Student outcomes of an international learning collaborative to develop patient safety and quality competencies in nursing

Abstract

Background

Patient harm is a global crisis fueling negative outcomes for patients around the world. Working together in an international learning collaborative fostered learning with, from and about each other to develop evidence-based strategies for developing quality and safety competencies in nursing.

Aims

To report student outcomes from an international learning collaborative focused on patient safety using the Quality and Safety Education for Nurses competency framework.

Methods

A global consortium of nursing faculty created an international learning collaborative and designed educational strategies for an online pre-workshop and a 10-day in-person experience for 21 undergraduate and graduate nursing students from six countries. A retrospective pre-test post-test survey measured participants’ confidence levels of patient safety competence using the health professional education in patient safety survey and content analysis of daily reflective writings.

Results

Statistical analysis revealed student confidence levels improved across all eight areas of safe practice comparing-pre and post-education (significance, alpha of P < 0.05). Two overarching themes, reactions to shared learning experiences and shared areas of learning and development, reflected Quality and Safety Education for Nurses competencies and a new cultural understanding.

Conclusions

The international learning collaborative demonstrated that cross-border learning opportunities can foster global development of quality and safety outcome goals.

Introduction

As a central tenet of nursing philosophy, students are taught that they must ‘first do no harm’. This famous phrase, ‘primum no nocere’ attributed to Hippocrates, is the foundation of healthcare practice and is reinforced in the Florence Nightingale pledge. More recently new meanings have led to innovative practices through new safety science that addresses preventable patient harm (James, 2013; Sherwood and Barnsteiner, 2017). The Joint Commission (2019) defines healthcare errors within the framework of a sentinel event as any patient safety event resulting in death, permanent harm or severe temporary harm. In spite of a focus on safety and quality, healthcare errors remain high and are a source of significant disability and death in most countries (National Academies of Sciences, Engineering and Medicine (NASEM), 2018; Rodziewicz and Hipskind, 2020). The World Health Organization (2018) recognises patient harm as the 14th leading cause of the global disease burden while healthcare errors and adverse events are reported in 8% to 12% of hospitalisations in Europe. Although the exact numbers are debated, it is estimated that 268,000 preventable deaths occur annually in the USA (Makary and Daniel, 2016) and 34,000 deaths occur in one year in Japan (Fujita et al, 2017).

The flood of alarming statistics has made patient safety a practice priority, yet less attention has focused on the global context (Ginsburg et al., 2012). While patient harm is a concern in every country; it is a confounding problem that benefits from international cooperation (Stevens et al., 2019). The 2018 report on global quality presents staggering data on preventable harm from almost every country, with strong recommendations to educate healthcare professionals in systems thinking to redesign healthcare (National Academies of Sciences, Engineering and Medicine, 2018). Nurse educators have long sought evidence for best practices for redesigning nursing curricula to integrate a systems thinking approach to quality and safety (Altmiller and Armstrong, 2017; Cronenwett et al., 2007; Mansour, 2012; Olds and Dolansky, 2017). Fitzsimmons (2020) noted that the 2020 COVID-19 global pandemic reinforced the imperative of a systems global approach to quality and safety, citing teamwork and collaboration as key strategies (Tannenbaum et al., 2020). These forces combined with international migration and multicultural patient populations, press nurse educators to foster global citizenship in preparing learners to improve quality and safety in real world practice. Thus, the purpose of this paper is to report student learning outcomes from an international learning collaborative to develop the Quality and Safety Education for Nurses (QSEN) competencies with participants from six countries.

Background

The International Network of Universities (INU) (2020), a consortium of 14 universities from 14 countries, is an example of a higher education approach to develop global citizenship. A primary goal of the INU is to seek international partnerships and experiences to help faculty and students develop global citizenship through innovative programming that enhances teaching and learning. Nursing faculty members from partner universities in Japan, Spain, Sweden, South Africa, the UK and the USA formed the nursing faculty leadership team to explore these concerns of global healthcare quality and safety and adopted curriculum integration of the QSEN competencies as its central globalisation focus (QSEN Institute, 2019).

Nurses need first to understand the healthcare systems in which they work to contribute to improvement (Korhan et al., 2017; Olds and Dolansky, 2017). Although systems differ, the priority of preventing patient harm is universal, committing nurse educators to sift through respective data to integrate quality and safety into curricula. Japan is the third largest economy in the world, yet the discrepancy between tightly controlled cost and desired flexibility of service delivery has impeded efforts to improve quality of care (Sakamoto and Rahman, 2018). Spain has the highest reported life expectancy among EU countries; however, increasing demand has made it difficult to support an efficient service delivery system designed for quality and safety efficiency (OECD and European Observatory on Health Systems and Policies, 2017a). Sweden has a more coordinated effort to increase patient safety at the national and regional levels, but hospital-acquired infections and the overuse of antibiotics plague improvement efforts (Ridelberg et al., 2016). In the past two decades, South Africa reports a growing prevalence of adverse drug event-related fatalities (Mekonnen et al., 2017) and has prioritised the National Guideline for Patient Safety Incident Reporting and Learning in the Health Sector of South Africa (National Department of Health, South Africa, 2017) to promote error reporting. Recent policy changes in the UK established the National Patient Safety Agency to improve error reporting (OECD and European Observatory on Health Systems and Policies, 2017b). In the USA, healthcare errors were cited as the third leading cause of death (Makary and Daniel, 2016).

Nursing students are expected to develop competencies to be able to lead quality and safety cultures (Ginsberg et al., 2012). In 2005, the QSEN project (Cronenwett et al., 2007) was founded on the recommendations of the Institute of Medicine (2003) report, Health Professions Education, that all healthcare professionals be prepared with essential quality and safety competencies. QSEN aims to prepare nurses with the knowledge, skills and attitudes identified for each of six competencies to impact patient care quality and safety wherever they work: (a) patient-centred care; (b) evidence-based practice; (c) teamwork and collaboration; (d) safety; (e) quality improvement; (f) informatics (Cronenwett et al., 2007).

Although the QSEN competencies have been implemented in many countries, little is known about how well the competencies adapt to the learning needs of nurses in other countries (Ginsburg et al., 2012; Stevens et al., 2019). Informed by worldwide challenges to improve patient care quality and safety, academic nursing leaders from six INU university schools of nursing formed the nurse faculty leadership team to design an international learning collaborative for students to facilitate global engagement and address quality and safety learning needs. Learning collaboratives have been shown to develop higher level thinking, oral communication, self-management, leadership skills, faculty–student interaction and diverse perspectives, all matching aims for the project (Nadeem et al., 2016). The nurse faculty leadership team collaborated to design an educational intervention to develop quality and safety competencies, one of the earliest projects to bring together learners from multiple countries related to quality and safety. Students chosen to participate completed virtual pre-workshop experiences concluding with a 10-day face-to-face immersion experience. Students completed retrospective pre and post measures to address the study aim to report student outcomes from an international learning collaborative focused on patient safety using the QSEN competency framework.

Methods

The nurse faculty leadership team, composed of one or two faculties from each of the six participating universities and one QSEN consultant (N = 9), spent a year working together virtually plus one in-person session to plan and develop the educational intervention based on the QSEN competencies. The goal of the project was to develop a model of international collaboration culminating in a 10-day immersion for faculty and students to develop the knowledge, skills and attitudes to deliver quality safe healthcare in their nursing practice. The purpose of the study was to measure the impact of participation in an international learning collaborative focused on patient safety using the QSEN competency framework on students’ understanding of quality and safety.

Project participants

Each of the nurse faculty leadership team recruited one or two students from their respective school of nursing to participate in the international learning collaborative, therefore participating students were from one of the six participating universities located in Japan, Spain, Sweden, South Africa, the UK and the USA. All had completed at least 2 years of a baccalaureate equivalent nursing programme with continued active enrollment, spoke and understood English, and voiced a commitment to improving patient safety and quality in an application essay. Students participated in an online orientation to the learning collaborative and international travel and study, and also prepared a presentation of their country’s healthcare system that was delivered early in the workshop agenda.

On-site workshop

The on-site multifaceted workshop was led by the nurse faculty leadership team at Hiroshima University in Japan. The interactive workshop engaged students in classroom, field study and simulation. Classroom included short theory bursts applied in case studies, reflective learning, gaming strategies, simulation learning and interactive small and large group work. Content included systems thinking, reflective practices, person-centred care, safety science, interprofessional team work and communication. Interactive learning used gaming, high fidelity simulation, videos with discussion, team project and team building exercises for building trust and communication. Field study included observations in acute care hospitals, community clinics and industrial sites known for safety focus and discussions with patient safety experts. During field study, participants learned how healthcare systems, innovation, education, environment and culture impact safety and quality of care. Outside class assignments included both independent and group work to facilitate their understanding of the QSEN competencies. Simulation scenarios encouraged students to think about how they might manage situations to reduce the risk of errors rather than the treatment of specific health conditions. Case studies and scenarios fostered enquiry as participants considered critical reasoning questions: ‘What happened?’, ‘What were the safety risks in this case?’, ‘How could it happen?’, ‘What was due to human error, the technology, the organisation?’, ‘What do you do to ensure a similar event does not happen again?’ and ‘How will the patient and family be informed of the situation?’.

Students were oriented to reflective practices and reflective writing (Horton-Deustch & Sherwood, 2017). At the end of each day, they were asked to respond to a writing prompt such as ‘What is the most important thing I learned today about improving patient-centred care?’ or ‘What do I do when I am uncertain?’. After viewing a video of a sentinel event, they were asked ‘What would I say to the mother of a 15-year-old who died because of a healthcare error?’ (Quality and Safety Education for Nurses (QSEN), 2020b) and ‘How will I enact my personal commitment to keeping patients safe?’.

Study participants and ethical review

The study procedures were reviewed and approved by the Human Research Ethics Committee. A retrospective pre-test post-test design was chosen based on the workshop content. On arrival at the workshop, the convenience sample of 21 students participating in the workshop was briefed on the data collection methods and given the opportunity to opt in or out of data collection voluntarily without any impact on their involvement in the workshop. All agreed to participate and are hereafter referred to as study participants (N = 21). To ensure confidentiality, each participant was given a randomised double-digit number sent by email as their own confidential study identifier so that participation was anonymous; no personal identifiers were used.

Data collection

Primary data collection used an online link to the Health Professional Education in Patient Safety Survey (H-PEPSS) (Ginsburg et al., 2012). The 38 item H-PEPSS, developed in Canada for self-reported patient safety competencies prior to entry to practice, focuses on the sociocultural aspects of patient safety. Psychometric properties reported that internal consistency reliability of the factors exceeded 0.80 for all six factors (Ginsburg et al., 2012). Seven items did not align with workshop objectives and activities so were deleted from the survey, leaving 31 items associated with six sociocultural dimensions of patient safety competence:

1. Contribute to a culture of patient safety

2. Work in teams for patient safety

3. Communicate effectively for patient safety

4. Manage safety risks

5. Optimise human and environmental factors

6. Recognise, respond to and disclose adverse events.

The remaining items were used to measure perceptions of the application of safety in clinical settings and comfort level to speak up. Participants were provided a link to the URL to complete the H-PEPSS survey at the end of the workshop as a retrospective pre-post questionnaire. Participants were asked to reflect back on their level of understanding of patient safety principles at the beginning of the workshop to score their pre-workshop understanding and then reflect on what they learned to score their level of understanding post-workshop. The retrospective pre-post survey was chosen because participants often report a higher level of knowledge pre-intervention than they actually had (Allen and Nimon, 2007) because they often do not know what they do not know. Demographic data (e.g. age group, gender, academic programme, country) were added to the electronic survey.

Data analysis

Descriptive and inferential statistical analysis of the results from the H-PEPSS was completed using SPSS v.26 (SPSS Inc., 2019) to analyse means and percentages.

Two trained team members analysed the qualitative data from the daily reflections collected at the end of each workshop day using content analysis aided by NVIVO Pro (QSR International, 2018). First, entries were read and re-read for a sense of the whole. Responses were collated to begin coding for thematic analysis using NVIVO. Each identified codes and sub-codes, then compared and discussed results. As further confirmation, the codes and themes were reviewed with the project expert consultant for final consensus.

Results

Demographic information is reported in Table 1. The majority of participants were female undergraduates with an average age of 27.5 years. Of 21 participants, data are missing for one participant.

Table 1.

Demographic data reporting gender and programme enrollment (N = 20; 1 missing data).

Answer	Mean (N)
Men	35% (7)
Women	65% (13)
Total	100% (20)
Undergraduate	60% (12)
Graduate	40% (8)
Total	100% (20)

Retrospective pre-post H-PEPPS analysis

H-PEPPS data are presented in Table 2. Using a single group retrospective pre-test post-test design, the impact of perceived confidence levels of patient safety from the six domains of the H-PEPSS survey, before and after completion of the workshop, were examined by the use of paired sample t-tests. The survey was slightly modified and section 2 (items 28–34) were removed because they were not applicable to the study population. Significance was set at alpha P < 0.05. Results showed significant improvements for all six patient safety domains (working with teams of other health professionals; communicating effectively; managing risks; understanding human factors and environment; recognise, respond to and disclose adverse events and close calls; and culture of safety) as well as the two remaining items that reflected perceptions of clinical safety and comfort in speaking up about patient safety.

Table 2.

H-PEPPS pre-post retrospective analysis comparing domains (N = 21).

Identified domains scored pre and post education intervention		Mean	SD	SEM	Significance (2-tailed)
Pair 1	Pre working with teams	3.6984	0.58123	0.12684	0.001
	Post working with teams	4.6984	0.42367	0.09245
Pair 2	Pre communicating effectively	3.7778	0.57090	0.12458	0.001
	Post communicating effectively	4.8095	0.30861	0.06734
Pair 3	Pre managing safety	3.6508	0.65384	0.14268	0.001
	Post managing safety	4.7619	0.38214	0.08339
Pair 4	Pre understanding human and environment factors	3.6667	0.59628	0.13012	0.001
	Post understanding human and environment factors	4.7143	0.43825	0.09563
Pair 5	Pre recognising respond and disclose adverse events	3.5000	0.47434	0.10351	0.001
	Post recognising respond and disclose adverse events	4.6270	0.46668	0.10184
Pair 6	Pre culture of safety	3.7937	0.52283	0.11409	0.001
	Post culture of safety	4.7976	0.21822	0.04762
Pair 7	Pre clinical safety	4.0119	0.63971	0.13960	0.001
	Post clinical safety	4.7262	0.41007	0.08948
Pair 8	Pre comfort speaking up about patient safety	3.8810	0.48988	0.10690	0.001
	Post comfort speaking up about patient safety	4.4524	0.57769	0.12606

df = 20.

SD: standard deviation; SEM: standard error of the mean.

Qualitative data

Content analysis of participants’ reflective writings revealed two overarching themes: reactions to shared learning experiences and new areas of learning and development. Each was further described by sub-themes discussed below.

Theme 1: Reactions to shared learning experiences

The first theme, reactions to shared learning experience, reflected two sub-themes expressed by participants: a range of new feelings and changed perspectives. One participant summed it up by saying that being in the learning collaborative was a ‘nourishing experience’.

Participants expressed a range of new feelings, the first sub-theme, about the workshop experience itself and their ability to apply concepts learned. Participants felt uncertainty over their ability to engage in meaningful communication with participants from other countries and if this would limit how they could make significant contributions for their group assignments. With English as a second language they felt insecure to speak up and present their work. Overall, participants stated they were glad to have new knowledge and the chance for ‘using their minds’. Gratitude was a clear expression; they were grateful for the opportunity of learning collaboratively with an international group of nursing student colleagues and from experts in the field. Further, they were grateful for this international cultural exchange with the chance to learn a lot of the history of Hiroshima, especially from the stories of survivors of the atomic bomb. Excitement was often expressed from experiencing a unique learning opportunity, seeing new places, cultures and people, new ideas and different healthcare systems. A participant shared the excitement of the nursing participants and gratitude for what was learned stating, ‘You must love what you do, happiness is important’.

Illustrating the second sub-theme of changed perspectives, participants described translation of these experiences into a more compassionate view of healthcare. They described new appreciation for the multiple cultures of the people they were encountering and learning from. They expressed how this was changing their perception of the nurses’ roles. One participant shared this new understanding about communication, ‘How you handle situations is key. Use a positive approach.’ Others pointed out the importance of hearing different points of view, ‘Different perspectives can make us view the world with different eyes.’ Another example of changed perspectives was seeing differences in how healthcare is accessed and financed among the countries represented. One stated they were challenged to ‘now try and change our own healthcare management’ by applying best practices.

Changed perspectives can be summed up by the adoption of the quality and safety competencies, ‘If I see a fall risk or an unnecessary process I might react and push for a change for I know it’s a better solution and I have a powerful argument – I’ll just say that I’m a quality and safety champion!’.

This statement illustrated that participants were feeling ‘empowered by the patient stories’ they heard and how nurses had a role in outcomes. This translated into willingness to learn accompanied by drive, and determination to apply what they learned in their home setting. When asked to draft a letter during a learning exercise to the mother of Lewis Blackman, a child who died from healthcare errors in the USA (Quality and Safety Education for Nurses (QSEN), 2020b), a participant reflected, ‘Through the many emotions that I experienced, I believe that willingness, drive, and determination were some of the most profound. I hope to one day be a nurse that sees the unseen and speaks the unspoken. I want to be a source of education, reliance, and trust that parents like you can rely on in the scariest of times.”

Theme 2: New areas of learning and development

The second major theme, new areas of learning and development, was represented by a participant statement that the experience ‘broadened my mind’. Sub-themes were communication, patient-centred care, teamwork, quality improvement and patient safety, all directly from the QSEN competencies. Communication was a sub-theme of new knowledge identified by the majority of participants, particularly as it related to the healthcare team as an essential element of patient safety and quality improvement. Nurse patient communication is critical, noting cultural differences from different countries of origin of the patient and/or the nurse. One commented, ‘For me, the most important thing is to watch, listen and communicate. Our job is to do that in order to achieve our goal: a safe, healthy and happy patient.’

A new appreciation for person-centred care was a second sub-theme, crossing all cultures, see people as humans, maintaining non-judgmental attitudes, inspired to do better and be a better person and professional. Participants described a strong commitment to their patients, expressing determination to keep the patient at the centre of their focus and care and provide safe care after becoming practising nurses. In Figure 1, the word ‘patient’ forms the centre of a word cloud derived from the qualitative data. One participant wrote, ‘The patient is a complex being so by understanding the patient and effects of actions on the patient [it] allows us to identify and reduce risks…the patient is our priority and we should act in a way which protects them.’

Figure 1.

Word cloud.

Teamwork was a frequently mentioned sub-theme described by participants, noting learning experiences helped them understand components of teamwork and the way effective teams impact patient safety such as relying on one another. Working through a high fidelity simulation helped practice teamwork and debrief on the impact. A participant reflected on teamwork in high performing hospitals, ‘…[it] made a great affect on how I see the health system, as well as my attitude, and it changed my (view) regarding the importance of communication in ensuring improved quality care… the importance of teamwork.’

For the fourth sub-theme, participants wrote about promoting and implementing quality standards, precision and accuracy as essential for safety culture. They valued learning experiences comparing quality improvement and safety processes in field trips to automotive manufacturing plants and healthcare settings. They saw firsthand how the environment influences outcomes for quality and efficiency, and applied this to nursing and healthcare, and achieving one’s goals. From the automotive factory line, participants observed the processes for detecting errors in process. Participants used the Japanese term, Kaizen, a ‘change for the better’, comparing and contrasting Kaizen at the various settings and identifying essential elements they wanted to adopt in their nursing practice. One participant said, ‘To improve myself and to share this new knowledge to others. I think we have to be more KAIZEN, to not focus just in the errors, but to learn (from) them.’

The fifth sub-theme reflected the importance of patient safety, noted as worldwide concern evident in all healthcare systems. They expressed how they had learned about different healthcare systems from multiple countries, they could compare and see advantages and disadvantages and from this they learned to do things differently. They talked about things they did not know before; their view of quality and safety had changed, especially from visiting hospitals. One noted how nurses followed strict guidelines to manage quality and safety. Participants described the approach to adverse events, and how they must look for the best way to prevent harm and learn from errors, noting the influence of the overall environment and context on human factors.

Participants cited the relevance of the QSEN competencies, the importance of their learning about situation, background, assessment and recommendation (SBAR) and Teach Back, communication techniques used in healthcare when relaying information to enhance accuracy for the purpose of improving safety and reducing errors. Participants expressed the importance of learning the new safety strategies with their colleagues, and how they were committed to changing their own practice, ‘…bring new experiences of safety into my practice. It is important in my everyday work.’

Discussion

The central healthcare tenet, ‘first do no harm’ was an overarching theme expressed in written reflections by participants in the international learning collaborative and these responses aligned with the QSEN competencies. The participants’ confidence levels measured by the H-PEPPS increased as a result of the education intervention, demonstrating an impact on participants’ knowledge and skills. The skills and practices identified were in direct alignment with the QSEN competencies of patient-centred care, teamwork and collaboration, communication, safety and quality improvement that were the foundation for the workshop activities; however, the areas of evidence-based practice and informatics were not strongly identified in the data probably because these two competencies were woven into the curriculum but were not explicitly discussed or measured. Themes of compassion and empathy expressed in their journaling illustrated improved attitudes about patient-centred care, which coupled with newly acquired knowledge and skills empowered them to become patient safety champions.

The educational intervention was effective across the diverse cultures represented at the workshop. These international patient safety efforts offer encouragement to nursing students to understand inconsistencies in healthcare and assess their own practice as they develop professional maturity. Speaking up to those in authority with the fear of disciplinary action varies with how well an organisation has developed a safety culture and practices that are endorsed in that particular setting. Helping students develop a mindful approach that incorporates active listening, fosters further understanding of patients’ cultural backgrounds and underlying values (Olds and Dolansky, 2017) helps optimise patient-centred care and teamwork; both are linked to better outcomes (Sherwood and McNeill, 2017; Stevens et al., 2019). In this study, participants noted the clinical relevance of communication skills they learned such as SBAR and Teach Back, and how they can be applied in their work. Although participants did discuss the role of evidence in their reflective writings, evidence-based practice was the least mentioned QSEN competency, perhaps because that content needs to be strengthened. Although its application was presented, informatics skill development was limited due to resource limitations.

Mansour (2012) and Stevens et al. (2019) note the lack of a modern global patient safety agenda to guide nursing education and practice and further remark on the dearth of related research. The recently published first State of the World Report on Nursing (World Health Organisation, 2020) calls for nurses, the largest of the world’s health professions, to step up leadership to influence healthcare delivery, but that commitment is predicated on changes in nursing education to prepare nurses firstly to develop safety competencies and secondly to learn effective empowering communication skills.

More opportunities are needed for nurses from diverse backgrounds and nationalities to come together to learn from, with and about each other to share knowledge, skills and attitudes that can shape organisational patient safety culture. Nurses are in leadership roles to be primary influencers. Nurses must be prepared for the real world challenges around patient safety and quality (Baillie, 2019; Stevens et al., 2019) with leadership capacity to drive progress in healthcare policy and delivery (World Health Organization, 2020). Nurse educators must align curriculum priorities and essentials with national and global safety priorities to match real world expectations. Collaboration is a key to creating the intersectional dialogue needed to achieve change to improve patient safety and quality outcomes across all countries.

Limitations

The study is limited by the sample size, convenience selection which may not be representative and lack of a comparison between undergraduate and graduate populations. The education intervention may not have focused equally on all six QSEN competencies, in particular evidence-based practice and informatics, due to time and resource constraints, therefore data collection tools may not have been totally consistent with content. Future programmes should ensure a balanced curriculum across all required competencies. Results could have been biased by the retrospective method of completing the survey even though evidence supports its use.

Conclusion

The staggering numbers associated with healthcare errors and adverse outcomes across the globe mandate bold action and global collaborations. By preparing nurses using the QSEN competencies as foundational elements of a global, collaborative learning experience, participant perspectives of patient safety were transformed. Strengthening the patient safety competencies of participants can help novice nurses develop the potential to change the prevailing paradigm, transform clinical practice and reduce preventable errors. Nurse educators in all global regions are charged with providing patient safety education to support mastery of competencies and meet the universal responsibility to focus on person-centred care, reduce errors and improve patient outcomes.

Key points for policy, practice and/or research

• The need to improve patient safety and quality is universal, with improvement needed in all healthcare systems.

• Quality and Safety Education for Nurses competencies can be adaptable in the global context.

• To prepare nurses to drive progress in healthcare, nursing education must align with clinical practice needs and national and global priorities.

• International learning collaboratives can be a way to share quality and safety competencies jointly within a multicultural context.

Biography

Julie Sanford is Professor and Dean of Nursing at the University of Mississippi Medical Center in Jackson, MS. She formerly served as Chair of the INU Nursing Collaborative.

Christine Argenbright is an Associate Professor at James Madison University, VA. Her programme focuses on leadership and quality/safety preparedness. She partnered with the Nursing Collaborative in 2017.

Gwen Sherwood is a Professor Emeritus at the University of North Carolina at Chapel Hill School of Nursing, was co-developer of QSEN, the Quality and Safety Education for Nurses project.

Portia J Jordan is a Professor in the Department of Nursing and Midwifery, Stellenbosch University. Her research interest is in critical care nursing, underpinned by evidence-based practice, patient safety education and implementation strategies.

Maria F Jimenez-Herrera is Associate Professor at University Rovira i Virgili, Tarragona, Spain. She is a member of the International Network of Universities, a committees and agencies member and her interests include the development of nursing knowledge.

Mariette Bengtsson is Associate Professor and Director of Studies, a member of the INU and co-developer of QSEN conferences to define a competency model to improve safety in nursing.

Michiko Moriyama is a member of the International Network of Universities’ Nursing Leadership Collaborative and is host of the INU Nursing Summer Workshop, which has been implemented since 2012 in Hiroshima, Japan.

Lee-Peng Lui is a Senior Lecturer and MSc Course Director at the School of Nursing, Kingston University. She participated in a patient safety workshop with INU nursing colleagues in 2017.

Maria McDonald is a PhD in Nursing student in the School of Nursing at the University of Virginia. She is a Board certified Family Nurse Practitioner, research assistant and graduate teaching assistant.