existing resources to
design and implement
improvements in practice
(e.g., National Patient
Safety Goals)

Use evidence and research-
based strategies to promote
a “just culture”

Commit to being a safety
mentor and role model

Accept the cognitive and
physical limits of human

Value a systems approach
to improving patient care
instead of blaming

Identify best practices
that promote patient,
community, and provider
safety in the practice setting

Integrate strategies and
safety practices to reduce
risk of harm to patients, self
and others
(e.g., risk evaluation and
mitigation strategy

Value the process of risk
reduction in health systems

Analyze human factors
safety design principles as
well as commonly used
unsafe practices (e.g.,
work-arounds, risky
behavior, and hazardous

Demonstrate leadership
skills in creating a culture
where safe design principles
are developed and

Engage in systems focus
when errors or near misses

Promote systems that
reduce reliance on memory

Appreciate the role of
systems problems as a
context for errors

Accept the limitations of


Identify effective strategies
to promote a high reliability

Create high reliability
organizations based on
human factors research

Report errors and support
members of the health
care team to be
forthcoming about errors
and near misses

Anticipate/prevent systems

Commit to working to
achieve a high reliability

Value the contribution of
standardization and
reliability to safety

Value open and honest
communication with
patients and families about
errors and hazards

Encourage reporting of
errors as a foundational
element to improve quality
and systems

Describe evidence-based
practices in responding to
errors and good catches

Use evidenced-based best
practices to create policies
to respond to errors and
“good catches”

Value the use of
organizational error and
reporting systems

Identify process used to
analyze causes of error
and allocation of
responsibility and
accountability (e.g., root
cause analysis and failure
mode effects analysis)

Design and implement
microsystem changes in
response to identified
hazards and errors

Commit to identification of
errors and hazards

Commit to individual
accountability for errors

Summarize methods to
identify and prevent
verbal, physical and
psychological harm to
patients and staff

Encourage a positive
practice environment of
high trust and high respect

Develop culture where
hostile work environment is
not tolerated.

Use best practices and legal
requirements to report and
prevent harm

Value a work and patient
care culture where dignity
and respect are fostered
inclusive of prevention of
assaults and loss of dignity
for patients, staff and

Analyze potential and
actual impact of national
patient safety resources,
initiatives and regulations
on systems and practice

Use national patient safety
resources to design and
implement improvements in

Value the relationship
between national patient
safety campaigns and
implementation of system
and practice


Teamwork and Collaboration
Knowledge Skills Attitudes

Analyze self and other team
members strengths,
limitations, and values

Demonstrate awareness of
personal strengths and
limitations as well as those
of team members

Value the contributions of
self and others to effective
team function

Understand the roles and
scope of practice of each
interprofessional team
member including patients,
in order to work effectively
to provide the highest level
of care possible

Work with team members
to identify goals for
individual patients and

Function competently
within own scope of
practice as a member of
the health care team

Ensure inclusion of patients
and family members as part
of the team based on their
preferences to be included

Respect the centrality of
the patient/family as core
member of any health
care team

Value the team approach to
providing high quality care

Analyze the impact of
team-based practice

Act with integrity,
consistency, and respect
for differing views

Continuously plan for
improvement in self and
others for effective team
development and

Commit to being an
effective team member

Be open to continually
assessing and improving
your skills as a team
member and leader

Analyze strategies for
identifying and managing
overlap in team member
roles and accountabilities

Guide the team in
managing areas of overlap
in team member

Use effective practices to
manage team conflict

Elicit input from other
team members to improve
individual, as well as
team, performance

Value conflict resolution as
a means to improve team

Support the development of
a safe team environment
where issues can be
addressed between team
members and conflict can
be resolved


Analyze strategies that
influence the ability to
initiate and sustain
effective partnerships with
member of nursing and
interprofessional teams

Initiate and sustain
effective health care teams

Integrate into practice
competencies as developed
(e.g., IPEC teamwork,
understanding each other’s
roles, communication)

Commit to interprofessional
and intraprofessional

Analyze impact of cultural
diversity on team

Communicate with team
members, adapting
communication style to the
needs of team and situation

Commit to cultural humility
within the team

Analyze differences in
communication style and
preferences among
patients and families,
nurses, and other members
of the health team

Communicate respect for
team member competence
in communication

Value different styles of

Describe strategies to
integrate patients/families
as primary members of the
healthcare team

Use patient-engagement
strategies to involve
patients/families in the
healthcare team

Value patients/families as
the source of control for
their health care

Describe strategies to
engage patients, families
and communities in health
promoting activities and

Use participatory
engagement strategies to
involve patients, families
and communities as
partners in promoting
healthy behaviors

Value equitable partnership
with patients, families and
communities in determining
health promotion priorities
and strategies

Describe appropriate
handoff communication

Use communication
practices that minimize
risks associated with
handoffs among providers
and across transitions of

Appreciate the risks
associated with handoffs
among providers and
across transitions in care

Analyze authority
gradients and their
influence on teamwork
and patient safety

Choose communication
styles that diminish the
risks associated with
authority gradients among
team members

Value the solutions
obtained through
collaborative efforts


Assert own position,
perspectives, and
supporting evidence in
discussion about patient

Identify system barriers
and facilitators of effective
team function

Lead or participate in the
design and
implementation of systems
that support effective

Value the influence of
system solutions in
achieving team

Examine strategies for
improving systems to
support team functioning

Apply state and national
policy efforts to practice
setting that improve
teamwork and

Value the importance of
state and national policy
work in setting standards
for improvement of
teamwork and collaboration

Patient-Centered Care
Knowledge Skills Attitudes
Analyze multiple
dimensions of patient-
centered care including
preferences and values, as
well as social, cultural,
psychological, and spiritual

Based on active listening to
patients, elicit values,
preferences, and
expressed needs as part of
clinical interview,
diagnosis, implementation
of care plan as well as
coordination and
evaluation of care

Commit to the patient being
the source of control and
full partner in his/her care

Analyze the factors that
create barriers to patient-
centered care

Identify and create plans to
address barriers in care
settings that prevents fully
integrating patient-centered

Commit to system changes
to create a patient-centered
care environment

Synthesize critical
information about health
literacy based on diversity
of patient population

Assess patients’
understanding of their
health issues and create
plans with the patients to
manage their health

Commit to patient-centered
collaborative care planning.

Accept that health literacy
is a problem in safe care,
especially during the
transition to home-based

Value diversity of health
literacy levels among
patient populations


Analyze the effectiveness of
methods to engage specific
patients as partners in their
health care

Effectively work with
patients to engage them in
their health care as they
deem appropriate for them

Respect preferences of
patients related to their level
of engagement in health
care decision-making.

Analyze patient-centered
care in the context of care
coordination, patient
education, physical comfort,
emotional support, and care

Work with patients to create
plans of care that are
defined by the patient

Commit to respecting the
rights of patients to
determine their care plan to
the extent that they want

Analyze ethical and legal
implications of patient-
centered care

Work to address ethical and
legal issues related to
patients’ rights to determine
their care

Respect that legal and
ethical issues provide a
framework for patient-
centered care

Describe the limits and
boundaries of patient-
centered care

Support patients in their
decisions even when the
decision conflicts with
personal values

Respect the boundaries of
therapeutic relationships

Analyze concepts related to
conflictual decision making
by patients

Assess level of patient’s
decisional conflict and
provide appropriate
support, education and

Respect the complexity of
decision making by patients

Analyze personal attitudes,
values, and beliefs related
to patient- centered care

Continuously assess and
monitor own efforts to be

Commit to continuously
assess own participation in
patient-centered care

Analyze strategies that
empower patients or
families in all aspects of
the health care process

Engage patients or
designated surrogates in
active partnerships along
the health-illness

Eliminate barriers to
presence of families and
other designated
surrogates based on
patient preferences

Respect patient preferences
for degree of active
engagement in care process

Honor active partnership
with patients or
designated surrogates in
planning, implementation,
and evaluation of care

Value the involvement of
patients and families in care

Analyze features of
physical facilities that
support or pose barriers
to patient-centered care

Create organizational
cultures so that patient
and family preferences
are assessed and

Appreciate physical and
other barriers to patient-
centered care


Assessment of research that
exists for physical designs
that promote patient-
centered care: (e.g.,
modules or pods concepts,
low barriers for children,
color designs that support
rest and stress reduction,

Evidence-based practice
Knowledge Skills Attitudes
Demonstrate knowledge of
health research methods
and processes

Use health research
methods and processes,
alone or in partnership
with scientists, to generate
new knowledge for

Appreciate strengths and
weaknesses of scientific
bases for practice

Describe evidence-based
practice to include the
components of research
evidence, clinical
expertise, and

Role model clinical
decision making based on
evidence, clinical
expertise, and

Value all components of
evidence-based practice

Identify efficient and
effective search strategies
to locate reliable sources
of evidence

Employ efficient and
effective search strategies
to answer focused clinical
or health system practices

Value development of
search skills for locating
evidence for best practice

Identify principles that
comprise the critical
appraisal of research

Critically appraise
original research and
evidence summaries
related to area of practice

Value knowing the
evidence base for one’s
practice specialty area

Summarize current
evidence regarding major
diagnostic and treatment
actions within the practice
specialty and healthcare
delivery system

Exhibit contemporary
knowledge of best
evidence related to
practice and healthcare

Value cutting-edge
knowledge of current

Determine evidence gaps
within the practice
specialty and healthcare
delivery system

Promote a research
agenda for evidence that is
needed in practice
specialty and healthcare

Value working in an
interactive manner with the
Institutional Review Board


Actively engage with the
institutional review board to
implement research
strategies and protect
human subjects

Identify strategies to
address gaps in evidence
based guidelines

Use quality improvement
methods to address gaps in
evidence based guidelines

Appreciate the gaps in
evidence related to practice

Develop knowledge that
can lead the translation of
research into evidence-
based practice

Build consensus among key
stakeholders through the
use of change theory to
create evidence-based care

Lead and marshal the
resources for change that
supports evidence-based

Champion the changes
required that support
evidence-based practice

Analyze how the strength
of available evidence
influences care-
(assessment, diagnosis,
treatment, and evaluation)

Implement care practices
based on strength of
available evidence

Appreciate the strength of
evidence on provision of

Evaluate organizational
cultures and structures
that promote evidence-
based practice

Participate in designing
organizational systems that
support evidence-based

Appreciate that
organizational systems can
significantly influence
nursing’s efforts in
evidence-based practice

Understand the need to
define critical questions
related to practice and
healthcare system delivery

Use coaching skills to
engage nurses in evidence
based practice and research

Appreciate that all nurses
can participate in creating
evidence-based practice

Knowledge Skills Attitudes
Analyze systems theory and
design as applied to health

Use performance
improvement tools (e.g.,
Lean, Six Sigma, PDSA) in
system analysis and design
to assess use of technology
to improve care)

Use project management
methods in relation to
implementation of new

Value systems thinking and
use of technology to
improve patient safety and

Appreciate the Systems
Development Lifecycle
(SDLC) in the design of
information systems


Model behaviors that
support theories and
methods of change

Evaluate benefits and
limitations of common
information systems
strategies to improve safety
and quality

Evaluate the strengths
and weaknesses of
information systems in

Participate in the
selection, design,
implementation, and
evaluation of information

Consistently communicate
the integral role of
information technology in
nurses’ work

Model behaviors that
support implementation
and an appropriate use of
electronic health records

Assist team members in
adopting information
technology by piloting and
evaluating proposed
information technologies

Participate in the design
of clinical decision
supports (CDS) systems
(e.g., alerts and reminders
in electronic health
Anticipate unintended
consequences of new

Recognize nursing’s
important role in selecting,
designing, implementing
and evaluating health
information systems for
practice environments.

Appreciate the need for an
interprofessional team to
make final decisions related
to selection and use of new
information systems

Value the use of
information technologies
in practice

Know the current regulatory
requirements for
information systems use

Use federal and other
regulations related to
information systems in
selecting and implementing
information systems in

Appreciate the role that
federal regulation plays in
developing and
implementing information
systems that will improve
patient care and create more
effective delivery systems

Identify the critical and
useful electronic data
needed to provide high
quality, efficient care

Search, retrieve, and
manage data to make
decisions using
information and

Appreciate the importance
of valid, reliable and
significant data to improve
quality and provide efficient


through effective decision
support (clinical, financial
and administrative

knowledge management

Use the existing coding and
billing system to
appropriately reflect the
level and type of service
delivered in practice

Model behaviors that
support implementation and
appropriate use of data
accessed through databases,
electronic health records,
dashboards, remote
monitoring devices,
telemedicine and other

and effective care

Evaluate benefits and
limitations of different
health information
technologies and their
impact on safety and

Promote access to patient
care information for all
who provide care

Serve as a resource for
documentation of nursing
care at basic and
advanced levels

Develop safeguards for
protected health

Comply with HIPAA
regulations in the use of
electronic health records
and other sources of
patient information.

Champion communication
technologies that support
clinical decision-making,
error prevention, care
collaboration, and
protection of patient

Appreciate the need for
consensus and
collaboration in
developing systems to
manage information in

Value the confidentiality
and security of all
electronic information


Understand how technology
can be used to engage and
empower patients as
partners in managing their
own care

Model behaviors that
support the use of consumer
informatics (e.g., consumer
website, social networking,
telemedicine, e-visits,

Access and evaluate the use
of mobile technologies
(e.g., sensing devices,
mobile communication
devices, smart phones and
other devices) to improve
quality and safety

Appreciate the benefits of
innovation for improving
patient safety and quality

Describe and critique
taxonomic and
terminology systems used
in national efforts to
enhance interoperability
of information systems
and knowledge
management systems

Access and evaluate high
quality electronic sources of
health care information

Support efforts to develop
interoperable regional
health information systems

Value the importance of
terminologies in
conducting searches for

Appreciate the
contribution of
information technology to
improve patient safety
(e.g, alerts reminders and
other forms of CDS)

Appreciate the time,
effort, and …

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