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The rewards of nursing in an ambulatory surgery center

The rewards of nursing in an ambulatory surgery center

The secret is finding balance and working collaboratively.

By Timothy P. Luckett, CRNFA


  • Working as a nurse in an ambulatory surgery center (ASC) requires the ability to take on multiple responsibilities.
  • Success as an RN in an ASC requires knowing when and how to delegate, understanding finances, staying organized, and building relationships with the administration.

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Maintaining clinical competency is your responsibility

Healthcare consumers expect competency from the nurses who care for them—and registered nurses (RNs) have an ethical and legal responsibility to maintain their competency. The scope of the professional nurse evolves continuously to adjust to the dynamic healthcare landscape, society’s changing needs, the political climate, and the expanding knowledge base of theory and scientific domains.

Competencies defined

The American Nurses Association (ANA) states that “assurance of competence is the responsibility of the profession, individual nurses, professional organizations, credentialing and certification entities, regulatory agencies, employers, and other key stakeholders.” ANA has 17 standards of practice and professional performance; each standard has two parts—a description of the standard itself and multiple competency statements for that standard.

Standards reflect philosophical values; they remain stable.

Competency statements, on the other hand, are revised as needed to incorporate advances in scientific knowledge and expectations for nursing practice. To demonstrate competency, the RN must meet all competencies for the given standard.

A general scope and standards apply to all nurses; additional scopes and standards apply to nurses in specialties. General standards are presented in nursing school; novice nurses should be establishing competency in these areas as they enter practice.

All nurses should be familiar with the scope and standards that drive their clinical practice. You’re responsible for ensuring that you meet the competencies for each standard. To find the standards, see Nursing: Scope and Standards of Practice (3rd edition) or your specialty organization’s website.

Maintaining your competency

You can maintain and enhance your competency through education, professional organizations, networking, conferences, webinars, continuing nursing education (CNE) modules, and certification.

Continue your formal education to give yourself new perspectives and keep up-to-date on society’s changing healthcare needs, the expanding knowledge base, and political currents affecting health care. The 2011 Institute of Medicine’s report The Future of Nursing: Leading Change, Advancing Health recommends that 80% of practicing nurses should have a bachelor’s of science degree in nursing by 2020.

Belong to a professional organization to stay current on changes that affect your practice. ANA’s website also offers valuable information to keep you informed of these changes.

Attend conferences and meetings where you can network with other nurses, learn from researchers, gain new information to take back to your workplace, and learn about new procedures your employer can implement to improve patient care.

Complete webinar courses and CNE modules. But make sure the information presented comes from a reputable source. For instance, Sigma Theta Tau (International Honor Society of Nursing) offers webinar courses that members can access for free. Another reputable website is that of the Institute for Healthcare Improvement’s Open School. It offers free courses in five categories that dovetail with competencies from the American Organization of Nurse Executives (AONE) and Quality and Safety Education for Nurses (QSEN). (See AONE and QSEN competencies.)

Read peer-reviewed nursing journals and take the CNEs they offer.

Become certified in your practice area. The American Nurses Credentialing Center (ANCC) states that its certification program “enables nurses to demonstrate their specialty expertise and validate their knowledge to employers and patients. Through targeted exams that incorporate the latest nursing-practice standards, ANCC certification empowers nurses with pride and professional satisfaction.” If you’re a specialty nurse, being certified in that specialty shows the public you’re competent and committed to lifelong learning.

Nurses at all levels should be actively involved in determining the competencies they need to stay current. Remember—you have an ethical and legal responsibility to the public, yourself, and the nursing profession to provide safe, timely, efficient, effective, equitable, and patient-centered care.

Margaret Strong is an associate professor of nursing at Baptist College of Health Sciences in Memphis, Tennessee.

Selected references

American Nurses Association. Nursing: Scope and Standards of Practice. 3rd edition. Silver Spring, MD:; 2015.

American Nurses Association. Nursing’s Social Policy Statement: The Essence of the Profession. Silver Spring, MD:; 2010.

American Nurses Credentialing Center. About ANCC. (n.d.)

American Organization of Nurse Executives. AONE guiding principles for the role of the nurse in future patient care delivery. 2010.

Institute for Healthcare Improvement. IHI Open School. (n.d.)

Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.

Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; 2003.

QSEN Institute. QSEN: Quality and Safety Education for Nurses.

Your path to becoming an administrative supervisor

Naomi, a novice staff nurse, calls her administrative supervisor, Madelyn, for assistance with Selma Rice, an 84-year-old patient  who has pulled out her I.V. line and wants to leave against medical advice (AMA). When Madelyn arrives on the nursing unit, she shows Naomi how to access the hospital policy and reviews the AMA procedure with her. After discussing Mrs. Rice’s situation, Madelyn and Naomi go to her room to explore whether anything more could be done to assist her. Madelyn discovers the patient wants to attend mass in memory of her husband and their 60th wedding anniversary. She contacts the hospital priest and asks him to meet with the patient. With this intervention, Mrs. Rice consents to stay in the hospital.

Madelyn encourages Naomi to provide a phone update to the patient’s son. Finally, Madelyn and Naomi collaborate to arrange an interdisciplinary meeting with the patient, her son, her physician, and her case manager to review plans for the rest of her hospital stay and discharge.

Looking for a professional challenge? Administrative supervisor may be the role for you. Every day, nurses like Naomi seek the assistance of administrative supervisors to help solve a wide range of problems.

Giving nurses whatever assistance they need to provide safe, effective patient care is an important part of this role. For instance, a supervisor may be asked to review and check a chest tube setup with a new nurse, explain hospital policy on administering I.V. metoprolol on a medical-surgical unit, or help a staff nurse obtain 3,000 mL of sterile normal saline solution for a patient’s continuous bladder irrigation.

In most acute-care hospitals, administrative supervisors are the on-site nurse leaders who work off-shifts, such as evening, night, and weekend shifts.


Each hospital establishes its own requirements for the administrative supervisor position. Generally, a candidate must have a current active nursing license and a bachelor of science in nursing degree; a master’s degree is preferable. Of course, you’ll need relevant clinical nursing experience as well, along with charge nurse or management experience. Administrative supervisors typically respond to all emergencies, such as cardiac arrests, so critical care experience is particularly helpful. Executive nurse board certification from the American Nurses Credentialing Center also is valuable.


An administrative supervisor is the visible on-site nursing and administrative leader, with responsibility for the entire hospital during the weekend, evening, or night shift. Responsibilities vary but typically include responding to emergencies, addressing patient and family concerns, staffing, and supporting the nursing staff. Some administrative supervisors still perform some of the functions described in historical publications, such as rounding on nursing units, making urgent decisions, and releasing bodies to funeral homes. (See Historical perspective.)

Most nurses with critical-care experience adapt easily to responding to patient emergencies, such as cardiac arrests, strokes, and rapid response situations. In such emergencies, the supervisor ensures the patient is receiving the necessary care and assists as needed with documenting care, talking with family members, or  finding a transfer bed for the patient. Supervisors also respond to general hospital emergencies, such as smoke and fire situations, a broken water pipe resulting in flooding, or a bomb threat.

Ensuring appropriate staffing for the current shift and the next one can be challenging. As patients are admitted, the administrativesupervisor must make sure appropriate staff are on hand to provide care. For the next shift, the supervisor reviews the scheduled staff and makes adjustments based on the unit census and patient acuity.

Empirical research on the administrative supervisor role is just beginning. In a recent pilot qualitative study, Weaver and Lindgren interviewed administrative supervisors and found that they oversee and do everything needed to keep the hospital running, with responsibilities for staffing and patient flow, crisis management, and managerial support for the staff.

Are you interested?

For nurses who aspire to be leaders, administrative supervisor can be an exciting and rewarding position. Instead of being assigned to care for patients, the supervisor’s assignment is to care for staff nurses. This means being available and making rounds on all nursing units to answer questions, solve problems, assist with patientcare issues, and mentor novice night nurses to help them become experienced charge nurses. And sometimes, the supervisor’s role is simply to comfort and reassure a nurse, even letting her cry on her shoulder.

Susan Heidenwolf Weaver is an education specialist at Saint Clare’s Health System in Denville, New Jersey.

Selected references

Clare M. Handbook for the Night Supervisor in the Small Hospital. St. Louis, MO: Catholic Hospital Association; 1965.

Pfefferkorn B. A new deal for the patient at night. Am J Nurs. 1932;32(11):1179-87.

Weaver SH, Lindgren T. Administrative supervisors: a qualitative exploration of their perceived role. Nurs Adm Q. 2016;40(2):164-72.

Smoothing your transition from RN to NP

Transitioning to the nurse practitioner (NP) role is exciting—but it can also be stressful. Fortunately, taking certain steps can make it smoother.

I’m a family NP (FNP), board certified by the American Nurses Credentialing Center (ANCC). Before graduation, I worked as a critical care nurse for 5 ½ years. I still vividly recall the struggles I had as a new registered nurse (RN) and later as a new FNP. Here are some suggestions for easing your transition from RN to NP to launch yourself to your next career stage.

Become board certified

To make you more confident in your abilities and boost your marketability, I highly recommend getting board certified as an NP. State requirements for certification differ; be sure to find out what they are for the state where you’ll practice. The two certifying bodies are the ANCC and the American Association of Nurse Practitioners.

I suggest you study for the exam for 3 to 4 months, take a review class, and then take the exam shortly afterward. Putting off the exam only allows time for fear and selfdoubt to creep in. Also, stay in your current job until you take the exam so you’re not dealing with the additional stressor of a new work environment at the same time.

Choose the patient population

Part of transitioning to the NP role is finding your first position. Before starting your job hunt, decide which patient population you’d like to serve. This helps you focus your job search. For example, if you decide you want to work in a specialty area, such as cardiac, you can concentrate your networking on that specialty area.

Get your name out there

Stay in touch with the NPs or physicians with whom you completed your clinical hours. Even if their practice doesn’t need a new NP when your job hunt begins, they can help you get your name out there for other opportunities. Whatever you do, don’t take a job solely for the sake of practicing as an NP. That’s a path that’s likely to lead to dissatisfaction.

Evaluate potential employers carefully

When interviewing for a position, make sure to ask about job expectations, including patient load, how much time you’d have with each patient, and work hours. Also, make sure the services you’d be asked to provide align with your state’s nurse practice act. In addition, ask about administrative support (for such tasks as scheduling and paperwork) and clinical support (for assistance with complex patients you might need help managing).

One Canadian study examined the requirements for a successful transition to practicing as an NP. Sullivan-Bentz, et al recommend that primary healthcare practices employing new NPs ensure these NPs receive formal mentorship and support from physicians and NPs familiar with the role and that written resources and colleagues are available for consultation and support. Ideally, your new work setting should provide such resources.

Set realistic goals and expectations for yourself

Recognize that as a new NP, you’re a novice—again. Having unrealistic expectations of yourself can increase your anxiety as you transition to your new role. The “imposter phenomenon” can occur in new NPs. In this phenomenon, people feel they’re not qualified for their jobs and are duping their bosses into believing otherwise; they also fear they’ll be found out someday.

To counter such feelings, use self-reflection on a daily basis. Recognize that the learning curve for a new NP can be steep, just as it was with the transition from nursing student to RN. Selfreflection helps you focus on what you’re learning rather than on what you feel you don’t know or didn’t do correctly. You might want to keep a journal to record your reflections.

Remember that when you become an NP, you assume a new professional role. You’re now a primary care provider. Even though you may be a seasoned RN with years of experience, the NP’s provider role is new to you. Questioning your assumptions and actions is normal because you’re making different types of patient-care decisions than you’ve made in the past. This can be intimidating.

What you can learn from my experience

To demonstrate the above points, let me walk you through the barriers and challenges I faced in my first NP role. My first position was with a practice where I’d previously spent 5 months of clinical time. On my first day, I had 12 patients, which I found a bit overwhelming. After I voiced my difficulty dealing with such a high patient load, my schedule lightened up a little, giving me some time to look up clinical information I needed and finish my charting.

But by the third week, flu season was hitting hard. My daily schedule reached 25+ patients; in some instances, I was doubleand triple-booked. I continued to voice my concerns about the safety of such a high patient load and whether I could provide thorough care—especially in light of being a new NP.

Although I believed my schedule didn’t allow time to provide adequate care for complex patients, I did what I could to provide the best care under the circumstances.

To compound matters, two pediatricians in our practice decided they would no longer answer questions from or provide guidance to NPs. Now that we’d graduated, they said, we should know the answers. This lack of support caused feelings of inadequacy, self-doubt, and job dissatisfaction. I knew this wasn’t the way I’d envisioned practicing as an NP, so I left this position after just 10 months.

Currently, I work in a neurology practice. Although I continue to feel intimidated at times, I’m getting more support. My FNP training has been extremely useful, but a specialty requires much on-the-job learning and independent reading. I’m struggling a bit to handle this new role.

The value of time

Even in the best-case scenario, the transition to NP can be difficult. The best advice I can give is to realize that adjusting to a new role takes time. Give yourself that time to ease your anxiety and self-doubt. Setting realistic goals, having an employer with realistic expectations of you, and getting solid support from colleagues also can smooth the transition.

To address the issue of realistic expectations on a broader scale, educate the medical community about the NP role. Emphasize that we are not  physicians and can’t be expected to practice the same way as physicians. NP and physician roles have certain similarities—but distinct differences.

Find a collaborating physician willing to take the time to learn what an NP is and does, and be patient with yourself during the transition phase. These are the keys to your success as an individual practitioner—and to the success of NPs collectively.

Kimberly Poje is an FNP at the Brain Center of Hudson Valley in Newburgh, New York.

Selected references

Barnes H. Nurse practitioner role transition: a concept analysis. Nurs Forum. 2015;50(3):137-46.

Huffstutler SY, Varnell G. The imposter phenomenon in new nurse practitioner graduates. Topics Adv Pract Nurs eJournal. 2006;6(2).

Sullivan-Bentz M, Humbert J, Cragg B, et al. Supporting primary health care nurse practitioners’ transition to practice. Can Fam Physician. 2010;56(11):1176-82.


Nurse staffing and patient experience outcomes: A close connection

As healthcare providers set and refine their strategies for staying competitive in a value-based delivery and payment system, a sharper understanding of the interplay between inputs and outputs becomes a strategic imperative. Nurse staffing is a key input for acute-care hospitals—key both for its impact on care and its budget prominence. This puts it squarely at the center of hospitals’ efforts to deliver on their value promise.

The relationship between staff­ing and patient outcomes across quality, safety, and experience domains is appreciated intuitively, if not always precisely understood. The imperative to strike the perfect balance drives considerable interest and research in fine-tuning this understanding. Yet vast scholarship on the topic hasn’t produced a precise staffing formula that will lead predictably to desirable outcomes.

That’s because high-quality nursing care hinges on much more than the number of nurses on the job for a particular patient load. It also depends on multiple under­-lying structural and process factors, such as nurses’ skills and education, availability of sufficient supplies and equipment, staff training, facilities, and reliable use of demonstrated best nursing practices—as well as such factors as interprofessional relationships, nurse engagement, and job satisfaction.
To fully understand the impact of staffing levels on patients’ clinical and experience outcomes, we must consider the relationships within and among these variables—something we can do only through data integration and cross-domain analytics.

Value of NDNQI data

In 2014, Press Ganey acquired the National Database of Nursing Quality Indicators® (NDNQI®)—the industry gold standard for assessing nursing excellence—from the American Nurses Association. NDNQI national benchmarking data are invaluable for monitoring key nursing-sensitive structure, process, and outcome measures. Similarly, Press Ganey’s vast patient experience database offers critical insight into patients’ perceptions about the effectiveness of hospital operations, clarity of the care team’s communication, and caregivers’ ability to meet patients’ needs.

As with nurse staffing, a growing body of evidence shows associations between patient-experience outcomes and clinical outcomes. Combining NDNQI and patient-
experience data provides unprecedented access to the relationships among key pieces of information. Together, these measures can help nurse leaders identify how performance changes in certain structural and process indicators affect patient safety, experience, and clinical outcomes.

Given the enormous impact of nursing on the patient experience—and because nurse staffing often is a lightning rod in the debate on how to deliver high-value care—using the combined dataset to better understand how the two relate is a research priority. Our early analyses show that performance on both Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains correlates significantly with nursing hours per patient day and RN hours per patient day, with the latter showing stronger associations in every domain. (See Correlations between nurse staffing and HCAHPS scores.) The link between more bedside nurses and a better patient experience isn’t surprising. That the correlations stretch across all experience domains—not just those that examine quality and frequency of nurse-patient interactions—is eye-opening.

Correlations between nurse staffing and HCAHPS scores

Staffing that meets patient needs and reduces suffering

While domain-level correlations confirm long-held beliefs about the relationship between staffing and patient experience, we seek to understand which aspects of the patient experience are most sensitive to staffing. Where do staffing levels make a difference in caregivers’ success in meeting patient needs? Where can staffing serve as a lever to improve performance?
Item- and question-level analyses help answer these questions. In the two tables HCAHPS scores and nursing hours per patient day and Press Ganey mean score, we see that for HCAHPS top-box scores and Press Ganey mean scores, every item showed sensitivity to staffing levels. Where the difference in patient experience scores is greatest (meaning when hospitals in the top decile of staffing ratios dramatically out­-perform hospitals in the bottom decile), staffing can be viewed as a more powerful performance-improvement lever.

HCAHPS scores and nursing hours per patient day

Reducing patient suffering

Of particular interest are differences in performance on key patient-experience questions related to patient suffering, which may indicate how effectively an organization provides patient-centered, personalized care. Press Ganey staff believe that relieving suffering should be central to efforts aimed at providing patient-centered care.

Patient suffering falls into two categories:

  • Inherent suffering results from the patient’s diagnosis, treatment, or both. It can’t be avoided entirely, but it can be mitigated. Some types of inherent suffering are well understood and addressed with some consistency—for instance, using pain control and explaining and managing symptoms. Inherent suffering includes psychosocial suffering, which caregivers are less comfortable with and therefore less practiced at addressing. Such suffering includes fear, anxiety, confusion, loss of dignity and autonomy, and uncertainty about self-care after discharge.
  • Avoidable suffering arises from systemic defects, which may include long waits to receive treatment, poor communication, poor coordination among providers, errors, and failure to follow best practices. An important first step in determining how to avoid that kind of suffering is to understand that dysfunction creates additional suffering for people already burdened by inherent suffering.

Inherent suffering can be reduced by understanding and meeting inherent patient needs. Performance on certain patient-experience survey questions can tell caregivers much about how well they’re meeting patients’ needs. Examining the relationship between staffing ratios and performance on these questions is illuminating. The table Reducing suffering: Top-decile vs. bottom-decile hospitals illustrates the dramatic differences in performance between top-decile and bottom-decile hospitals on questions relating to patient anxiety, autonomy, and the need to be informed about and involved in their care. These differences speak volumes about the importance of adequately resourced nursing units to give caregivers sufficient time to meet these patient needs.

Reducing suffering Top-decile hospitals

It’s never just one thing

These findings don’t suggest that increasing nurse-patient ratios will automatically lead to performance improvements. Certainly, adequate nurse staffing is key to a range of outcomes, but changing staffing volume alone won’t produce optimal outcomes. Multiple aspects of structure and process also shape outcomes, and these findings must be leveraged with that in mind.

Such factors as demographics of the nursing force, education and certification, engagement, and organizational staffing models are associated with patient-experience outcomes, as are cultural and structural practices and processes. In this regard, answers to the questions below also factor into outcomes:

  • Is the nursing staff following best practices associated with better patient experiences?
  • Are they executing on those best practices consistently and in the prescribed manner every single time?
  • Do nurses have the right resources and training to promote consistency?

For example, a best practice such as purposeful hourly rounding on patient experience can have a dramatic impact. A 2013 Press Ganey study shows that patients who report they were visited by staff hourly during their hospital stay were much more likely to give top box scores on all HCAHPS questions—a clear sign their needs were being met more consistently. See the table Effect of hourly rounding on HCAHPS scores for details.

Effect of hourly rounding on HCAHPS scores

The concept of value over volume extends beyond changes to delivery and payment models. For hospitals, “getting it right” with their nursing organizations is particularly important because nursing care provides much of the value hospitals create. Adequate human resources are critical, but they’re not enough on their own. Nurse leaders must consider the full range of inputs—in addition to adequate human resources—that drive outcomes, including staff quality or caliber, the environment in which they operate, and shared commitment to providing a high-value experience for patients.

Nell Buhlman is senior vice president of Clinical and Quality Solutions at Press Ganey Associates in South Bend, Indiana. Note: Charts are copyrighted by Press Ganey and used with permission.

Selected references

Armstrong K, Laschinger H, Wong C. Workplace empowerment and Magnet hospital characteristics as predictors of patient safety climate. J Nurs Care Qual. 2009;24(1):55-62.

Dempsey C, Reilly B, Buhlman N. Improving the patient experience: real-world strategies for engaging nurses. J Nurs Adm. 2014; 44(3):142-51.

Halm MA. Hourly rounds: what does the evidence indicate? Am J Crit Care. 2009;18(6): 581-84.

On the road to zero CAUTIs: Reducing urinary catheter device days

Catheter-associated urinary tract infections (CAUTIs) are common healthcare-associated infections that can prolong lengths of stay and increase morbidity and mortality. Despite their best efforts, many hospitals continue to struggle with climbing CAUTI rates. Recognizing inappropriate or prolonged urinary catheterization as a primary risk factor, our team decided to target urinary-catheter device days as a way to reduce CAUTIs.

The specific aim of this quality-improvement initiative was to decrease the number of urinary catheters inserted and reduce the time they stayed in place. Each additional day of indwelling catheterization further increases the risk of developing a CAUTI. We anticipated that by inserting fewer catheters and removing them earlier, we would decrease CAUTI incidence.

Targeted areas for improvement included all five of the noncritical care units at our 140-bed community medical center. At the start of this initiative, our critical care unit was exceeding at preventing device-associated infections, but our medical-surgical units were seeing a higher-than-expected CAUTI incidence. As we approached 2013, a system-wide task force was poised to introduce several evidence-based initiatives aimed at reducing CAUTIs.

In addition to the task-force solutions intended to standardize the evidence-based processes used with urinary catheters, our team added several other strategies to enhance our culture of safety and accountability around urinary catheters. To monitor our progress, we identified the urinary catheter device-utilization ratio (DUR) and actual number of CAUTIs as performance measures. Reported monthly, the DUR reflects the proportion of total patients with indwelling urinary catheters. Before our project began, validation studies were done to ensure the accuracy of DUR reporting. CAUTIs were identified and reported by the infection preventionist.

Electronic solutions

In January 2013, we implemented several electronic solutions to support our goal of reducing urinary catheter device days. We also implemented evidence-based indications for urinary catheter insertion and maintenance, based on guidelines from the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Association for Professionals in Infection Control and Epidemiology (APIC), recommended by the system-wide task force for CAUTI prevention. (See Evidence-based indications for indwelling urinary catheters).

Time-limited catheterization orders and a nurse-driven protocol for catheter removal were the primary electronic solutions supporting this initiative. We also implemented:

  • an algorithm for bladder scanning and intermittent catheterization for failure to void
  • electronic alerts to remind physicians and nurses when a temporary catheter had been in place more than 48 hours
  • revised nursing flowsheets to align our documentation with intervention-bundle recommendations from HICPAC and APIC.

These interventions reinforced our commitment to keeping each catheter in place only as long as medically indicated.

Clinician education and training

Recognizing the importance of clinician education and training to
im­prove outcomes and prevent complications related to urinary catheters, we partnered with the manufacturer of our urinary cathe­ters to develop and implement a training program aimed at expanding knowledge and improving catheter insertion and maintenance competencies. Each unit identified a nurse champion to attend this special training event. In addition to acquiring knowledge and skills, champions learned strategies for sharing the information at the unit level.

As part of the training program, skill stations were set up to review competencies and update techniques. Training emphasized the maintenance bundle and daily reevaluation of the continued need for a catheter.

Nurses aren’t the only clinicians who interact with catheterized patients, so a special session was held for non-nursing staff, such as physical therapists and transport personnel. This contributed to an overall increase in bundle compliance.

Improving our culture of safety

The final and most challenging aspect of this initiative was implementing interventions aimed at improving our culture of safety and accountability around urinary catheters. We recognized this as the most crucial step to sustaining the change. Our goal was to transform our culture from one where the urinary catheter is considered the norm for certain types of patients to one where it’s seen as an exception.

Daily review of all catheters

The team implemented a daily review of all catheters, including the indication for the catheter and patient’s length of stay, at unit-based shift huddles and the daily hospital-wide safety huddle. Sharing this information in as many forums as possible provides an opportunity for peer coaching and peer checking. It encourages nurses to challenge each other about the patient’s ongoing need for a catheter and offers a forum to suggest alternatives.

Partnering with physicians also was crucial to the success of our project. To gain physicians’ participation and input, we incorporated a review of urinary catheters at daily interdisciplinary rounds. This promoted further collaboration and teamwork around this initiative.

Finally, we engaged patients and family members, explaining the risks associated with catheterization and setting the stage for early removal at the time of catheter insertion. One of our best strategies has been to educate patients so they request early catheter removal.

Redundant auditing processes

To monitor the effectiveness of our interventions, we established redundant auditing processes to determine compliance with evidence-based recommendations for in- sertion and care maintenance bundles. (See Maintenance bundle audit elements.) Clinical nurses on each unit, nurse leaders across the organization, and third-party auditors from the clinical effectiveness department participate in the audit process. Results are shared at the unit level and with relevant committees and workgroups. Trends are identified and analyzed to help determine solutions.

Compliance with each bundle element as well as overall compliance has risen steadily since implementation. For October 2014, the overall urinary catheter bundle compliance rate was 94.7%. A true measure of success for this project has been the steady decline in urinary catheter device days and the actual number of CAUTIs. (See Statistics tell the story.)

Nurses at all levels can influence patient outcomes in a positive way. By focusing on evidence-based prevention strategies and promoting a culture of safety and accountability, we were able to exceed our goal for reducing urinary-catheter device days. We saw a shift in culture when our nurses began leading the way by advocating for fewer catheter insertions and promoting earlier removal. As a result, we are well on our way to zero CAUTIs—and your organization can be, too. 9

Editor’s note: For more information about CAUTI, see “ANA CAUTI Reduction Tool” at

Selected references

Association for Professionals in Infection Control and Epidemiology. Guide to Preventing Catheter-Associated Urinary Tract Infections. April 2014.
Accessed November 3, 2014.

Centers for Medicare & Medicaid Services. Catheter-Associated Urinary Tract Infections (CAUTIs). Accessed November 14, 2014.

Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-26. Accessed November 3, 2014.

Institute for Healthcare Improvement. How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Updated December 2011. Accessed November 14, 2014.

Catherine V. Smith is a clinical nurse specialist at Sentara Williamsburg Regional Medical Center in Williamsburg, Virginia.

Choosing the right restraint

Nurses at the bedside are experts in driving the safest, most effective patient care. In some cases, nursing assessment and clinical judgment suggest the need to apply restraints. A patient who is violent or self-destructive or whose behavior jeopardizes the immediate physical safety of him- or herself or another person may meet the behavioral health requirements for restraints. Examples of such behaviors include:

  • hitting, kicking, or pushing
  • pulling on an I.V. line, tube, or other medical equipment or device needed to treat the patient’s condition
  • attempting to get out of a bed, chair, or hospital room before discharge, in patients who are confused or otherwise unable to follow safety directions.

Before using restraints, always explore alternatives for keeping the patient and others safe. When considering such options, discuss with the patient any conditions that may need to be addressed, such as pain, anxiety, fear, or depression. If distraction and other alternatives prove ineffective at calming the patient and he or she continues to pose a risk, consult with other healthcare team members. You may want to use an algorithm to help determine if your patient requires restraints. (access the author’s algorithm.) Placing a patient in restraints requires a consult from the behavioral health team to consider behavioral restraint options—for instance, certain medications, distraction, seclusion, blanket wraps, or manual locked restraints. If such options don’t apply to your patient, proceed with restraints applicable for nonviolent, nonself-destructive patients, such as mitts, soft wrist restraints, or a chest vest. (See Decision tree for nonviolent, nonself-destructive restraint.)

Restraint options

Which type of restraint to use depends on the patient’s behavior and condition.

Hand mitts and freedom sleeves

If the patient is confused and impulsive and doesn’t follow directions but can be redirected, consider hand mitts to decrease grabbing ability. Or consider “freedom sleeves” (also called soft splints). These are a good deterrent for patients trying to remove a medical device from the face or head (such as a nasogastric tube or drain). With freedom sleeves, patients have difficulty bending their arms. Be aware, though, that the sleeves don’t necessarily prevent them from removing I.V. lines. Hand mitts and freedom sleeves let the patient move the arms up and down but limit the ability to bend and grab tubes or drains. They can be removed by unstrapping the hook-and-loop closures and sliding them off the arms. Be sure to monitor patients closely because they may try to remove these restraints themselves.

Enclosure bed

An enclosure bed helps prevent patient injury by stopping the patient from getting out of bed unassisted. It may be a good option for patients who meet the criteria for this bed. (For more information, read “Enclosure bed: A protective and calming restraint” in this issue.)

Chest vests and lap belts

Chest vests and lap belts (also called waist belts) may be warranted for confused or impulsive patients who are continually trying to get out of bed or a chair after repeated redirection, when it’s unsafe for them to get up unaided. Apply the vest or belt according to the manufacturer’s instructions. Fasten it securely to an immovable part of the bed or chair. Make sure you can easily slide your fingers underneath the vest or belt so it’s not too tight. It shouldn’t press uncomfortably against the skin, which could cause redness or impede expansion of the patient’s midsection during respiration. Instruct the patient to call for assistance when he or she wants to get up.

Limb restraints

Soft bilateral limb holders on both wrists may be appropriate for patients who are becoming increasingly agitated, can’t be redirected with distraction, and keep trying to remove needed medical devices. When device removal would pose serious harm to the patient and cause a significant setback to recovery, or if the patient is a physical threat to him- or herself or others, limb restraints help protect the patient and staff and remind the patient not to pull on the device. Typically, these restraints are used for patients in intensive care units who have endotracheal tubes, intracranial pressure monitoring devices, chest tubes, external fixators, skeletal traction, or other devices whose removal would imperil the patient’s health. In many cases, these patients are receiving sedatives or opioids to relieve pain and anxiety, impairing their safety awareness. In more extreme cases, patients who are severely agitated or intoxicated, are undergoing alcohol or drug withdrawal, or can’t follow safety directions may require arm and leg restraints, chemical restraint, or both. These methods should be used only for short periods. Monitoring requirements may call for one-to-one observation. Soft limb restraints are preferred, but locked cuff restraints can be used if soft restraints prove ineffective. Chemical restraints require a pro­vider assessment and a one-time order with close patient monitoring. Four-point restraints, which restrain both arms and both legs, usually are reserved for violent patients who pose a danger to themselves or others. Caregivers may use a combination of chemical sedation and four-point restraints to calm the patient as long as he or she poses a danger. Monitor the patient in four-point restraints every 15 minutes. Know that these restraints must be reduced and removed as soon as safely possible. To reduce a four-point restraint, remove it slowly—usually one point at a time—as the patient becomes calmer. During removal, reorient the patient and contract with him or her for safe behavior.

A last resort

Keeping patients and others safe is extremely important, but restraints should be used only as a last resort. When they’re needed, choose the least restrictive restraint possible. Reassess a restrained patient continually and remove restraints as soon as possible. During the restraint episode, educate patients and their families about the restraints and keep them engaged in the care the patient’s receiving. Be sure to document your assessment findings and progress toward restraint removal to help “tell the story” of the restraint incident.


Centers for Medicare & Medicaid Services. State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Revision protocol (09-26-2014). P.131 482.13(e)(8)(i). Accessed November 15, 2014.

Huang YT. Factors leading to self-extubation of endotracheal tubes in the intensive care unit. Nurs Crit Care. 2009;14:(2):68-74.

Click here for information on distraction techniques and on applying restraints.

Christy Rose is a staff nurse in the surgical intensive care unit at Denver Health Medical Center in Denver, Colorado.

Read the next article: Enclosure bed: A protective and calming restraint

When and how to use restraints

Few things cause as much angst for a nurse as placing a patient in a restraint, who may feel his or her personal freedom is being taken away. But in certain situations, restraining a patient is the only option that ensures the safety of the patient and others.

As nurses, we’re ethically obligated to ensure the patient’s basic right not to be subjected to inappropriate restraint use. Restraints must not be used for coercion, punishment, discipline, or staff convenience. Improper restraint use can lead to serious sanctions by the state health department, The Joint Commission (TJC), or both. Use restraints only to help keep the patient, staff, other patients, and visitors safe—and only as a last resort. Continue reading »

Assessing and documenting patient restraint incidents

Restraining a patient is considered a high-risk intervention by the Centers for Medicare & Medicaid Services, The Joint Commission (TJC), and various state regulatory agencies, so healthcare pro­viders must carefully assess and document the patient’s condition.

Assessing the patient’s medical condition

Review the patient’s medical record for preexisting conditions that can cause behavioral changes—for instance, delirium, intoxication, and adverse drug reactions. If the behavior results from an underlying medical problem, accurate assessment allows timely medical intervention and may reduce the restraint period required or even eliminate the need for restraint.

Assessing the patient’s behavior

To establish the patient’s behavioral baseline, assess his or her mental status, mood, and behavioral control. This allows clinicians to later determine how the patient is tolerating restraint and helps ensure restraint will be discontinued as soon as clinically indicated.

Medications can be an important part of a restraint intervention. Appropriate use of as-needed medications can shorten the restraint time. Assess the patient’s response to medications.

Assessment during the restraint period

A restrained patient is susceptible to injuries caused by restricted breathing, circulatory problems, and mechanical injuries. Once restraints have been applied, take steps to ensure a safe, injury-free outcome. Perform a quick head-to-toe assessment to help identify areas of concern or conditions that require further monitoring.

Being restrained is a traumatic experience for the patient, so continually assess how he or she is dealing with the stress.


Accurate documentation of the restraint episode is vital to safe, effective patient care and provides information that can improve the quality of care. Document the reason for restraint and that you explained the reason to the patient and family.

You can use a flowsheet to document assessments. The flowsheet should include the following:

  • patient behavior that indicates the continued need for restraints
  • patient’s mental status, including orientation
  • number and type of restraints used and where they’re placed
  • condition of extremities, including circulation and sensation
  • extremity range of motion
  • patient’s vital signs
  • skin care provided
  • food, fluid, and toileting offered.

Also, include the education you provide to the patient and family. Remember—the goal is to remove the restraints as soon as possible.

Post-restraint debriefing

When the restraint episode ends, a nurse or other qualified caregiver should debrief the patient. Reviewing the restraint episode with the patient yields important information that can help lead to restraint-free treatment. Information gained from debriefing helps the treatment team design therapeutic interventions that may help prevent the need for restraints. Be sure to document the debriefing.

Toward restraint-free care

Accurate assessment and documentation of restraint episodes provide valuable information to improve treatment processes, ultimately helping nurses create an environment where restraint-free care is possible.


CMS Manual System. Pub. 100-07 State Operations. Provider Certification. Transmittal 37. Subject: Revise Appendix A, “Interpretive Guidelines for Hospitals.” October 17, 2008. Accessed November 19, 2014.

The Joint Commission. Sentinel Event Alert. Issue 8, November 18, 1998. Preventing Restraint Deaths. Accessed November4, 2014.

Jim Woodard is the associate chief nursing officer at Porter Adventist Hospital in Denver, Colorado.

Enclosure bad

Enclosure bed: A protective and calming restraint

An enclosure bed can be used as part of a patient’s plan of care to prevent falls and provide a safer environment. This specialty bed has a mesh tent connected to a frame placed over a standard medical-surgical bed. Although it’s considered a restraint because it limits the patient’s ability to get out of bed, an enclosure bed is less restrictive than other types of restraints. It can be used as an alternative when a vest restraint would cause more agitation and wrist restraints aren’t appropriate.

My 750-bed academic medical center became interested in the enclosure bed in 2007 as a way to decrease patient falls and patient-sitter costs. We’ve seen the enclosure bed have a calming effect on patients and give them more freedom than wrist and ankle restraints. Our hospital rents the bed; for a 24-hour period, the daily rental expense is much lower than the cost of a patient sitter. (See A look at the enclosure bed.)


Use of the enclosure bed hinges on the patient’s behavior, so a patient-specific comprehensive assessment must be done. The bed may be indicated for patients who are at high risk for falls; are confused, impulsive, restless, or agitated; are unable to ask for assistance or respond to redirection; or who climb out of bed when it’s unsafe to do so.

Other patients who might benefit from an enclosure bed include those with Alzheimer’s disease or other types of dementia, traumatic brain injury, seizure disorder, Huntington’s disease, or developmental delays. The bed also may be indicated for patients recovering from stroke, as well as for patients with delirium associated with alcohol withdrawal who have completed treatment for acute withdrawal.

Inclusion criteria

To be considered for the enclosure bed, the patient must be at high risk for falling and must demonstrate one or more of the following:

  • impulsiveness
  • agitation
  • inability or unwillingness to ask for assistance or respond to redirection
  • unsteady gait
  • wandering behavior.

A history of falling alone isn’t enough to warrant use of the enclosure bed or other restraints.

Exclusion criteria

Patients shouldn’t be placed in an enclosure bed if they are violent, combative, self-destructive, suicidal, or claustrophobic. Although the bed has small holes for one or two I.V. lines and an indwelling urinary catheter, patients with multiple lines generally are excluded. If the patient becomes increasingly agitated, terrified, or distraught after being placed in the bed, clinicians must reassess the situation and try a different intervention.

Evaluation period

Before our hospital decided to add the enclosure bed to our approved specialty rental inventory, staff nurses and other providers conducted an evaluation to identify patient risk behaviors that could be managed in this bed. The hospital conducted a 6-month trial of the enclosure bed, during which staff used the bed and completed an evaluation tool. The tool asked specific questions about staff comfort level with the bed, ease of use, family response to the bed, and whether the bed met the patient’s needs.

Education and implementation

Based on staff feedback and positive patient outcomes during the evaluation, the enclosure bed was added to potential interventions to prevent falls and to provide a safer environment for patients. Our facility has developed processes to request or order the bed, monitor the patient while in the bed, and discontinue the bed.

The enclosure bed was introduced as a type of restraint to providers who have the authority to order restraints. Staff nurses received education on indications for the bed, how to operate it, and documentation requirements. Nursing staff at the unit level worked with provider teams to implement the enclosure bed.

Education consisted of reviewing the procedural checklist, watching an instructional video and completing a self-learning module on restraint use. During the demonstration on how to zip the panels and use the locks on the zippers, nurses had the chance to get into the bed to see what it’s like.

Required processes

Before an enclosure bed is requested, nursing staff must review with the provider team the behavior that puts the patient at risk for falls and injury, as well as for impulsive behavior that harm the patient or staff. One example is an impulsive patient with early-onset dementia who is hitting and kicking at staff.

As with all restraints, an enclosure bed requires a provider restraint order that must be renewed every 24 hours. Before a patient is placed in the bed, staff try less restrictive options, such as distraction, bed and chair alarms, reducing stimuli, and moving the patient to a room closer to the nursing station. Once the decision to use an enclosure bed is made, clinicians must educate the family about the bed, its function, the reason for using it, how the panels are zipped and unzipped, and how the bed contributes to a cocoon-like environment. If family members aren’t available in the hospital, the charge nurse contacts a family member by phone to explain the change in the patient’s care.

Using a restraint flowsheet, nursing staff document the patient’s response to the enclosure bed and the frequency with which they met the patient’s care needs during bed use.
When the patient’s behavior improves, the enclosure bed is discontinued. The specialty bed coordinator is notified and the vendor picks up the bed.

Placing the patient in the bed

Before using the bed, inspect it for proper assembly. Then unzip the bed and adjust the head of the bed. Once the patient has been placed in the bed, sit in a chair next to the bed for a few minutes with the sides unzipped to help him or her get acclimated. Adjust the head of the bed so the patient can sit in it comfortably. Then zip the sides and see how the patient reacts to the enclosure. If the patient will be left alone, place a call button within reach.

The patient’s activity schedule should include getting him or her out of the bed multiple times a day. Staff should assist the patient to ambulate at least three times daily. The patient should sit in a bedside chair for all meals, if able to tolerate ambulation and activity. According to the Centers for Medicare & Medicaid Services’ Interpretive Guideline §482.13(e) (6), “a temporary, directly supervised release…for the purposes of caring for a patient’s needs
(e.g. toileting, feeding, or range-of-motion exercises) is not considered a discontinuation of the restraint. As long as the patient remains under direct staff supervision, the restraint is not considered to be discontinued because the staff member is present and is serving the same purpose as the restraint.”


In our hospital, the enclosure bed was incorporated quickly into the safety plan for med-surg patients. The adult med-surg nursing staff has used the bed with more than 200 patients. On average, patients stay in the bed about 6 days; no patient falls or injuries have occurred. In some facilities, using the bed decreases overall sitter expenses. Our experience has shown a slight reduction in sitter hours when the bed is used.

Based on our positive experiences and patient outcomes, we will continue to use the enclosure bed as an option for fall prevention and patient safety.

Several patients have been discharged from our hospital with a plan of care that included an enclosure bed. In the home, the bed can be used for patients with agitation secondary to dementia or for pediatric patients with significant chronic neurologic or behavioral problems. The experience the families gained with the enclosure bed in the hospital helped provide a safe discharge plan for several patients.

Involving staff with an initial trial of the bed, identifying appropriate patient criteria, and educating staff, patients, and families about the bed’s benefits have contributed to successful implementation of this specialty bed.

Click here for information on caring for a patient in an enclosure bed, using the enclosure bed with pediatric patients.


Centers for Medicare & Medicaid. Interpretive Guidelines for Hospitals. State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Conditions of Participation for Hospitals, 42 CFR Appendix A.§482.13(e)(6). October 2008. R37SOMA.pdf. Accessed November 9, 2014.

Jennifer L. Harris is a senior advanced practice nurse at the University of Rochester Medical Center-Strong Memorial Hospital in Rochester, New York.

Read the next article: Assessing and documenting patient restraint incidents

Developing a quality framework for annual nursing competencies

Patients expect safe, high-quality care when they enter a healthcare facility, and healthcare facilities pride themselves on the care they provide. With so much emphasis on quality, many people were shocked in 1999 when the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System. This report estimated that 44,000 to 98,000 preventable medical errors occur each year and called for a greater focus on safe, high-quality care in the U.S. healthcare delivery system.

With the problem clearly identified, healthcare facilities have since been brainstorming ways to improve the quality of care they provide. In 2005, the Robert Wood Johnson Foundation funded “Quality and Safety Education for Nurses” (QSEN), an initiative that identified six key areas of focus building on the IOM’s recommendations—patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

QSEN sought to infuse these six key areas into nursing education programs throughout the country. The original pilot programs saw great success. The academic side has been developing a clear, consistent framework of high-quality, safe nursing care. But in the clinical environment, segregated changes have occurred with no consistency among organizations.

This perception intensified when the 2010 IOM report The Future of Nursing: Leading Change, Advancing Health found that quality and safety issues are still prevalent. The report called on healthcare organizations to strengthen continuing-education programs. With this call, an opportunity to integrate QSEN competencies into clinical education has emerged. The framework and standardization of QSEN, based partly on the IOM reports, may be the answer to the need for a structured response to healthcare quality and safety.

QSEN as a model

Seeing an opportunity for quality improvement (QI), I began a QI project focusing on a large teaching hospital in central Pennsylvania. Although the nursing education department and 25 clinical educators form the backbone of annual competency development, they lacked a standard format to guide them from year to year. Nursing leaders at this hospital, which has more than 1,500 nurses in dozens of care areas, were challenged to find a way to hold competencies to a standardized plan while allowing for the unique needs of each unit.

Realizing the QSEN initiative could serve as a model for solving this dilemma, I approached the director of education about a QI project through which to imbed key quality and safety focus areas in a standardized framework for annual competencies. The project was quickly approved, and I posed the following question to guide it: Regarding acute-care clinical nurse educators, what are the effects of a QSEN-based workshop on educator knowledge and ability to develop evidence-based, safe, quality care competencies compared to pre-education knowledge and ability?

Project description

After receiving approval from the institutional review boards of my educational institution and the hospital serving as the project site, I developed an educational plan, which the hospital’s director of nursing education approved. At a staff meeting scheduled before the design of competencies for 2013, I described the project to all educators present; all of them gave their consent to participate.

After the educators completed a pre-knowledge and confidence survey, they viewed a presentation covering the current state of competency design, the gap related to quality and safety, and the ability of the QSEN project to serve as a foundation for a framework. The presentation covered each individual competency area in detail. After the educational session, attendees completed a post-knowledge and confidence survey.

After the live educational session, biweekly emails were sent to all consenting participants over the next 26 weeks. The emails were designed to support educators as they began to design competencies for the 2013 competency year. Topics included a focus on the six key competency areas as well as competency design and overall support for the nurse educator role. Once the 13 biweekly emails were sent and the 2013 competency year was underway in the nursing education department, a summative follow-up computerized survey was sent to solicit final thoughts on the project and the ability to improve the quality and safety aspect of annual nursing competencies. I met with the nurse-educator group for a final summary and wrap-up meeting.

Results of knowledge and confidence surveys

Twelve participants completed the pre- and post-surveys around the live educational session. Quantitative data analysis using statistical computerized software showed significant differences in educators’ knowledge of the QSEN competency project, confidence in designing and implementing annual competencies, and potential for competency development in such key areas as informatics and collaboration. The analysis found marked improvements in educator confidence in designing competencies within the various quality and safety areas after the educational intervention.

Qualitative data analysis of the pre-education surveys showed many focus areas where educators couldn’t identify examples of competencies. But in the post-education survey, educators gave examples for all categories. For patient-centered care, they submitted such competencies as early mobilization and pain control. For informatics, they submitted medication documentation and exit care (patient-education material). Other categories yielded similar responses. Compared to pre-education qualitative data, post-education data showed an overall increase in educator confidence and knowledge in designing competencies in most of the quality and safety areas.

Final survey results

After the biweekly emails and launch of the 2013 competency year, the summative computerized survey was sent; the response rate was 7/12 (58%). The eight survey questions explored how the framework of quality and safety focus areas affects nursing competencies and educators’ ability to design them. All respondents said the framework helped them to better focus and measure competency, specifically in the areas of quality and safety; 88% believed adding the framework strengthened the overall process of competency measurement. A request to identify specific competencies used for each of the six focus areas yielded many responses—except in the informatics area, which got no specific responses. (See Major themes of qualitative survey results below.)

Major themes of qualitative survey results

Qualitative results were analyzed for themes. Three major themes came through:

• Keeping quality and safety at the forefront of the competency program required the framework presented.
• Respondents appreciated the evidence base for the process of competency development.
• Respondents wished to continue the processes that had been started.


This QI project sought to determine the effects of a QSEN-based workshop on the knowledge and ability of acute-care clinical nurse educators to develop evidence-based, safe, quality-care competencies, compared to pre-education knowledge and ability. The project found that providing a workshop focused on nurse educators’ knowledge and ability to design safe, quality-care competencies made a statistically significant difference in annual competency planning. Everyone involved at the project hospital, from administrators to nurse educators, enthusiastically accepted the overall idea of presenting such a focused framework for acute-care nursing competencies. At the initial education session, it was clear that the nursing education department already was focusing on specific areas to achieve quality care but hadn’t broken the work down into a framework.

The framework provided was consistent to hold all areas of acute care accountable, but flexible enough so each diverse unit could create specific competencies related to its patient population. For example, while all units designed a competency around teamwork and collaboration, the step-down unit’s specific competency differed from that of the surgical intensive care unit.

Not all participants preferred email communication, but they agreed it was helpful to have constant reinforcement of key topics to motivate and empower them when designing competencies. The director of nursing education was especially excited about the project because it provided a specific way to document the work being done toward improving the quality and safety of patient care.

Quality and safety are necessities in health care. The nursing profession must respond in specific ways to calls for a higher quality of care. Starting with annual nursing competencies, a great opportunity exists to make a difference by standardizing a framework of competency design that keeps nursing departments accountable to evidence-based focus areas while sustaining the drive toward quality outcomes. This project is a first step in bridging the gap and improving care in clinical areas.

Selected references

Armstrong G, Headrick L, Madigosky W, Ogrinc G. Designing education to improve care. Jt Comm J Qual Patient Saf. 2012; 38(1):5-14.

Conway ME. Competency control. HomeCare. 2009; March.

Disch J. QSEN? What’s QSEN? Nurs Outlook. 2012;60(2):58-9.

Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.

Joint Commission, The. Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. February 23, 2010.
Accessed November 10, 2014.

Quality and Safety Education for Nurses. Competencies. Accessed November 11, 2014.

Aislynn Moyer is the director of professional development for the Pennsylvania State Nurses Association in Harrisburg.

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