Significant changes in the healthcare environment have occurred that offer challenges for quality improvement and nursing education programs, and thus impact both nursing practice and education. We formed an academic-practice partnership to actively engage students enrolled in an undergraduate nursing research course in quality processes with participation in a medical center’s performance improvement program. This article describes the development of the partnership; and projects, results, and implications for practice. Students worked collaboratively in groups with hospital staff performance improvement preceptors and a course faculty member. Using the Plan, Do, Check, Act (PDCA) model, students collected, analyzed, and disseminated data from existing projects, or those for which the organization had identified a need. Leaders involved in the inception of this partnership agreed that it achieved its goals of enabling the college to effectively teach recently mandated quality improvement methodologies to achieve competency and enhancing the medical center’s capabilities to obtain data for quality improvement purposes. The academic-practice partnership continues to evolve, and we offer discussion about lessons learned and partnership growth.
Key words: Safe care, Quality Improvement, QI methodologies, Academic-Practice Partnership, Collaborative, nursing research, nursing competencies, Continuous Improvement, Process Improvement
No other health care provider is in a better position to ensure that safe, quality healthcare is available to all patients than nurses providing bedside care. Staff nurses are expected to be involved in collecting quality improvement data on a regular basis as part of their daily work through activities such as reporting falls and adverse drug events. However, many do not graduate from nursing programs with the knowledge, skills, or attitudes necessary to move beyond the task of reporting. With the ever increasing demand to provide safe, quality care and document its achievement, it is imperative that hospitals have a pool of graduate nurses prepared to participate in quality improvement upon hiring. One way to accomplish this is for healthcare quality improvement departments and academic nursing programs to come together to provide nursing students with basic knowledge, skills, and attitudes related to quality improvement.
The United States has and is continuing to undergo changes in its healthcare system that significantly impact quality improvement programs and nursing education. The nursing profession began to conduct research related to patient safety and quality of care in 1994 through the American Nurses Association (ANA) Safety and Quality Initiative (Montalvo, 2007). This research led to the development of the National Database of Nursing Quality Indicators® (NDNQI) that consists of 13 nursing-sensitive outcomes which measure the value of nurses in promoting safe, quality patient care (ANA, n.d.; Montalvo, 2007). To Err is Human: Building a Safer Health System (Institute of Medicine [IOM], 1999) informed both healthcare providers and the American public that healthcare was not as safe as it should be and identified the human and financial costs of medical errors, factors contributing to medical errors, and strategies for improvement. In 2000, the Agency for Healthcare Research and Quality (AHRQ) received a $50 million Congressional appropriation to broaden research, provide support, and develop demonstration projects; the term “never event” was coined (IOM, 1999). Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) provided six specific aims, applicable to all health constituencies, to achieve substantial improvements in healthcare. These aims stated that healthcare should be safe, effective, patient centered, timely, efficient, and equitable. In 2002, the Health Quality Alliance (HQA) formed a public/private collaborative effort that represented diverse stakeholders with a goal to make easily understood information related to hospital performance available to the public (Jha, Li, Orav, & Epstein, 2005).
Recognition of the need to prepare students in the health professions to provide safe, quality healthcare occurred with the publication of Health Professions Education: A Bridge to Quality (IOM, 2003) which stated that, “Educators and accreditation, licensing and certification organizations should ensure that students and working professionals develop and maintain proficiency in five core areas: delivering patient-centered care; working as part of interdisciplinary teams; practicing evidence-based medicine; focusing on quality improvement and using information technology” (p.4). The Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI) (2003) recognized the need to support and educate professional staff through preceptorships and educational opportunities to promote quality care on medical-surgical units through their program Transforming Care at the Bedside.
QSEN has established nursing pre-licensure competencies for knowledge, skills, and attitudes in the areas of quality and safety... The RWJF provided initial funding for Quality and Safety Education for Nurses (QSEN) to evaluate and enhance nursing school curricula on the topics of quality and safety (Quality and Safety Education for Nursing [QSEN], 2012). In 2009, the RWJF awarded The American Association of Colleges of Nursing (AACN) and the University of North Carolina School of Nursing grants to conduct an innovative and far-reaching project aimed at preparing nurses with the knowledge, skills, and attitudes necessary to improve the quality and safety of the healthcare systems in which they work (QSEN, 2012). QSEN has established nursing pre-licensure competencies for knowledge, skills, and attitudes in the areas of quality and safety as well as other areas (QSEN, 2009). In 2008, the AACN revised the Essentials of Baccalaureate Education for Professional Nursing (AACN, 2008) to require that students in these programs participate in the process of retrieval, appraisal, and synthesis of evidence by collaborating with members of the healthcare team to improve patient outcomes.
In summary, The Future of Nursing: Leading Change, Advancing Health (IOM, 2010) states that nurses should be full partners in redesigning healthcare by taking responsibility for identifying problems; developing and implementing improvement plans; tracking improvements; and making changes to achieve established goals. No other health care provider is in a better position to ensure that safe, quality healthcare is available to all patients than nurses providing bedside care. To take advantage of their position, nurses must understand and have the skills necessary to participate in the quality improvement process. Both hospital quality improvement and nursing education programs face challenges in providing these skills.
Nursing staff often collect and report data... but are not actively involved in developing improvement plans or outcomes... Quality improvement (QI) staff cannot be expected to collect, monitor, and report all data necessary and required for agencies such as The Centers for Medicare/Medicaid and The Joint Commission. Nursing staff often collect and report data, in areas such as patient falls and medication errors, through a hospital’s mandatory reporting system, but are not actively involved in developing improvement plans or outcomes for these patient safety measures. There are several factors that impact the nurse’s ability to participate in these efforts. First, the average age of the nursing workforce was 47 years in 2008 and was expected to be 44.5 years by 2012 (AACN, 2012b). Twenty-two or more years ago, when these nurses graduated, QI was not part the health care system nor part of the nursing curriculum. Therefore, staff nurses providing bedside care may not have acquired, through experience or entry level education, the knowledge, skills, or attitudes to fully participate in Quality Improvement as it is evolving today.
...many nursing faculty may be educationally or experientially unprepared to teach students the QI process. Most nursing programs are in the process of integrating QSEN competencies into their curricula, but curriculum change is a slow process. Baccalaureate nursing programs are making, or have made, curricular changes to ensure graduates fulfill the Essentials of Baccalaureate Education for Professional Nursing (AACN, 2008). The average age of masters and doctorally prepared faculty of all ranks is greater than 55 years of age (AACN, 2012a). With this average age, many nursing faculty may be educationally or experientially unprepared to teach students the QI process. Challenges facing QI in the health care setting and nursing education programs can be compatible. Progress toward meeting the needs of both can be achieved through the formation of academic-practice partnerships. The partnership described in this article brought together staff from a hospital QI department and baccalaureate nursing program faculty to guide students through developing and implementing a QI project.
An academic-practice partnership enables partners to develop mutual goals, share knowledge, and meet the needs of both groups. An academic-practice partnership enables partners to develop mutual goals, share knowledge, and meet the needs of both groups. The AACN and American Association of Nurse Executives (AONE) developed and published guiding principles to develop and sustain effective academic-practice partnerships (AACN, 2010) and an academic-practice partnerships tool kit to assist potential partners in developing new academic-practice partnerships (AACN, n.d.). The partnership described in the remainder of this article was informally established before the guidelines and tool kit were published, but has evolved to incorporate many of these principles.
Our partnership began when the faculty teaching the undergraduate nursing research course voiced a strong belief that teaching nursing research in the classroom environment using traditional methods was not effective. Initially, faculty designed research projects that the students could conduct with a convenience sample of other nursing students, faculty, and staff of the college. These early projects included comparing manual to electronic blood pressure readings and comparing blood glucose levels obtained by finger-stick with three finger cleaning methods. These projects were effective in moving the research course beyond the classroom and were applicable to best clinical practice, but did not benefit anyone except the students in the course.
The course faculty then reached out to the infection control manager and chief nursing officer of a hospital closely associated with the college to involve students in infection control projects. Course faculty designed the projects, which were approved by the hospital’s operating committee. The initial infection control project was observation of staff nurses’ hand hygiene compliance with the Centers for Disease Control and Prevention (CDC) guidelines, followed by surveying nurses about their knowledge of the CDC guidelines and reasons for complying or not complying. As a result of this project, approximately 200 additional alcohol based hand hygiene dispensers were placed throughout the hospital, and the seeds for an academic-practice partnership were planted. A second infection control project was implemented in which students cultured portable phones carried by nurses, with the hospital laboratory providing the culture media and analysis of the cultures. Not surprisingly, the cultures grew organisms associated with hospital acquired infections. Results of this project led to the identification and adoption of a cleaning product with residual action throughout the hospital. These two projects benefited the hospital, patients, and students, and the academic-practice partnership grew into a more formal structure.
Developing the Partnership between a College of Nursing and a Hospital Performance Improvement Department
Our shared vision was that students would become familiar with the QI process by using the basic Plan, Do, Check, Act (PDCA) process to implement priority QI activities. The hiring of a new Vice President for Performance Improvement (PI), a doctorally prepared RN with experience in nursing education and joint QI projects with graduate nursing students, brought the partnership to a new level. Prior to the beginning of the 2011 fall semester, the Introduction to Nursing Research course faculty; staff in the PI Department; and Vice President for Performance Improvement met to begin developing the partnership and identifying projects in which students could participate during the upcoming semester. Our shared vision was that students would become familiar with the QI process by using the basic Plan, Do, Check, Act (PDCA) process to implement priority QI activities. The mutual goals that we developed identified projects that 1) could be completed within the time frame of the course, and 2) were appropriate for student participation and level of knowledge. Project results would be presented as PDCA posters in the hospital cafeteria during National Healthcare Quality Week and at an area undergraduate nursing research symposium (See Figure for example). Members of the PI staff and the Vice President for PI agreed to work with student groups as mentors alongside the course faculty throughout the semester. The nursing research course faculty revised the course to add content comparing and contrasting the research process to the QI process and scheduling “time back,” or compensatory time, for project data collection, analysis, and poster presentations in the course calendar. The Vice President for PI agreed to cover the expense of having student posters professionally printed. The projects completed during the first semester of the partnership related to 30 day pneumonia readmissions; deep vein thrombosis prophylaxis; availability and use of personal protective equipment for isolation rooms; and TeamSTEPPS™ (U.S. DHHS, n.d.) implementation as a problem solving/communication tool for nursing.
Five projects were implemented during the second semester of the partnership. The first project stemmed from unacceptably high 30 day readmission rates for pneumonia. Nurses’ perceptions of why pneumonia immunization status was not documented on charts were obtained and analyzed. The results indicated that both physicians and nurses lacked accurate information related to indications for and contraindications to the immunization; therefore it was neither ordered nor given. In a second project, charts of patients readmitted within 90 days of discharge were reviewed and patients and/or families interviewed regarding perceived reasons for readmission. The most striking results indicated that, although discharge teaching was documented on over 90% of readmitted patient records, 50% of patients had not seen a physician between discharge and readmission, and over 30% cited medication problems as the reason for readmission. A third project involved the evaluation of the incorporation of TeamSTEPPS™ in the hospital’s nursing on-boarding process. Data suggested that new graduates were more satisfied with their orientation when they conducted “briefs” and “debriefs” with their preceptors and that the number of preceptors had a negative effect on the frequency of “briefs” and “debriefs” (U.S. DHHS, n.d.). As a result, efforts were made to limit the number of preceptors for new graduates and charge nurses were encouraged to ensure that “briefs” and “debriefs” were conducted. An increase in the rate of improperly timed, dated, and illegibly signed orders identified during routine chart reviews led to an educational campaign, led by our students, for both physicians and nurses to raise awareness of the importance of signing, dating, and timing orders. In the final project, patients were interviewed about their satisfaction with culturally sensitive care and were found to be satisfied.
As the partnership continued, four projects started in fall semester 2012, all of which addressed medication reconciliation issues. The “teach-back” method to ensure that patients understood new medications was reinforced in the emergency department (ED) of the hospital through the use of email reminders, handouts at staff meetings, and adding teach-back information to a “huddle” notebook. When it was determined that 60% of the ED nurses knew about the teach-back method, but only 50% used it to educate patients, content included in a peer communication tool (such as the huddle) helped to keep this information in the forefront of nurses' thoughts (NC Program, 2011).
Patient-maintained medication lists can be critical to medication reconciliation when a patient is admitted to the hospital, visits an ED, or sees multiple health care providers. Students surveyed patients admitted to the ED to determine if they had a patient-maintained medication list and, if the patient had a list, what was included on it, whether it was carried at all times, and if it was current. Results of the survey showed that there was a significant opportunity to reduce potential medication reconciliation errors in this setting by educating patients about the importance of patient maintained medication lists. The vast majority of patients under age 65 years did not have a patient-maintained medication list, and only 67% of patients 65 years or older had lists. Of those who had patient maintained medication lists, many were not current and did not include over the counter (OTC) medications, vitamins, or other supplements.
Anticoagulants are classified as medications that increase the risk of hospital readmission. A Lovenox® project was instituted on an orthopedic unit where it was found that, although 100% of nurses surveyed were aware of the Lovenox® take home kit and its contents, they did not always witness patients administer it prior to discharge or document that teaching was completed. This led students to create and/or use a Lovenox® information sheet for patients; a nurse discharge checklist; information posters to hang around the unit; a Lovenox® information video (Sanofi-Aventis, n.d.) for both nurses and patients; and the establishment of a Lovenox® TV channel for the hospital.
The fourth project for the semester identified and analyzed nurses’ perceptions of barriers to medication reconciliation. Students found that 72% of nurses found medication reconciliation to be fairly or very difficult and time consuming, with 54% of nurses spending and average of 15 to 20 minutes per reconciliation. Sixty percent of nurses did not believe the medication lists they received were accurate; only 88% believed they included all prescription medications; and fewer than 50% believed the lists contained OTC medications, vitamins, and supplements. Using a Pareto chart (ASQ, 2004) to analyze characteristics of patients for whom nurses found medication reconciliation most difficult, the following characteristics accounted for more than 65% of the difficulty: confused/nonresponsive patients; patients taking 16 or more medications; and patients >75 years of age.
Projects underway at the time this article was written included: 1) application of “Medication Reconciliation Alert ≥16 Medications” stickers on the charts of patients who qualify for this designation on two nursing units, with a survey related to the stickers’ effectiveness to follow; 2) analysis of post fall data for the last two quarters of 2012 (which is anticipated to trigger revision of the post fall data tool and identify specific areas of fall prevention needing improvement); 3) auditing the effective use of specialty beds in the intensive care unit with subsequent cost analysis of renting versus purchasing specialty beds; and 4) the impact of patient journaling for patient satisfaction with communication with doctors and nurses on one unit. Nurse managers and PI staff collaborated to prioritize the projects to be implemented.
As with almost every new endeavor, we encountered some unanticipated obstacles, but believe we learned from them. Following the first semester of the partnership, faculty and PI staff met to evaluate the initiative and discuss lessons learned in order to improve the process. We believed that the partnership achieved its vision that students acquire the knowledge and skills to participate in QI upon graduation and that project results were useful to the PI staff. Our lessons learned supported that we should indeed take time to develop the academic-practice partnership to ensure positive experiences for everyone involved.
Our shared enthusiasm for beginning the partnership with only two weeks of planning before the semester start was too ambitious. Our shared enthusiasm for beginning the partnership with only two weeks of planning before the semester start was too ambitious. During the first semester, we found that we needed to more carefully select projects in the future, and PI staff needed to be better oriented to the research course objectives and content. PI staff also needed access to the course syllabus and textbook so they could conceptualize course requirements and help students see relationships between what they learned in class and what they were doing with their QI projects. Faculty needed to provide a thorough course orientation, clear description of assignments, and clear delineation of how allotment of class time and “time back” fit within the credit hour allocation for the course. They also needed to ensure integration of the research process with QI methodology and help students compare and contrast these two processes throughout the course. Regular meetings with student project groups, PI staff mentors, and course faculty needed to be incorporated into the course calendar, preferably during regularly scheduled class times.
We also needed to establish an effective method of communication among students, PI mentors, and faculty. If the project for which students were collecting data required access to charts of discharged patients, early computer access to that data for students was essential and required coordination with the practice setting’s information technology department as well as lead time until data could be accessed. The PI staff and faculty needed to identify research questions prior to student involvement. If the project required a data collection tool, we needed to identify either an existing tool or faculty and QI mentors needed to work together to develop a tool (as tool development was beyond the scope of students' ability).
These lessons learned paved the way to a strong partnership with mutual respect, trust, and shared decision making, responsibility, and knowledge. Prior to beginning the second semester of the partnership, we were able to implement many of the lessons learned. We resolved communication issues and PI staff access to course content by having PI mentors added as instructors to the web-based nursing research course platform. This allowed students, faculty, and PI mentors to communicate through course email and discussions and gave PI mentors full access to course content. Faculty made additional course revisions; scheduled set meeting times for students, mentors, and faculty on the course calendar; and communicated with the hospital’s information technology department to ensure that students would have access to needed data. These lessons learned paved the way to a strong partnership with mutual respect, trust, and shared decision making, responsibility, and knowledge. Moving forward, students have implemented projects which have provided useful data and many have led to significant implications for practice and improvement in the organization.
Partnership and Growth
Students have indicated that they feel a real sense of accomplishment that they have contributed to the goal of providing safe, quality care for patients as part of a team. The partnership is not static but continues to evolve to take advantage of new opportunities and ideas. Now in its fourth semester, the partnership has completed 13 projects with four more in progress. Approximately 120 students have participated in the partnership, and approximately 90 students have graduated with the knowledge and skills necessary to actively contribute to the quality improvement process as new graduate staff nurses. Many of the graduates were hired by the medical center participating in the partnership.
All students have disseminated the results of their projects either as poster or podium presentations at area research symposiums (Figure). Additionally students have disseminated results by presentations to hospital staff through the medical center’s Practice and Research Councils, the PI Group, National Quality Week, and the Senior Management Team. Student posters have been displayed as exemplars for both the college’s and medical center’s successful national accreditation visits. Patients and visitors were encouraged to review all posters during National Quality Week.
Two students, a course faculty member, and the Vice President for PI have submitted results of the medication reconciliation project for publication in a peer reviewed nursing journal. Since the inception of our partnership, the hospital and college also have joined forces to establish a Center for Nursing Research and Innovation and a dedicated education unit (DEU) for students. While the dean of the college, the chief nursing officer and chief executive officer of the medical center were the leaders in developing these joint efforts, we hope and believe that our partnership set an example for these collaborative endeavors.
The students’ projects, which have been implemented on a number of different nursing units, appear to have created a “trickle-down effect.” Unit managers and hospital committees now actively participate in the development and implementation of student projects. Staff nurses readily agree to complete surveys and interviews related to the projects and are eager to learn the results. Nurse managers and staff nurses share their knowledge with students in a way that is beyond what students experience in their clinical rotations. Students have indicated that they feel a real sense of accomplishment that they have contributed to the goal of providing safe, quality care for patients as part of a team. There is no doubt that the partnership has benefitted both students and the PI Department.
Despite the emphasis on QI in hospitals and nursing education’s incorporation of QSEN pre-licensure competencies into curricula, we have a long way to go. Nearly thirty-nine percent of new graduates thought they were “poorly” or “very poorly” prepared to implement QI measures and “not at all prepared” to use QI techniques (Kovner, Brewer, Yingrengreung & Fairchild, 2010). Although baccalaureate degree nursing (BSN) graduates reported significantly higher preparation than associate degree graduates in such skills as data collection, analysis, measurement, and measuring change, they were unprepared to implement QI measures (Kovner et al., 2010). As a result of their research, Kovner et al. (2010) recommended that nurse educators and hospitals partner to more effectively implement QI education and that QI projects be made a specific requirement for graduation.
In the first randomized sample of early-career registered nurses (RNs), Djukic, Kovner, Brewer and Bernstein (2013) compared two cohorts for participation in QI activities. The authors anticipated that there would be differences because Cohort 1 was surveyed in 2008 and Cohort 2 2010. In those two years, numerous quality initiatives were implemented in hospital and nursing education programs as well as an increased number of magnet hospitals; greater participation in NDNQI; an increase in individuals completing QI training through the Healthcare Improvement Open School for Health Professions; and the development of the QSEN web site (Djukic et al., 2013). Although none of these resources were available to Cohort 1, there were no statistically significant (p=0.05) differences in QI participation between the cohorts. The authors cited several programs to improve engagement of RNs in QI and suggest that academic-practice partnerships are a promising strategy (Djukic et al., 2013). Phase II of this study is assessing pre and post attitude, skills, and knowledge of those students participating in the study.
...our academic-practice partnership enables the PI Department to expand its data collection and analysis and implement small changes it might otherwise not have been able to initiate. We believe that incorporating the QI process into a nursing research course and providing “real life”, “real time” QI learning experiences is a viable strategy to ensure that new graduates are prepared to participate in the QI process. Expanding a nursing research course beyond the classroom brings the course to life. We believe this type of collaboration can be effective in any healthcare setting that can collaborate with an academic partner. Furthermore, our academic-practice partnership enables the PI Department to expand its data collection and analysis and implement small changes it might otherwise not have been able to initiate. Students benefit by working collaboratively with nurse managers and staff that may well be involved in hiring them as graduates. They now have resumes demonstrating experience in developing presentations and disseminating research findings. Several students have expressed an interest in working in the patient safety or quality area in the future to expand their experience. We believe that when education and practice engage in academic-practice partnerships to teach QI, we can move forward toward our shared vision of nurses becoming a driving force in quality improvement.
Deborah Flores, EdD, RN
Deborah Flores, EdD, RN, was Vice President for Performance Improvement at Research Medical Center and the primary partner to develop the collaborative relationship with the Research College of Nursing in Kansas City, MO. She had developed a similar collaborative with the Texas A & M College of Nursing and Health Sciences at the Corpus Christi, TX campus for undergraduate and graduate students. Dr. Flores has presented on this collaborative for Kansas City Nursing Executives and is working on further research to determine measurable outcomes of this project. She is certified in healthcare quality (CPHQ). Currently, she is the Administrator/Provider for a medical clinic in Guatemala and a consultant for Joint Commission International.
Gale Hickenlooper, RN, MPH
Gale Hickenlooper, RN, MPH is an Assistant Professor at Research College of Nursing in Kansas City, MO. As one of two faculty teaching the introductory nursing research course to undergraduate students, she helped develop the partnership with the Research Medical Center Performance Improvement Department. The partnership has provided students with hands on experience conducting quality improvement projects using the PDCA approach in the Medical Center.
Rebecca Saxton, PhD, RN
Rebecca Saxton earned her BSN, MSN, and Doctorate while affiliated with the Kansas City higher educational system. She is certified in perioperative nursing practice (CNOR) and nursing education (CNE). Dr. Saxton is an Associate Professor at Research College of Nursing (RCN) in Kansas City, MO and the Director for the Center for Nursing Research and Innovation, a collaborative project of RCN and Research Medical Center aimed at providing faculty and staff nurses with the resources to conduct quality nurse-led research. She attended one of the first QSEN Faculty Development conferences and is RCN’s “QSEN champion.” She has presented aspects of the academic-practice partnership described in this article at the 2011 AACN Baccalaureate Conference and the 2012 QSEN National Forum.
American Association of Colleges of Nursing. (n.d.). Academic-practice partnerships tool kit. Retrieved fromwww.aacn.nche.edu/leading-initiatives/academic-practice-partnerships/tool-kit
© 2013 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2013
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