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  • What Happened to Alex? Alex James was a runner, like his dad. One day, he collapsed during a run and was hospitalized for five days. He went through lots of tests, but was given a clean bill of health. Then, a month later, he collapsed again, fell into a deep coma, and died. His father wanted to know — what had gone wrong? Dr. John James, a retired toxicologist at NASA, tells the story of how he uncovered the cause of his son’s death and became a patient safety advocate.
  • Improving Care in Rural Rwanda When Dr. Patrick Lee and his teammates began their quality improvement work in Kirehe, Rwanda, last year, the staff at the local hospital was taking vital signs properly less than half the time. Today, the staff does that task properly 95% of the time. Substantial resource and infrastructure inputs, combined with dedicated Rwandan partners and simple quality improvement tools, have dramatically improved staff morale and the quality of care in Kirehe.

nursing quality improvement case study

  • Research article
  • Open access
  • Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

  • Jannine van Schothorst–van Roekel 1 ,
  • Anne Marie J.W.M. Weggelaar-Jansen 1 ,
  • Carina C.G.J.M. Hilders 1 ,
  • Antoinette A. De Bont 1 &
  • Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

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Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Peer Review reports

The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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Acknowledgements

The authors would like to thank all participants for their contribution to this study.

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

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Jannine van Schothorst–van Roekel, Anne Marie J.W.M. Weggelaar-Jansen, Carina C.G.J.M. Hilders, Antoinette A. De Bont & Iris Wallenburg

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A.W. and I.W. developed the study design. J.S. and A.W. were responsible for data collection, enhanced by I.W. for data analysis and drafting the manuscript. C.H. and A.B. critically revised the paper. All authors have read and approved the manuscript.

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van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

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Quality improvement into practice

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  • Peer review
  • Adam Backhouse , quality improvement programme lead 1 ,
  • Fatai Ogunlayi , public health specialty registrar 2
  • 1 North London Partners in Health and Care, Islington CCG, London N1 1TH, UK
  • 2 Institute of Applied Health Research, Public Health, University of Birmingham, B15 2TT, UK
  • Correspondence to: A Backhouse adam.backhouse{at}nhs.net

What you need to know

Thinking of quality improvement (QI) as a principle-based approach to change provides greater clarity about ( a ) the contribution QI offers to staff and patients, ( b ) how to differentiate it from other approaches, ( c ) the benefits of using QI together with other change approaches

QI is not a silver bullet for all changes required in healthcare: it has great potential to be used together with other change approaches, either concurrently (using audit to inform iterative tests of change) or consecutively (using QI to adapt published research to local context)

As QI becomes established, opportunities for these collaborations will grow, to the benefit of patients.

The benefits to front line clinicians of participating in quality improvement (QI) activity are promoted in many health systems. QI can represent a valuable opportunity for individuals to be involved in leading and delivering change, from improving individual patient care to transforming services across complex health and care systems. 1

However, it is not clear that this promotion of QI has created greater understanding of QI or widespread adoption. QI largely remains an activity undertaken by experts and early adopters, often in isolation from their peers. 2 There is a danger of a widening gap between this group and the majority of healthcare professionals.

This article will make it easier for those new to QI to understand what it is, where it fits with other approaches to improving care (such as audit or research), when best to use a QI approach, making it easier to understand the relevance and usefulness of QI in delivering better outcomes for patients.

How this article was made

AB and FO are both specialist quality improvement practitioners and have developed their expertise working in QI roles for a variety of UK healthcare organisations. The analysis presented here arose from AB and FO’s observations of the challenges faced when introducing QI, with healthcare providers often unable to distinguish between QI and other change approaches, making it difficult to understand what QI can do for them.

How is quality improvement defined?

There are many definitions of QI ( box 1 ). The BMJ ’s Quality Improvement series uses the Academy of Medical Royal Colleges definition. 6 Rather than viewing QI as a single method or set of tools, it can be more helpful to think of QI as based on a set of principles common to many of these definitions: a systematic continuous approach that aims to solve problems in healthcare, improve service provision, and ultimately provide better outcomes for patients.

Definitions of quality improvement

Improvement in patient outcomes, system performance, and professional development that results from a combined, multidisciplinary approach in how change is delivered. 3

The delivery of healthcare with improved outcomes and lower cost through continuous redesigning of work processes and systems. 4

Using a systematic change method and strategies to improve patient experience and outcome. 5

To make a difference to patients by improving safety, effectiveness, and experience of care by using understanding of our complex healthcare environment, applying a systematic approach, and designing, testing, and implementing changes using real time measurement for improvement. 6

In this article we discuss QI as an approach to improving healthcare that follows the principles outlined in box 2 ; this may be a useful reference to consider how particular methods or tools could be used as part of a QI approach.

Principles of QI

Primary intent— To bring about measurable improvement to a specific aspect of healthcare delivery, often with evidence or theory of what might work but requiring local iterative testing to find the best solution. 7

Employing an iterative process of testing change ideas— Adopting a theory of change which emphasises a continuous process of planning and testing changes, studying and learning from comparing the results to a predicted outcome, and adapting hypotheses in response to results of previous tests. 8 9

Consistent use of an agreed methodology— Many different QI methodologies are available; commonly cited methodologies include the Model for Improvement, Lean, Six Sigma, and Experience-based Co-design. 4 Systematic review shows that the choice of tools or methodologies has little impact on the success of QI provided that the chosen methodology is followed consistently. 10 Though there is no formal agreement on what constitutes a QI tool, it would include activities such as process mapping that can be used within a range of QI methodological approaches. NHS Scotland’s Quality Improvement Hub has a glossary of commonly used tools in QI. 11

Empowerment of front line staff and service users— QI work should engage staff and patients by providing them with the opportunity and skills to contribute to improvement work. Recognition of this need often manifests in drives from senior leadership or management to build QI capability in healthcare organisations, but it also requires that frontline staff and service users feel able to make use of these skills and take ownership of improvement work. 12

Using data to drive improvement— To drive decision making by measuring the impact of tests of change over time and understanding variation in processes and outcomes. Measurement for improvement typically prioritises this narrative approach over concerns around exactness and completeness of data. 13 14

Scale-up and spread, with adaptation to context— As interventions tested using a QI approach are scaled up and the degree of belief in their efficacy increases, it is desirable that they spread outward and be adopted by others. Key to successful diffusion of improvement is the adaption of interventions to new environments, patient and staff groups, available resources, and even personal preferences of healthcare providers in surrounding areas, again using an iterative testing approach. 15 16

What other approaches to improving healthcare are there?

Taking considered action to change healthcare for the better is not new, but QI as a distinct approach to improving healthcare is a relatively recent development. There are many well established approaches to evaluating and making changes to healthcare services in use, and QI will only be adopted more widely if it offers a new perspective or an advantage over other approaches in certain situations.

A non-systematic literature scan identified the following other approaches for making change in healthcare: research, clinical audit, service evaluation, and clinical transformation. We also identified innovation as an important catalyst for change, but we did not consider it an approach to evaluating and changing healthcare services so much as a catch-all term for describing the development and introduction of new ideas into the system. A summary of the different approaches and their definition is shown in box 3 . Many have elements in common with QI, but there are important difference in both intent and application. To be useful to clinicians and managers, QI must find a role within healthcare that complements research, audit, service evaluation, and clinical transformation while retaining the core principles that differentiate it from these approaches.

Alternatives to QI

Research— The attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods. 17

Clinical audit— A way to find out if healthcare is being provided in line with standards and to let care providers and patients know where their service is doing well, and where there could be improvements. 18

Service evaluation— A process of investigating the effectiveness or efficiency of a service with the purpose of generating information for local decision making about the service. 19

Clinical transformation— An umbrella term for more radical approaches to change; a deliberate, planned process to make dramatic and irreversible changes to how care is delivered. 20

Innovation— To develop and deliver new or improved health policies, systems, products and technologies, and services and delivery methods that improve people’s health. Health innovation responds to unmet needs by employing new ways of thinking and working. 21

Why do we need to make this distinction for QI to succeed?

Improvement in healthcare is 20% technical and 80% human. 22 Essential to that 80% is clear communication, clarity of approach, and a common language. Without this shared understanding of QI as a distinct approach to change, QI work risks straying from the core principles outlined above, making it less likely to succeed. If practitioners cannot communicate clearly with their colleagues about the key principles and differences of a QI approach, there will be mismatched expectations about what QI is and how it is used, lowering the chance that QI work will be effective in improving outcomes for patients. 23

There is also a risk that the language of QI is adopted to describe change efforts regardless of their fidelity to a QI approach, either due to a lack of understanding of QI or a lack of intention to carry it out consistently. 9 Poor fidelity to the core principles of QI reduces its effectiveness and makes its desired outcome less likely, leading to wasted effort by participants and decreasing its credibility. 2 8 24 This in turn further widens the gap between advocates of QI and those inclined to scepticism, and may lead to missed opportunities to use QI more widely, consequently leading to variation in the quality of patient care.

Without articulating the differences between QI and other approaches, there is a risk of not being able to identify where a QI approach can best add value. Conversely, we might be tempted to see QI as a “silver bullet” for every healthcare challenge when a different approach may be more effective. In reality it is not clear that QI will be fit for purpose in tackling all of the wicked problems of healthcare delivery and we must be able to identify the right tool for the job in each situation. 25 Finally, while different approaches will be better suited to different types of challenge, not having a clear understanding of how approaches differ and complement each other may mean missed opportunities for multi-pronged approaches to improving care.

What is the relationship between QI and other approaches such as audit?

Academic journals, healthcare providers, and “arms-length bodies” have made various attempts to distinguish between the different approaches to improving healthcare. 19 26 27 28 However, most comparisons do not include QI or compare QI to only one or two of the other approaches. 7 29 30 31 To make it easier for people to use QI approaches effectively and appropriately, we summarise the similarities, differences, and crossover between QI and other approaches to tackling healthcare challenges ( fig 1 ).

Fig 1

How quality improvement interacts with other approaches to improving healthcare

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QI and research

Research aims to generate new generalisable knowledge, while QI typically involves a combination of generating new knowledge or implementing existing knowledge within a specific setting. 32 Unlike research, including pragmatic research designed to test effectiveness of interventions in real life, QI does not aim to provide generalisable knowledge. In common with QI, research requires a consistent methodology. This method is typically used, however, to prove or disprove a fixed hypothesis rather than the adaptive hypotheses developed through the iterative testing of ideas typical of QI. Both research and QI are interested in the environment where work is conducted, though with different intentions: research aims to eliminate or at least reduce the impact of many variables to create generalisable knowledge, whereas QI seeks to understand what works best in a given context. The rigour of data collection and analysis required for research is much higher; in QI a criterion of “good enough” is often applied.

Relationship with QI

Though the goal of clinical research is to develop new knowledge that will lead to changes in practice, much has been written on the lag time between publication of research evidence and system-wide adoption, leading to delays in patients benefitting from new treatments or interventions. 33 QI offers a way to iteratively test the conditions required to adapt published research findings to the local context of individual healthcare providers, generating new knowledge in the process. Areas with little existing knowledge requiring further research may be identified during improvement activities, which in turn can form research questions for further study. QI and research also intersect in the field of improvement science, the academic study of QI methods which seeks to ensure QI is carried out as effectively as possible. 34

Scenario: QI for translational research

Newly published research shows that a particular physiotherapy intervention is more clinically effective when delivered in short, twice-daily bursts rather than longer, less frequent sessions. A team of hospital physiotherapists wish to implement the change but are unclear how they will manage the shift in workload and how they should introduce this potentially disruptive change to staff and to patients.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this article?

Adopting a QI approach, the team realise that, although the change they want to make is already determined, the way in which it is introduced and adapted to their wards is for them to decide. They take time to explain the benefits of the change to colleagues and their current patients, and ask patients how they would best like to receive their extra physiotherapy sessions.

The change is planned and tested for two weeks with one physiotherapist working with a small number of patients. Data are collected each day, including reasons why sessions were missed or refused. The team review the data each day and make iterative changes to the physiotherapist’s schedule, and to the times of day the sessions are offered to patients. Once an improvement is seen, this new way of working is scaled up to all of the patients on the ward.

The findings of the work are fed into a service evaluation of physiotherapy provision across the hospital, which uses the findings of the QI work to make recommendations about how physiotherapy provision should be structured in the future. People feel more positive about the change because they know colleagues who have already made it work in practice.

QI and clinical audit

Clinical audit is closely related to QI: it is often used with the intention of iteratively improving the standard of healthcare, albeit in relation to a pre-determined standard of best practice. 35 When used iteratively, interspersed with improvement action, the clinical audit cycle adheres to many of the principles of QI. However, in practice clinical audit is often used by healthcare organisations as an assurance function, making it less likely to be carried out with a focus on empowering staff and service users to make changes to practice. 36 Furthermore, academic reviews of audit programmes have shown audit to be an ineffective approach to improving quality due to a focus on data collection and analysis without a well developed approach to the action section of the audit cycle. 37 Clinical audits, such as the National Clinical Audit Programme in the UK (NCAPOP), often focus on the management of specific clinical conditions. QI can focus on any part of service delivery and can take a more cross-cutting view which may identify issues and solutions that benefit multiple patient groups and pathways. 30

Audit is often the first step in a QI process and is used to identify improvement opportunities, particularly where compliance with known standards for high quality patient care needs to be improved. Audit can be used to establish a baseline and to analyse the impact of tests of change against the baseline. Also, once an improvement project is under way, audit may form part of rapid cycle evaluation, during the iterative testing phase, to understand the impact of the idea being tested. Regular clinical audit may be a useful assurance tool to help track whether improvements have been sustained over time.

Scenario: Audit and QI

A foundation year 2 (FY2) doctor is asked to complete an audit of a pre-surgical pathway by looking retrospectively through patient documentation. She concludes that adherence to best practice is mixed and recommends: “Remind the team of the importance of being thorough in this respect and re-audit in 6 months.” The results are presented at an audit meeting, but a re-audit a year later by a new FY2 doctor shows similar results.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this paper?

Contrast the above with a team-led, rapid cycle audit in which everyone contributes to collecting and reviewing data from the previous week, discussed at a regular team meeting. Though surgical patients are often transient, their experience of care and ideas for improvement are captured during discharge conversations. The team identify and test several iterative changes to care processes. They document and test these changes between audits, leading to sustainable change. Some of the surgeons involved work across multiple hospitals, and spread some of the improvements, with the audit tool, as they go.

QI and service evaluation

In practice, service evaluation is not subject to the same rigorous definition or governance as research or clinical audit, meaning that there are inconsistencies in the methodology for carrying it out. While the primary intent for QI is to make change that will drive improvement, the primary intent for evaluation is to assess the performance of current patient care. 38 Service evaluation may be carried out proactively to assess a service against its stated aims or to review the quality of patient care, or may be commissioned in response to serious patient harm or red flags about service performance. The purpose of service evaluation is to help local decision makers determine whether a service is fit for purpose and, if necessary, identify areas for improvement.

Service evaluation may be used to initiate QI activity by identifying opportunities for change that would benefit from a QI approach. It may also evaluate the impact of changes made using QI, either during the work or after completion to assess sustainability of improvements made. Though likely planned as separate activities, service evaluation and QI may overlap and inform each other as they both develop. Service evaluation may also make a judgment about a service’s readiness for change and identify any barriers to, or prerequisites for, carrying out QI.

QI and clinical transformation

Clinical transformation involves radical, dramatic, and irreversible change—the sort of change that cannot be achieved through continuous improvement alone. As with service evaluation, there is no consensus on what clinical transformation entails, and it may be best thought of as an umbrella term for the large scale reform or redesign of clinical services and the non-clinical services that support them. 20 39 While it is possible to carry out transformation activity that uses elements of QI approach, such as effective engagement of the staff and patients involved, QI which rests on iterative test of change cannot have a transformational approach—that is, one-off, irreversible change.

There is opportunity to use QI to identify and test ideas before full scale clinical transformation is implemented. This has the benefit of engaging staff and patients in the clinical transformation process and increasing the degree of belief that clinical transformation will be effective or beneficial. Transformation activity, once completed, could be followed up with QI activity to drive continuous improvement of the new process or allow adaption of new ways of working. As interventions made using QI are scaled up and spread, the line between QI and transformation may seem to blur. The shift from QI to transformation occurs when the intention of the work shifts away from continuous testing and adaptation into the wholesale implementation of an agreed solution.

Scenario: QI and clinical transformation

An NHS trust’s human resources (HR) team is struggling to manage its junior doctor placements, rotas, and on-call duties, which is causing tension and has led to concern about medical cover and patient safety out of hours. A neighbouring trust has launched a smartphone app that supports clinicians and HR colleagues to manage these processes with the great success.

This problem feels ripe for a transformation approach—to launch the app across the trust, confident that it will solve the trust’s problems.

Before continuing reading think about your own organisation— What do you think will happen, and how would you use the QI principles described in this article for this situation?

Outcome without QI

Unfortunately, the HR team haven’t taken the time to understand the underlying problems with their current system, which revolve around poor communication and clarity from the HR team, based on not knowing who to contact and being unable to answer questions. HR assume that because the app has been a success elsewhere, it will work here as well.

People get excited about the new app and the benefits it will bring, but no consideration is given to the processes and relationships that need to be in place to make it work. The app is launched with a high profile campaign and adoption is high, but the same issues continue. The HR team are confused as to why things didn’t work.

Outcome with QI

Although the app has worked elsewhere, rolling it out without adapting it to local context is a risk – one which application of QI principles can mitigate.

HR pilot the app in a volunteer specialty after spending time speaking to clinicians to better understand their needs. They carry out several tests of change, ironing out issues with the process as they go, using issues logged and clinician feedback as a source of data. When they are confident the app works for them, they expand out to a directorate, a division, and finally the transformational step of an organisation-wide rollout can be taken.

Education into practice

Next time when faced with what looks like a quality improvement (QI) opportunity, consider asking:

How do you know that QI is the best approach to this situation? What else might be appropriate?

Have you considered how to ensure you implement QI according to the principles described above?

Is there opportunity to use other approaches in tandem with QI for a more effective result?

How patients were involved in the creation of this article

This article was conceived and developed in response to conversations with clinicians and patients working together on co-produced quality improvement and research projects in a large UK hospital. The first iteration of the article was reviewed by an expert patient, and, in response to their feedback, we have sought to make clearer the link between understanding the issues raised and better patient care.

Contributors: This work was initially conceived by AB. AB and FO were responsible for the research and drafting of the article. AB is the guarantor of the article.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: This article is part of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ , including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ ’s quality improvement editor post are funded by the Health Foundation.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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nursing quality improvement case study

Evaluation of the Nursing Information System and Quality Indicators Improvement: A Case Study in Taiwan from 2011 to 2022

nursing quality improvement case study

Wu, M., Lai, S., Huang, C., & Chang, T. (2023). Evaluation of the nursing information system and quality indicators improvement: A case study in Taiwan from 2011 to 2022. Online Journal of Nursing Informatics (OJNI), 26 (3), https://www.himss.org/resources/online-journal-nursing-informatics

Objectives : Nursing information systems (NISs) support nurses in their daily tasks in the hospital. This study evaluated the perception of NIS by experts and nurses and investigated process improvement in quality indicators before and after implementation of NIS in a tertiary care hospital in Taiwan from 2011 to 2022.

Methods : This study included three parts. (1) Two external experts and 16 internal experts used Stage 6 guidelines of the Electronic Medical Record Adoption Model (EMRAM) (HIMSS, 2018) and NISTIR 7804 (Lowry, 2015) to evaluate the NIS, respectively. (2) A structured questionnaire was applied for evaluation of NIS experiences among nurses in this tertiary care hospital in Taiwan. (3) Quality indicators, including the incidence of pressure injuries, the incidence of falls, medication administration errors, and blood transfusion errors (near miss), were tracked using the event reporting system.

Results : (1) After the examination of the external and internal experts in 2020, the medication administration system was highlighted as the weakness for NIS. Accordingly, the following process improvement focused on the closed-loop and interface of medication administration in 2021. (2) The 879 nurses had a moderate to high degree of positive attitude (4.67-5.48 points) towards the effect of NIS. (3) The incidences of pressure injuries and falls were 0.35 and 0.07 per 100 patient days in 2011, while in 2019, with the subsystems of NIS established, the incidences of pressure injuries and falls were 0.21 and 0.07, respectively. The number of medication administration and blood transfusion errors (near misses) decreased from 43 and 8 errors per month in 2011 to 70 and 1 error per month in 2019, respectively. After improving the closed-loop and interface of medication administration in 2021, medication administration errors declined to 17 cases per month in 2022.

Conclusion : After identifying and improving the weakness of NIS, our findings demonstrated that the refined NIS might have a positive association with quality indicators, providing evidence that optimizing NIS may benefit patients’ healthcare outcomes.

Introduction

Nursing information systems (NIS) are essential in contemporary clinical nursing practice, promoting the shift from traditional paper‑based records to electronic documentation systems. The aims of NIS encompass completing care records and improving care quality (American Nurses Association [ANA], 2016; Classen et al., 2020), resulting in easier access to health information, improved readability of nursing documents, avoidance of repetition in the documenting process, better support of workflow, and greater respect for legal rules and principles (Samadbeik et al., 2017). Moreover, the data of NIS can be allowed to enter hospital electronic health records (EHR), and the timely interoperation between EHR and other information platforms in the hospital, which not only facilitates clinical decision-making but also improves clinical services and thus increases the quality of care (Shaikh et al., 2022). In the face of ever-changing scenarios in clinical settings, continuous evaluation, and improvement of NIS and EHR based on expert advice, user opinions, and systematic results are needed (Ellsworth et al., 2017: Shaikh et al., 2022).

The Electronic Medical Record Adoption Model (EMRAM), proposed by the Health Care Information Management Systems Society (HIMSS) Analytics (HIMSS, 2018), is universally recognized as a standard for the assessment of EHRs. It provides a comprehensive stage-wise framework guiding health organizations in tracking their level of adoption of EHR (Shaikh et al., 2022). The HIMSS defines EHR as a longitudinal electronic record of patient health information produced by visits to healthcare settings. HIMSS Analytics also developed EMRAM Stage 6 guidelines to list key NIS elements, with closed-loop medication administration and blood transfusion systems considered crucial for nursing practice (HIMSS, 2018). Open-source EHR systems have gained notable recognition due to their availability, wider compatibility, user-friendliness, and unrestricted modification and restructuring. In addition, Samadbeik et al. (2017) suggested that the expectations and needs of nurses should be involved in redesigning the development of the specific system. This will facilitate their positive attitude toward the new system and reduce resistance to its implementation. Furthermore, as quality indicators could reflect the safety of patients, it is also a vital consideration for system evaluation.

Despite the broader application of NIS, the evaluation of NIS has seldom been done thoroughly and sufficiently (Rogers et al., 2013) and was usually criticized for lacking comprehensive theoretical and practical tools, methods, and existing guides (Yusof et al., 2008). Additionally, although previous literature has indicated that using electronic nursing records in the clinical decision support system (CDSS) could reduce the risk of general injury events, such as hospital-acquired pressure injury and inpatient falls (Furukawa et al., 2020), the evidence of the relationship between NIS and such quality indicators is limited. Therefore, the purpose of this study was (1) to use Stage 6 guidelines of the Electronic Medical Record Adoption Model (EMRAM) (HIMSS, 2018) and NISTIR 7804 (Lowry, 2015) to evaluate the NIS by external experts and internal experts, respectively; (2) to apply a structured questionnaire to evaluate nurses’ experiences on NIS; and (3) investigate the process improvement in quality indicators, including the incidence of pressure injuries, the incidence of falls, blood transfusion errors, and medication administration errors before and after implementation of NIS in a tertiary care hospital in Taiwan from 2011 to 2022.

This case study was conducted in a 1,648-bed tertiary care hospital in Taiwan. A computer-based NIS was adopted in 2011 and sustained in a stepwise way until 2019. During this period, the research hospital implemented its self-developed NIS based on HIMSS-EMRAM, and several subsystems were included in the NIS, such as the nursing shift system, nursing task listing, barcode medication administration, barcode blood transfusion, nursing record/nursing care plan, nursing assessment system, nursing CDSS in pressure injury/fall, and automatic transmission of vital signs. In 2020, evaluations of experts and nurses were performed to determine any flaws of the NIS. According to the results of experts and nurses, the research hospital improved the closed-loop of medication administration and the computer interface in 2021. Additionally, the quality indicators including the incidence of pressure injuries, the incidence of falls, medication administration errors, and blood transfusion errors (near miss) between 2011 to 2022 were investigated (Figure 1).

Figure 1: Nursing process redesign and improvement in the NIS

This study encompassed three parts. First, two external experts identified the weaknesses of the NIS using the HIMSS-EMRAM evaluation (HIMSS, 2018). Sixteen internal experts were recruited, using inclusion criteria of having experience using an NIS, more than 10 years of work experience, serving as a nursing information instructor at the worksite, and providing consent for participation. The internal experts conducted the NISTIR 7804 Technical Evaluation (Lowry, 2015) through a two-round Delphi process and a focus group for identification of the disadvantages of the NIS.

Second, a structured questionnaire was employed to explore the perception of nurses on NIS. We assessed the time proportion spent on subsystems in NIS (e.g., nursing record information system, the automatic transmission system of vital signs, the barcode medication administration system, the barcode blood transfusion system, the nursing shift system, the nursing task listing, and others) in daily work using self-reported items to ascertain the subsystem most frequently used in NIS among nurses. In addition, we used the 19-item Computer System Usability Questionnaire (CSUQ) (Lewis, 1995) in which each item is rated on a 7-point scale, with higher scores indicating greater usability.

Furthermore, to evaluate the perceptions of participants about the effectiveness of NIS, we added three other items in the structured questionnaire. The three items were as follows and rated on a 7-point scale, with higher scores indicating more positive perceptions: (1) NIS can help reduce the required nursing time during clinical practice, (2) NIS can help me practice contemporary nursing knowledge and improve the outcome of clinical nursing care, and (3) NIS can reduce nursing errors and increase patient safety. Five experts confirmed the validity of the content, and the validity index of the content was 0.93–0.98. The reliability was verified by 30 nursing staff members, who determined the internal consistency (Cronbach’s α) of the questionnaire through a pilot study; the Cronbach's α was 0.89–0.98.

Finally, we used event reports in NIS to evaluate the quality indicators, including incidence of pressure injuries, incidence of falls, number of medication administration errors, and number of blood transfusion errors.

This study was approved by the institutional review board of the case hospital (IRB-CCH-IRP-Y1070243).

Evaluation by external and internal experts

The results from external experts indicated the following weaknesses. (1) The checklist of nursing tasks only covered examination and dressing change, while medication orders would be excluded, but the daily tasks of nurses implementing medication orders were indispensable. (2) It was required to improve the automatic drug dose calculation function. (3) Unit dose dispensing had not yet been practiced, making dose checks on the units necessary.

Sixteen internal experts completed 175 items in the NISTIR 7804 Technical Evaluation (Lowry, 2015). The results demonstrated that the average score was 0.6 points (a score of 4 points indicated the problem most in need for improvement), and 17 items out of the 175 items had an average score of higher than 1 point. After a focus group meeting, internal experts concluded the four improvements as follows. (1) The function of automatic calculation for drug dose in the medication administration system should be developed to reduce the hand-calculation errors. (2) It would be recommended to confirm the accuracy of identification to the right patients and drugs. (3) Avoiding truncation of the 5 rights of the patients in the interface of medication administration system was necessary. (4) There was a need to establish limitations when the second record of the same patient had been opened by the other user at the same time.    

After combining the suggestions of external and internal experts, the greatest weakness of the NIS was the medication administration system; thereby, a process improvement was proposed in the closed-loop medication system in 2021 (Figure 2), which would benefit in the formation of a better-connected system between the physicians, pharmacists, and nurses.

Figure 2: Complete closed-loop administration for medications in 2021

Moreover, the improvement of the drug administration computer interface was also executed to display the complete information of the drugs in 2021 (Figure 3).

Figure 3: The computer interface change of medications administration system in 2021

Nurses ’ evaluation of the NIS

Characteristics of nurses

We included 879 nurses (95.7% women), of whom 38.3% were between 26 and 30 years old, 89.3% had university-level education or higher, and 37.5% had nursing experience of 2 to 5 years. Furthermore, most of the participants had 0 to 3 (30.8%) or more than 10 years (30.1%) of experience in information technology and an acceptable level of perceived information technology competence (74.3%).

The usage of NIS subsystems among nurses

The most frequently used subsystem of NIS was the nursing record information system (34.24%), followed by the barcode medication administration system (22.76%), the automatic transmission system of vital signs (17.96%), the nursing shift system and the nursing task listing (14.66%), the barcode blood transfusion system (7.72%) and others (2.66%).

Experience of NIS

The overall mean (SD) of 19 items in the CSUQ (Lewis, 1995) was 5.25 (0.88) and the range was 4.67–5.48 points, indicating a moderate level of usability of the NIS. In terms of perceptions of NIS effectiveness, the overall mean (SD) of 3 items was 5.21 (0.99) and the range of the self was 5.16–5.25, which indicated that nurses also had moderately positive perceptions of NIS effectiveness. The mean score was 5.22 for the item “this system can help reduce the required nursing time during clinical practice.”; 5.16 for the item “this system can help me practice contemporary nursing knowledge and improve the outcome of clinical nursing care.”; and 5.25 for the item “this system can help reduce nursing errors and increase patient safety.” (Table 1).

Table 1: Nurses experience of NIS (N=879)

Quality indicators from 2011 to 2022

Quality indicators in the present study included pressure injuries, falls, medications, and blood transfusion errors. The NIS was introduced in 2011 and the implementation of CDSS in fall and pressure injuries began in 2013. The results showed that the incidence of pressure injury was 0.35 per 100 patient days in 2011, and 0.21 per 100 patient days in 2019. The incidence of falls was 0.07 per 100 patient days in 2011 and 2019. The barcode medication administration and barcode blood transfusion systems were launched in 2011. The incidence of blood transfusion error decreased from 8 to 1 error per month in 2011 to 2019. For medication administration error, there were 42 and 70 errors per month in 2011 and 2019, respectively. The research hospital carried out the HIMSS stage 6 evaluation in 2020 (HIMSS, 2018) and the results of internal and external experts both mentioned the problem of the medication administration system. Therefore, in 2021, the closed-loop system and the computer interface of the medication system were refined for ease of use; subsequently, the number of errors decreased to 17 errors per month in 2022 (Figure 4).

Figure 4: Trajectory of Quality Indicators among 2011 to 2022

Evaluation of NIS by external and internal experts

Today’s clinical care largely depends on NIS, primarily due to the shortages of nursing human resources, and comorbidities associated with aging. Establishing an NIS is expected to facilitate clinical care (Chang et al., 2020). Our results suggested that the main weakness proposed by two external experts was the medication administration system, which was consistent with the recommendation of internal experts' evaluation in our study. The weakness of the medication administration system included the hand-calculation of medication doses, the accuracy of patients and dosage, truncated display of medication, and synchronous use of several users. These findings were in line with an inpatient wards observational study in Singapore which found that the most common medication error encompassed dose error, and supply errors which might occur from labeling errors, workflow issues, wrong drug preparation technique, and improper procedure for the use of personal digital assistants (Foo et al., 2017). Furthermore, previous research on barcoded medication administration (BCMA) systems in five hospitals identified the errors of BMCA included wrong medication dose and route, inappropriate monitoring of medication, wrong patient, and medication omitted or not administered as documented (Koppel et al., 2008).  

Nurses’ evaluation of the NIS

We found that the most frequently used subsystem of NIS was the nursing record information system. The nursing record information system of NIS covers a broad range of nursing practices in clinical settings, including the admission nursing assessment, physical examinations, nursing care plans, and clinical decision-making, which requires that nurses spend a lot of time on this subsystem. On the other hand, the barcode blood transfusion system was the least frequently used subsystem in our study. Blood transfusion is a treatment for patients with massive bleeding and anemia, but these patients are not commonplace in our research settings, making the time required to apply this system less. A 19-question survey based on the CSUQ (Lewis, 1995) showed that nurses had a moderate level of usability of the NIS. The poor performing items were in order of " Whenever I make a mistake using the system, I recover easily and quickly”, “The information (such as online help, on-screen messages, and other documentation) provided with the system is clear”, “It is easy to find the information I needed”, “The interface of the system is pleasant”, and “ System has all the functions and capabilities I expect it to have ”.

A previous study used the CSQU to survey EHR usage and satisfaction in the simulated situations of diabetes and congestive heart failure, and the 16 healthcare providers (15 physicians and 1 nurse) demonstrated that the overall average score exceeded 6, and the worst performing item was " System gives error messages that tell me how to fix problems ", followed by " System has all the functions and capabilities I expect it to have", "Whenever I make a mistake using a system, I recover easily and quickly", "The information (such as online help, on-screen messages, and other documentation) provided with the system is clear ” (Fischer et al., 2020). Our results were not completely consistent with that of Fischer et al. (2020) which may be due to the different settings and participants. Their research was focused on the scenario of diabetes and congestive heart failure, while our study ascertained the overall perception of the NIS. In addition, 94% of the subjects in their study were physicians (16 physicians and 1 nurse), with a longer average age and work experience; in contrast, a total of 879 participants in our study were all nurses. Moreover, the average score of the overall CSUQ of the Fischer et al. (2020) study was higher than our study, and the poor performance items were also different. The poor performance items in our study were mainly related to the difficulty of problem-solving in the system when users encountered obstacles.

Furthermore, it was noted that the interface was less user-friendly, plus nurses spent a lot of time on the medication administration system in their daily tasks; therefore, nurses are prone to have a lower level of perception of the usability of NIS. Previous literature suggested that nurses' needs should be considered and the design of short steps to accomplish tasks was recommended; in addition, a single screen to display necessary information would improve the satisfaction of the user with the system (Moghaddasi et al., 2017).

In our study, nurses had moderately positive perceptions of NIS effectiveness in terms of reducing the required nursing time during clinical practice, the ability to practice contemporary nursing knowledge and improve the outcome of clinical nursing care, reducing nursing errors and increasing patient safety. A recent study of nurses' attitude to nursing information systems found that nurses perceived moderate positive attitude of NIS on saving time, improved the documentation of patient care, improved nursing care and improved communication among healthcare providers (Sinha & Joy, 2022). However, Sharma et al. (2020) investigated the attitude towards hospital information systems among nurses in a tertiary care hospital in northern India, and the results showed that nurses had lower positive attitudes on how health information systems save time for patient care, reduce duplicate of work, and promote knowledge. This difference in the attitude toward information systems may be due to the characteristics of the participants; that is, our study participants had higher age and proportion of women, and less computer experience and time to use the computer, which may result in weaker positive attitudes about health information systems.

Evaluation results of quality indicators

Our results showed that the quality indicators, including the incidence of falls and pressure injuries, and the number of errors in medication and blood transfusions, increased in the initial years after the primary construction of NIS. With stepwise improvement of NIS through user feedback and gradually established subsystems in the NIS, most indicators expressed a trend of improvement except drug administration errors. After using barcodes in medication administration and blood transfusion systems, blood transfusion errors were reduced correspondently, but not medication administration errors. Blood transfusions are regulated under the national requirements for blood products; therefore, the barcodes on blood bags and procedures are relatively complete and consistent.

However, there were still several obstacles hindering improvement in the medication administration subsystem. First, since the contents of some prescriptions in NIS were not structured, doctors tended to describe the medication information by handwriting. Second, the display of prescriptions and medication administration systems was truncated. Third, nurses still needed to manually check the dosage calculations at the bedside. The results of Tyllinen et al. (2019) for different drug system design tests found that incomplete drug information system design caused more errors. This study found that improving the loop of medication administration system and interfaces through the results of internal and external experts may reduce the number of medication errors, which echoed the recommendation to apply structured information design to improve drug safety (Sheikh, 2020).

In conclusion, from the evaluation of external and internal experts, the medication administration system was identified as the core weakness of NIS, including the closed-loop and interface issues, and nurses also reported that the frequency of usability of medication administration system was second to nursing records in clinical practice. The research hospital refined the relevant system accordingly and there was an improvement in quality indicators in the long period observation. Our results recommended that nursing administrators value the continuous evaluation and optimization of NIS for promoting healthcare outcomes. In terms of study limitation, with the nature of case study, it should be carefully considered when interpreting these results for other hospitals with different levels, location, and patient characteristics.

Online Journal of Nursing Informatics

Powered by the HIMSS Foundation and the HIMSS Nursing Informatics Community, the Online Journal of Nursing Informatics is a free, international, peer reviewed publication that is published three times a year and supports all functional areas of nursing informatics.

Read the Latest Edition

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Chang, I. C., Lin, P. J., Chen, T. H., & Chang, C. H. (2020). Cultural impact on the intention to use Nursing Information Systems of nurses in Taiwan and China: Survey and analysis. Journal of Medical Internet Research, 22 (8), e18078. https://doi.org/10.2196/18078

Classen, D. C., Holmgren, A. J., Newmark, L. P., Seger, D., Danforth, M., & Bates, D. W. (2020). National trends in the safety performance of electronic health record systems from 2009 to 2018. JAMA network open, 3 (5), e205547-e205547. https://doi.org/10.1001/jamanetworkopen.2020.5547

Ellsworth, M. A., Dziadzko, M., O'Horo, J. C., Farrell, A. M., Zhang, J., & Herasevich, V. (2017). An appraisal of published usability evaluations of electronic health records via systematic review. Journal of the American Medical Informatics Association, 24 (1), 218-226. https://doi.org/https://doi.org/10.1093/jamia/ocw046

Fischer, S. H., Safran, C., Gajos, K. Z., & Wright, A. (2020). Visualization of electronic health record data for decision-making in diabetes and congestive heart failure. ACI Open, 4, e35-e43. DOI https://doi.org/10.1055/s-0040-1702213 .

Foo, G. T. T., Tan, C. H., Hing, W. C. H., & Wu, T. S. (2017). Identifying and quantifying weaknesses in the closed loop medication management system in reducing medication errors using a direct observational approach at an academic medical centre. The Journal of Pharmacy Practice and Research, 47 (3), 212-220. https://doi.org/10.1002/jppr.1235

Furukawa, M. F., Eldridge, N., Wang, Y., & Metersky, M. (2020). Electronic health record adoption and rates of in-hospital adverse events. Journal of Patient Safety, 16 (2), 137-142. https://doi.org/10.1097/PTS.0000000000000257

Healthcare Information & Management Systems Society. (2018). Acute Care EMRAM Stage 7 Reviewer's Guide . HIMSS. https://www.himss.org/about-himss

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. T. (2008). Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15 (4), 408–423. https://doi.org/10.1197/jamia.M2616

Lewis, J. R. (1995). IBM Computer Usability Satisfaction Questionnaires: Psychometric Evaluation and Instructions for Use.  International Journal of Human-Computer Interaction ,  7 (1), 57. 

Lowry, S., Ramaiah, M., Patterson, E., Prettyman, S., Simmons, D., Brick, D., Paul, L., C., M. & Taylor, S. (2015). (NISTIR 7804-1) Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization, NIST Interagency/Internal Report (NISTIR), National Institute of Standards and Technology. https://doi.org/10.6028/NIST.IR.7804-1

Moghaddasi, H., Rabiei, R., Asadi, F., & Ostvan, N. (2017). Evaluation of Nursing Information Systems: Application of usability aspects in the development of systems. Healthcare informatics research, 23 (2), 101–108. https://doi.org/10.4258/hir.2017.23.2.101

Rogers, M. L., Sockolow, P. S., Bowles, K. H., Hand, K. E., George, J. (2013). Use of a human factors approach to uncover informatics needs of nurses in documentation of care. International Journal of Medical Informatics , 82, 1068‑74.

Samadbeik, M., Shahrokhi, N., Saremian, M., Garavand, A., & Birjandi, M. (2017). Information processing in nursing information systems: An evaluation study from a developing country. Iranian Journal of Nursing and Midwifery Research, 22 (5), 377–382. https://doi.org/10.4103/ijnmr.IJNMR_201_16

Shaikh, M., Vayani, A. H. M., Akram, S., & Qamar, N. (2022). Open-source electronic health record systems: A systematic review of most recent advances. Health Informatics Journal, 28 (2), 1-31. https://doi.org/10.1177/14604582221099828

Sharma, P., Dhaliwal, A., Sharma, S. B., Yaddanapudi, L. N. (2020). Knowledge and attitude regarding use of hospital information system among nursing personnel in a tertiary care hospital in north India. Journal of Postgraduate Medicine Education and Research, 54 (1), 1-4.

Sheikh, A. (2020). Realising the potential of health information technology to enhance medication safety. BMJ Quality & Safety, 29 (1), 7-9. https://doi.org/10.1136/bmjqs-2019-010018

Sinha, R. K., & Joy, J. (2022). Nurses' knowledge of and attitude to nursing information systems. British Journal of Nursing, 31 (12), 648–654. https://doi-org.autorpa.cmu.edu.tw:8443/10.12968/bjon.2022.31.12.648

Tyllinen, M., Kaipio, J., & Lääveri, T. (2019). Usability analysis of contending electronic health record systems. Studies in Health Technology and Informatics, 257 , 430-435. https://doi.org/10.3233/978-1-61499-951-5-430

Yusof, M. M., Papazafeiropoulou, A., Paul, R. J., Stergioulas, L. K. (2008). Investigating evaluation frameworks for health information systems. International Journal of Medical Informatics , 77 (6), 377–385. https://doi.org/10.1016/j.ijmedinf.2007.08.004

Author Bios

Mei-Wen Wu PhD, RN is a registered nurse. She earned her Nursing PhD degree from the Hungkuang University, Taiwan (R.O.C.). She has 20 years of nursing Supervisor experience in ChangHua Christian Hospital, Taiwan (R.O.C.) Her work focuses specifically on nursing clinical management and quality improvement.

Shu-Mei Lai MS, RN is a registered nurse. She earned her bachelor of science degree from the Central Taiwan University of Science and Technology, and a master of science in healthcare administration from Asia University, Taiwan. For the past fifteen years, her focus has been on nursing quality management in the nursing department at Changhua Christian Hospital in Taiwan with a focus on nursing quality improvement and nursing informatics.

Chi-Yi Huang, PhD is a manager of the medical education department. She received her PhD in Education from Tainan University (R.O.C.), Taiwan. She has 7 years of experience as an administrative supervisor at Changhua Christian Hospital in Taiwan. Her work focuses on educational administration and quality improvement.

Tsai-Hsiu Chang, PhD, RN is an associate professor of Nursing Department at Hungkuang University. She received her PhD in Education from National Taiwan Normal University (R.O.C.), Taiwan. She has 28 years of experience as a teacher, with a focus in community health nursing and nursing research.

nursing quality improvement case study

Heather Larivee, a continuous quality improvement expert and the CEO of Sparkflo, LLC , a business consultancy, says she has worked with healthcare organizations that organize small groups of experienced nurses into such teams. These nurses generally do not deliver direct clinical care, but focus exclusively on observing and determining how to improve healthcare and nursing care within an organization.

Examples include analyzing treatment protocols for patients with chronic heart failure or sepsis or determining how to improve protocols in order to avoid wrong-site surgeries — operations performed on the wrong arm or hip, for example.

“CQI nurses are vital to healthcare improvement efforts because they are able to strategically see the bird's-eye view via the data and because their hands-on clinical experience and knowledge can better inform the tactical process changes in order to drive improvements in clinical safety and quality,” Larivee says. “CQI nurses are the bridge to successful, sustainable quality improvement programs,” she adds.

Learn more about the best organizational foundations for effective quality improvement in “A Business Guide to Effective Quality Improvement in Healthcare.”

Nursing Quality Improvement Project Ideas and Guide on Improved Nursing Care

The Agency for Healthcare Research and Quality (AHRQ) is part of the U.S. Department of Health and Human Services. It focuses on gathering and producing evidence to improve healthcare, with an overall goal of delivering safer, more equitable, and more affordable care.

The AHRQ has produced guides, factsheets, and other information for improving nursing care and overall healthcare. The guides and factsheets offer project ideas for quality improvement in nursing, including the following:

  • Improving healthcare-related communication about individual patients during shift changes of nurses or other healthcare professionals
  • Improving nursing teamwork
  • Improving patient safety by improving the nursing workload
  • Preventing catheter-related infections
  • Preventing falls and injuries in patients within healthcare facilities
  • Preventing pneumonia that can come from airway ventilators used on patients — called ventilator-associated pneumonia
  • Preventing pressure ulcers (bedsores) in patients within healthcare facilities
  • Reducing medication errors
  • Reducing nurse fatigue and stress
  • Reducing staff turnover among nurses

What Is Quality Improvement in Nursing?

Quality improvement in nursing is similar to continuous quality improvement in nursing and to continuous quality improvement in healthcare overall. The terms continuous quality improvement and quality improvement are often used interchangeably in healthcare, as is the older term quality assurance .

Nursing and Other Organizations That Work to Promote Healthcare Quality Improvement

A number of nursing and healthcare organizations work to promote healthcare quality improvement through education, publishing materials, and guidelines and standards.

Here are some of the leading nursing organizations championing quality improvement:

  • American Nurses Association (ANA): This is a leading nursing organization representing roughly 4 million registered nurses in the United States.
  • The American Nurses Credentialing Center Magnet Recognition Program: Operated by a subsidiary of the ANA, this program gives “magnet” recognition to healthcare facilities that show extraordinary excellence in nursing services.
  • Nursing Alliance for Quality Care (NAQC): This is a nonprofit partnership of leading nursing organizations and other healthcare groups. It is now managed by the American Nurses Association.

Other leading organizations for promoting quality improvement in healthcare include the following:

  • Hospital Compare
  • Hospital Quality Alliance
  • Institute for Healthcare Improvement
  • The Joint Commission
  • National Coordinating Council for Medication Error Reporting and Prevention
  • National Quality Forum
  • Physician Consortium for Performance Improvement

The American Nurses Association’s Role in Quality Improvement Efforts

Dating back to 1896, the American Nurses Association has worked for quality improvement in nursing for much of its existence. In more recent decades, it has focused on quality improvement through the following methods:

  • Advocacy: It encourages legislation to increase patient safety and improve healthcare and promotes those goals in other ways.
  • Feedback: It provides feedback to other national quality improvement organizations in healthcare.
  • How healthcare organizations classify patients and their conditions in terms of understanding the staffing needed to improve their outcomes
  • The impact of the healthcare industry on the U.S. economy
  • The relationship between nurse staffing levels and patient outcomes
  • Standards: It has developed some of its own standards, including the National Database of Nursing Quality Indicators® (NDNQI®).

The Research Efforts in Nurse Quality and Quality Improvement in Nursing

Here are more resources that are instrumental to research efforts in nurse quality and quality improvement in nursing:

  • The National Database of Nursing Quality Indicators
  • Research on Patient Classification Systems
  • Research on the Relationship Between Nurse Staffing and Patient Outcomes

Quality Improvement Theory in Nursing

Quality improvement theory in nursing is the same as in healthcare generally.

Beginning two decades ago, many nursing educators began advocating for nursing schools to do more to teach quality improvement theory to nurses.

“In the future, the clinical and economic interests of nurses will depend heavily on their ability to improve quality,” Linda Norman, a Senior Associate Dean for Academics at Vanderbilt University’s School of Nursing, wrote in the journal Nursing Outlook in 2001.

“Thus, to advance as a profession in the years ahead, nurses will need good data on measures of quality that are linked to nursing, and they will need to know how to use this data to continuously improve the quality of nursing care,” she noted.

Since then, nursing schools have been increasingly teaching quality improvement theory and methods in their education programs.

One umbrella effort has been the Quality and Safety Education for Nurses Institute — or QSEN Institute — housed at the Frances Payne Bolton School of Nursing at Case Western University. The institute is a collaboration between nursing and healthcare leaders who gather the best information on good nursing and healthcare practices.

Katreena Merril

“What it does is outline all the information new registered nurses should know,” says Katreena Collette Merrill, Associate Dean of Undergraduate Studies and an Associate Professor in Nursing at Brigham Young University. “It really set the standards for nursing education. When I came from the healthcare environment and went to academics full-time, they weren’t really talking about improvement as much as they were talking about the basics (or nursing). Now, they’re teaching the principles” of quality improvement.

Is your organization ready for effective quality improvement? Use this template to understand questions your organization must ask to assess whether it can execute good quality improvement. This template is free for download, and you can customize it to fit your needs.

Quality Improvement Process Checklist

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Learn more about the history of quality improvement and about leaders who developed the concept — in general and in healthcare — in “Continuous Quality Improvement in Healthcare: Principles, Process, and Tools.”

Nursing Leaders’ Important Historical Role in Advancing CQI in Healthcare

For more than two decades, nurses and nursing leaders have been at the forefront of advancing CQI in healthcare.

Mary Jean Schumann

Mary Jean Schumann is an Associate Professor at the George Washington University School of Nursing and the Chair of the Nursing Alliance for Quality Care. She helped lead the development of the NDNQI standards when she worked for the ANA from 2001-2010.

As a practicing nurse in the 1980s, Schumann remembers how nurses could see healthcare practices and procedures that were harmful — even contributing to patient deaths. But nurses were told they didn’t have the data to back up their concerns, Schumann says.

ANA and others started thinking about how to collect that data, focus on improvement, and understand the benefits of good nursing. “That’s how we got to the nursing outcome indicators,” Schumann says. Their goal, she says, was to answer the following question: “How do you measure the impact of nursing?”

Nurses Continue to Play a Vital Role in Quality Improvement in Healthcare

Nurses remain vital to continuous quality improvement in healthcare. In fact, many believe they might have the most important position — because they are in the best position to see how providers deliver and can improve healthcare services.

There are two reasons for their unique perspective on this issue:

  • They are around patients all the time and see the problems and inefficiencies firsthand.   

Stephanie Sargent

Stephanie Sargent is Vice President of Product Development and Quality for SE Healthcare , a South Carolina healthcare analytics and quality improvement company. She is also a former nurse, having practiced for 15 years.

  • “You hear people describing the ‘sharp points’ of healthcare. Those individuals at the sharp points are those actually laying hands on patients — doing the work of patient care,” Sargent says. Most often, those are nurses, she says. Through her work as a nurse, “I really understood the problems and where there were horrible inefficiencies or gaps in quality — and areas of risk.”  
  • Nurses also understand most parts of a healthcare organization’s systems and processes.  “I also think nurses get the whole picture,” says BYU’s Merrill. “They see all aspects. ”For example, Merrill says, when an organization works on decreasing pressure ulcers (or bedsores), nurses understand how an organization’s nutrition experts can help — because nutrition can have a bearing on the skin breaking down more easily. Or the nurse will know about the vendor that provides the hospital beds and changes that could be made to decrease bedsores. “The nurse knows all of the stakeholders,” she says.

Learn more about the benefits of good quality improvement programs, along with the main questions to answer as part of your quality improvement work, in “A Business Guide to Effective Quality Improvement in Healthcare.”

What Are Examples of Quality Improvement in Nursing?

Quality improvement in nursing are initiatives created to improve patient outcomes and upgrade the overall quality of care. Examples include reducing medical errors, increasing staff communication, implementing evidence-based practices, and upgrading discharge planning.

Experts interviewed for this article cited two nursing-related quality improvement projects they were involved with that were simple, but very beneficial. They both addressed hospital or nursing storage areas.

  • A More Organized Storage Closet:   

Kimberly McAdams

Kimberly McAdams, a process improvement expert and principal with FireFly Consulting , remembers one small project where a hospital focused on better organization of a nurses’ storage closet on one floor of the hospital. As a result of the project, they removed materials that nurses never used; organized and repositioned materials they used most often within the closet; and developed a plan for how the most-used items would be continually replenished.

  • In the end, “nurses were coming from other floors” to use the closet, McAdams says, because it was easier to quickly get the materials they needed.  
  • Better Placement of a Supply Area:   

Jan Wilson

Jan Wilson, Director of Learning Design and Outcomes for Relias , a company that provides performance metrics, assessments, training, and education to the healthcare industry, remembers a nursing home company quality improvement project that closely observed how caregivers did their jobs, including performing various specific tasks. As part of the project, they timed how long it took caregivers to do certain duties.

  •   Wilson says that at first workers were concerned about the timing, but as part of the project, they recorded the distance workers walked to get certain materials and supplies. That supply area was then moved closer to the workers, Wilson says.

You can use a process checklist to help manage a quality improvement process. Use this template, designed specifically for implementing and executing an effective quality improvement process. This template is free for download, and you can customize it to fit your needs.

Managing Change Checklist

Download Managing Change Quality Improvement Template

Excel | Word | PDF

See more real-world examples of continuous quality improvement projects in healthcare in the “Largest Roundup of Healthcare Improvement Examples and Projects.”

What Is a Quality Improvement Management Nurse and What Do They Do?

Increasingly, healthcare organizations are creating positions and hiring professionals — including nurses — who are focused only on healthcare and nursing quality improvement.

An increasingly common job title is quality improvement management nurse . The person in that job does the following:

  • Combines expertise in healthcare, quality improvement, and management to lead systemic improvements in policies and processes
  • Continually assesses performance data and trends in healthcare metrics
  • Continually works with other organization managers to ensure that problems in healthcare processes are identified and fixed
  • Ensures the organization complies with requirements from state and federal agencies and the Joint Commission, which accredits hospitals
  • Helps design and execute training programs
  • Provides feedback and recommendations for improvement to an organization’s top leaders
  • Solicits and collects feedback from patients, employees, and members of the public

Strategies for Quality Improvement in Critical Care Nursing

Experts have also made recommendations for quality improvement in critical care nursing. The process, of course, is similar to quality improvement in other nursing areas, as well as healthcare quality improvement in general. Recommendations include the following:

  • Choose the right healthcare metric to measure. The metric needs to be a relevant gauge for true health benefits. An example of a good metric is the rate of catheter-related urinary tract infections, which have been a problem throughout the U.S. healthcare system.
  • Collect the best and most relevant data. The development of electronic health records for all patients helps here, compared to decades ago when data was handwritten on paper within patient charts. But there is still information outside of electronic health records that can be helpful for understanding how to improve a healthcare process.
  • Disseminate the data. The medical teams involved must understand what the current data shows about a healthcare process and recognize how that data is changing as the process shifts. You can better engage everyone involved by using charts and graphics to show the data.
  • Empower nurses. There are more nurses than any other group of healthcare workers, and their jobs put them in positions to understand problems and make change. They are often motivated to bring about change, and quality improvement systems need to take advantage of that, along with their experience and abilities.

Quality Improvement Tools in Healthcare and Nursing

Quality improvement tools in nursing are the same as quality improvement tools in healthcare in general. You can learn more about some of these tools in “A Business Guide to Effective Quality Improvement in Healthcare.”

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College of Nursing

Driving change: a case study of a dnp leader in residence program in a gerontological center of excellence.

View as pdf A later version of this article appeared in Nurse Leader , Volume 21, Issue 6 , December 2023 . 

The American Association of Colleges of Nursing (AACN) published the Essentials of Doctoral Education for Advanced Practice Nursing in 2004 identifying the essential curriculum needed for preparing advanced practice nurse leaders to effectively assess organizations, identify systemic issues, and facilitate organizational changes. 1 In 2021, AACN updated the curriculum by issuing The Essentials: Core Competencies for Professional Nursing Education to guide the development of competency-based education for nursing students. 1 In addition to AACN’s competency-based approach to curriculum, in 2015 the American Organization of Nurse Leaders (AONL) released Nurse Leader Core Competencies (updated in 2023) to help provide a competency based model to follow in developing nurse leaders. 2

Despite AACN and AONL competency-based curriculum and model, it is still common for nurse leaders to be promoted to management positions based solely on their work experience or exceptional clinical skills, rather than demonstration of management and leadership competencies. 3 The importance of identifying, training, and assessing executive leaders through formal leadership development programs, within supportive organizational cultures has been discussed by national leaders. As well as the need for nurturing emerging leaders through fostering interprofessional collaboration, mentorship, and continuous development of leadership skills has been identified. 4 As Doctor of Nursing Practice (DNP) nurse leaders assume executive roles within healthcare organizations, they play a vital role within complex systems. Demonstration of leadership competence and participation in formal leadership development programs has become imperative for their success. However, models of competency-based executive leadership development programs can be hard to find, particularly programs outside of health care systems.

The implementation of a DNP Leader in Residence program, such as the one designed for The Barbara and Richard Csomay Center for Gerontological Excellence, addresses many of the challenges facing new DNP leaders and ensures mastery of executive leadership competencies and readiness to practice through exposure to varied experiences and close mentoring. The Csomay Center , based at The University of Iowa, was established in 2000 as one of the five original Hartford Centers of Geriatric Nursing Excellence in the country. Later funding by the Csomay family established an endowment that supports the Center's ongoing work. The current Csomay Center strategic plan and mission aims to develop future healthcare leaders while promoting optimal aging and quality of life for older adults. The Csomay Center Director created the innovative DNP Leader in Residence program to foster the growth of future nurse leaders in non-healthcare systems. The purpose of this paper is to present a case study of the development and implementation of the Leader in Residence program, followed by suggested evaluation strategies, and discussion of future innovation of leadership opportunities in non-traditional health care settings.

Development of the DNP Leader in Residence Program

The Plan-Do-Study-Act (PDSA) cycle has garnered substantial recognition as a valuable tool for fostering development and driving improvement initiatives. 5 The PDSA cycle can function as an independent methodology and as an integral component of broader quality enhancement approaches with notable efficacy in its ability to facilitate the rapid creation, testing, and evaluation of transformative interventions within healthcare. 6 Consequently, the PDSA cycle model was deemed fitting to guide the development and implementation of the DNP Leader in Residence Program at the Csomay Center.

PDSA Cycle: Plan

Existing resources. The DNP Health Systems: Administration/Executive Leadership Program offered by the University of Iowa is comprised of comprehensive nursing administration and leadership curriculum, led by distinguished faculty composed of national leaders in the realms of innovation, health policy, leadership, clinical education, and evidence-based practice. The curriculum is designed to cultivate the next generation of nursing executive leaders, with emphasis on personalized career planning and tailored practicum placements. The DNP Health Systems: Administration/Executive Leadership curriculum includes a range of courses focused on leadership and management with diverse topics such as policy an law, infrastructure and informatics, finance and economics, marketing and communication, quality and safety, evidence-based practice, and social determinants of health. The curriculum is complemented by an extensive practicum component and culminates in a DNP project with additional hours of practicum.

New program. The DNP Leader in Residence program at the Csomay Center is designed to encompass communication and relationship building, systems thinking, change management, transformation and innovation, knowledge of clinical principles in the community, professionalism, and business skills including financial, strategic, and human resource management. The program fully immerses students in the objectives of the DNP Health Systems: Administration/Executive Leadership curriculum and enables them to progressively demonstrate competencies outlined by AONL. The Leader in Residence program also includes career development coaching, reflective practice, and personal and professional accountability. The program is integrated throughout the entire duration of the Leader in Residence’s coursework, fulfilling the required practicum hours for both the DNP coursework and DNP project.

The DNP Leader in Residence program begins with the first semester of practicum being focused on completing an onboarding process to the Center including understanding the center's strategic plan, mission, vision, and history. Onboarding for the Leader in Residence provides access to all relevant Center information and resources and integration into the leadership team, community partnerships, and other University of Iowa College of Nursing Centers associated with the Csomay Center. During this first semester, observation and identification of the Csomay Center Director's various roles including being a leader, manager, innovator, socializer, and mentor is facilitated. In collaboration with the Center Director (a faculty position) and Center Coordinator (a staff position), specific competencies to be measured and mastered along with learning opportunities desired throughout the program are established to ensure a well-planned and thorough immersion experience.

Following the initial semester of practicum, the Leader in Residence has weekly check-ins with the Center Director and Center Coordinator to continue to identify learning opportunities and progression through executive leadership competencies to enrich the experience. The Leader in Residence also undertakes an administrative project for the Center this semester, while concurrently continuing observations of the Center Director's activities in local, regional, and national executive leadership settings. The student has ongoing participation and advancement in executive leadership roles and activities throughout the practicum, creating a well-prepared future nurse executive leader.

After completing practicum hours related to the Health Systems: Administration/Executive Leadership coursework, the Leader in Residence engages in dedicated residency hours to continue to experience domains within nursing leadership competencies like communication, professionalism, and relationship building. During residency hours, time is spent with the completion of a small quality improvement project for the Csomay Center, along with any other administrative projects identified by the Center Director and Center Coordinator. The Leader in Residence is fully integrated into the Csomay Center's Leadership Team during this phase, assisting the Center Coordinator in creating agendas and leading meetings. Additional participation includes active involvement in community engagement activities and presenting at or attending a national conference as a representative of the Csomay Center. The Leader in Residence must mentor a master’s in nursing student during the final year of the DNP Residency.

Implementation of the DNP Leader in Residence Program

PDSA Cycle: Do

Immersive experience. In this case study, the DNP Leader in Residence was fully immersed in a wide range of center activities, providing valuable opportunities to engage in administrative projects and observe executive leadership roles and skills during practicum hours spent at the Csomay Center. Throughout the program, the Leader in Residence observed and learned from multidisciplinary leaders at the national, regional, and university levels who engaged with the Center. By shadowing the Csomay Center Director, the Leader in Residence had the opportunity to observe executive leadership objectives such as fostering innovation, facilitating multidisciplinary collaboration, and nurturing meaningful relationships. The immersive experience within the center’s activities also allowed the Leader in Residence to gain a deep understanding of crucial facets such as philanthropy and community engagement. Active involvement in administrative processes such as strategic planning, budgeting, human resources management, and the development of standard operating procedures provided valuable exposure to strategies that are needed to be an effective nurse leader in the future.

Active participation. The DNP Leader in Residence also played a key role in advancing specific actions outlined in the center's strategic plan during the program including: 1) the creation of a membership structure for the Csomay Center and 2) successfully completing a state Board of Regents application for official recognition as a distinguished center. The Csomay Center sponsored membership for the Leader in Residence in the Midwest Nurse Research Society (MNRS), which opened doors to attend the annual MNRS conference and engage with regional nursing leadership, while fostering socialization, promotion of the Csomay Center and Leader in Residence program, and observation of current nursing research. Furthermore, the Leader in Residence participated in the strategic planning committee and engagement subcommittee for MNRS, collaborating directly with the MNRS president. Additional active participation by the Leader in Residence included attendance in planning sessions and completion of the annual report for GeriatricPain.org , an initiative falling under the umbrella of the Csomay Center. Finally, the Leader in Residence was involved in archiving research and curriculum for distinguished nursing leader and researcher, Dr. Kitty Buckwalter, for the Benjamin Rose Institute on Aging, the University of Pennsylvania Barbara Bates Center for the Study of the History of Nursing, and the University of Iowa library archives.

Suggested Evaluation Strategies of the DNP Leader in Residence Program

PDSA Cycle: Study

Assessment and benchmarking. To effectively assess the outcomes and success of the DNP Leader in Residence Program, a comprehensive evaluation framework should be used throughout the program. Key measures should include the collection and review of executive leadership opportunities experienced, leadership roles observed, and competencies mastered. The Leader in Residence is responsible for maintaining detailed logs of their participation in center activities and initiatives on a semester basis. These logs serve to track the progression of mastery of AONL competencies by benchmarking activities and identifying areas for future growth for the Leader in Residence.

Evaluation. In addition to assessment and benchmarking, evaluations need to be completed by Csomay Center stakeholders (leadership, staff, and community partners involved) and the individual Leader in Residence both during and upon completion of the program. Feedback from stakeholders will identify the contributions made by the Leader in Residence and provide valuable insights into their growth. Self-reflection on experiences by the individual Leader in Residence throughout the program will serve as an important measure of personal successes and identify gaps in the program. Factors such as career advancement during the program, application of curriculum objectives in the workplace, and prospects for future career progression for the Leader in Residence should be considered as additional indicators of the success of the program.

The evaluation should also encompass a thorough review of the opportunities experienced during the residency, with the aim of identifying areas for potential expansion and enrichment of the DNP Leader in Residence program. By carefully examining the logs, reflecting on the acquired executive leadership competencies, and studying stakeholder evaluations, additional experiences and opportunities can be identified to further enhance the program's efficacy. The evaluation process should be utilized to identify specific executive leadership competencies that require further immersion and exploration throughout the program.

Future Innovation of DNP Leader in Residence Programs in Non-traditional Healthcare Settings

PDSA Cycle: Act

As subsequent residents complete the program and their experiences are thoroughly evaluated, it is essential to identify new opportunities for DNP Leader in Residence programs to be implemented in other non-health care system settings. When feasible, expansion into clinical healthcare settings, including long-term care and acute care environments, should be pursued. By leveraging the insights gained from previous Leaders in Residence and their respective experiences, the program can be refined to better align with desired outcomes and competencies. These expansions will broaden the scope and impact of the program and provide a wider array of experiences and challenges for future Leaders in Residency to navigate, enriching their development as dynamic nurse executive leaders within diverse healthcare landscapes.

This case study presented a comprehensive overview of the development and implementation of the DNP Leader in Residence program developed by the Barbara and Richard Csomay Center for Gerontological Excellence. The Leader in Residence program provided a transformative experience by integrating key curriculum objectives, competency-based learning, and mentorship by esteemed nursing leaders and researchers through successful integration into the Center. With ongoing innovation and application of the PDSA cycle, the DNP Leader in Residence program presented in this case study holds immense potential to help better prepare 21 st century nurse leaders capable of driving positive change within complex healthcare systems.

Acknowledgements

         The author would like to express gratitude to the Barbara and Richard Csomay Center for Gerontological Excellence for the fostering environment to provide an immersion experience and the ongoing support for development of the DNP Leader in Residence program. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Return to College of Nursing Winter 23/24 Newsletter

Quality improvement studies in nursing homes: a scoping review

Affiliations.

  • 1 University of North Carolina at Chapel Hill, Chapel Hill, USA. [email protected].
  • 2 Duke University and Durham VA GRECC, Durham, USA.
  • 3 University of North Carolina at Chapel Hill, Chapel Hill, USA.
  • PMID: 34384404
  • PMCID: PMC8361800
  • DOI: 10.1186/s12913-021-06803-8

Background: Quality improvement (QI) is used in nursing homes (NH) to implement and sustain improvements in patient outcomes. Little is known about how QI strategies are used in NHs. This lack of information is a barrier to replicating successful strategies. Guided by the Framework for Implementation Research, the purpose of this study was to map-out the use, evaluation, and reporting of QI strategies in NHs.

Methods: This scoping review was completed to identify reports published between July 2003 through February 2019. Two reviewers screened articles and included those with (1) the term "quality improvement" to describe their methods, or reported use of a QI model (e.g., Six Sigma) or strategy (e.g., process mapping) (2), findings related to impact on service and/or resident outcomes, and (3) two or more NHs included. Reviewers extracted data on study design, setting, population, problem, solution to address problem, QI strategies, and outcomes (implementation, service, and resident). Vote counting and narrative synthesis were used to describe the use of QI strategies, implementation outcomes, and service and/or resident outcomes.

Results: Of 2302 articles identified, the full text of 77 articles reporting on 59 studies were included. Studies focused on 23 clinical problems, most commonly pressure ulcers, falls, and pain. Studies used an average of 6 to 7 QI strategies. The rate that strategies were used varied substantially, e.g., the rate of in-person training (55%) was more than twice the rate of plan-do-study-act cycles (20%). On average, studies assessed two implementation outcomes; the rate these outcomes were used varied widely, with 37% reporting on staff perceptions (e.g., feasibility) of solutions or QI strategies vs. 8% reporting on fidelity and sustainment. Most studies (n = 49) reported service outcomes and over half (n = 34) reported resident outcomes. In studies with statistical tests of improvement, service outcomes improved more often than resident outcomes.

Conclusions: This study maps-out the scope of published, peer-reviewed studies of QI in NHs. The findings suggest preliminary guidance for future studies designed to promote the replication and synthesis of promising solutions. The findings also suggest strategies to refine procedures for more effective improvement work in NHs.

Keywords: Implementation strategies; Long term care; Nursing homes; Quality improvement; Residential aged care.

© 2021. The Author(s).

Publication types

  • Accidental Falls / prevention & control
  • Nursing Homes
  • Pressure Ulcer*
  • Quality Improvement*
  • Total Quality Management

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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StatPearls [Internet].

Quality improvement.

Isha Puri ; Caitlyn M. Hollingshead ; Prasanna Tadi .

Affiliations

Last Update: November 13, 2023 .

  • Definition/Introduction

Avedis Donabedian, noted by many as the father of quality improvement, helped form the foundation of the field in 1966 with the publication of the article "Evaluating the Quality of Medical Care." [1] This article first details fundamental concepts still central today in quality improvement, such as the importance of considering structures, outcomes, and processes. [2]

Quality improvement (QI) is a process of approaching systemic problems in healthcare. The healthcare system comprises many people with different scopes of training and expertise functioning in social hierarchies [3] that use many pieces of technology, such as the electronic medical record. The way that these people, technologies, and patients interact is crucial and forms the processes that affect the care of patients and ultimately can affect patient outcomes. Human error is unavoidable. In 1999, it was estimated that 98,000 patients died because of medical errors. [4] QI aims to achieve predictable outcomes from these processes that improve patient care.

Quality initiatives and performance improvement efforts must clearly define the problem on which the quality initiative focuses. A single project goal should be defined, and it must be specific, measurable, achievable, realistic, and timely. [5] Defining the locations, processes, and disciplines involved in the QI initiative is imperative. Once a clear, concise problem statement and a hypothesis regarding the outcome of the proposed intervention are formed, it is often helpful to deliver a powerful emotional message among the stakeholders to motivate them and emphasize the importance of the quality initiative. A patient-centered approach that considers the patient's experience is central to all approaches to QI.

QI initiatives utilize several methods to plan and frame systemic change in healthcare. These include Lean, Six Sigma, and the Model for Improvement theories. Essential tools are also utilized in QI initiatives, including Pareto charts, Ishikawa diagrams, Shewhart charts, run charts, and scatter plots.

  • Issues of Concern

Six Sigma aims to decrease the error rate to 3.4 per million opportunities. [6] [7]  Sigma is used as an abbreviation for standard deviation, and the name implies the goal of keeping the process output within six standard deviations of the mean. [8]  However, the aim of 3.4 per million opportunities accounts for a decrease of 1.5 standard deviations to account for random variation. [8]  Its primary focus in reducing error is to decrease variability. [6] [9]  It employs a process known as DMAIC (Define-Measure-Analyze-Improve-Control). [6]  In this process, the problem is defined and fully understood, the defects in the system are measured, the root causes are analyzed, the system is improved with the intent to remove the causes of error, and the process undergoes continuous control measures to ensure that the root causes do not recur. [6]  Six Sigma has been utilized in healthcare to improve the processes of admission, discharge, and medication reconciliation. As the focus of Six Sigma is error reduction, often error rate is used as the driving metric; however, it has also been used to focus on productivity and process time. [6]  The control step must be maintained to ensure that the achieved improvement continues. Six Sigma is often combined with Lean and is called Lean Six Sigma. [10]

Lean was first developed by the Toyota company, which utilized it in automobile manufacturing. [11]  It was later used in the healthcare and business sectors after it was noted to be successful in manufacturing. The purpose of Lean is to decrease waste by eliminating processes that do not add perceived value from the customer's standpoint. [11]  The Lean methodology for healthcare describes eight kinds of waste: defects, overproduction, transportation, waiting, inventory, motion, overprocessing, and human potential. [11]  In short, the Lean methodology aims to eliminate unneeded work and product and use everyone involved in the process to their highest potential. The five steps used to eliminate waste are to understand the perceived value by patients, observe the system as it currently works as a team, visualize how the system would work if all steps flowed into each other without stopping while entertaining all suggestions for change by all parties in the group, and the rapid deployment of the improvement plan with guides that encourage everyone involved in the process to think past historical and interdepartmental challenges. [11]  The final step involves continuous improvement by finding all opportunities for improvement. [11]  There is an emphasis on giving power and accountability to all people involved in the system rather than those in administration, as those involved in the day-to-day implementation of processes can understand the nuances of the process.

The Model for Improvement

The Model for Improvement was conceived in the 1990s by Associates in Process Improvement. [12]  It is based on the work of Deming, who first developed the PDSA (plan, do, study, act) cycle. [12]  It serves as a framework for organizations to improve, as there is an emphasis on interconnected processes and continual improvement. [12]  In this framework, the problem is thoroughly explored, desired outcomes are defined in detail, an aim statement is created that comprehensively describes the scope and aims of the initiative, and a team is formed that brings technical expertise, knowledge, and involvement in the routine implementation of the process. [12]

Measurement is critical in The Model for Improvement, and measurements are divided into process, outcome, and balancing measures. [12]  Outcome measures have to do with the desired result, process measurements center around the process itself, and balancing measures note other metrics to ensure that there is no worsening in other areas because of the implementation of the intervention. [12]  PDSA cycles are implemented in continuous cycles that define crucial metrics and opportunities for improvement, execute an intervention, study the results of that intervention, and use the data obtained from the intervention to determine whether it represents an improvement. [12]  In summary, this framework hinges on carefully defining what is trying to be achieved, obtaining data to know that the planned implementation is an improvement, and thinking carefully about what changes can result in improvement. [12]  Once the end goal has been achieved, this can be followed by an SDSA (standardize, do, study, act) cycle to maintain the achieved improvement.

Ishikawa diagrams, or fishbone diagrams, endeavor to clarify an issue's root cause by diagraming all contributors. [13]  They are often used during the Plan stage of the PDSA cycle to evaluate potential root causes and contributions to complicated systemic issues. The SIPOC Tool can outline the processes required from beginning to end to complete the initiative. SIPOC includes suppliers, inputs, processes, outputs, and customers. [14]  Once the processes have been defined, the team can focus on outcomes of interest.

Run charts and scatter plots help visualize simple trends in data. [15]  Control charts can be used to visualize more complex trends and variations. [16]  Common cause variation is defined as variation that is inherent to the system. [16]  Special cause variation is the variation that is introduced by adding an additional element to the system. [16]  Shewhart charts are a type of control chart meant to detect decreases in error rates that display binary data. [17]  It tracks the proportion of consecutive time with the event of interest and the number of cases that do not have the event of interest. [17]

A Pareto chart can be of value per the 80/20 rule. The 80/20 rule, or Pareto rule, dictates that 80% of outcomes originate from 20% of factors. [18]  A Pareto chart is a special bar chart with several factors that contribute to the outcome arranged in the magnitude of occurrence from highest to lowest that combines a line graph. [18]  The overlying line graph displays the cumulative percentage. [18]  The data categories contributing to 80% of the bar chart are where the focus should be to achieve an adequate quality goal. [9]  These charts can help to visualize whether the change is an improvement.

One of the most important issues linked with research is that the rights and confidentiality of human subjects must be protected. Ethics are of utmost importance. To ensure this, institutional review boards are tasked with reviewing research to ensure that they adhere to ethical standards.

In 1949, the Nuremberg Code was enacted for medical experiments. [19] The Nuremberg Code was developed because of the ethical issues that arose from the trials and war crimes in Nuremberg. [19] Research participants must have the right to withdraw from a research project anytime. [19] The World Medical Association developed the Declaration of Helsinki. [20] These guidelines note that the potential value of the knowledge obtained needs to outweigh any risk to research participants. [20] Research should only be conducted once informed consent has been taken from involved human subjects. [19]

Quality improvement projects are generally not considered research; however, the distinction sometimes becomes less clear. [21] Many scholars have attempted to delineate the difference between work considered research and that considered quality improvement. [21] QI projects are based on evidence-based medicine, built upon existing knowledge, and aim to improve institution-specific processes. If there is doubt whether a proposed quality improvement project would be considered clinical research, then the institutional review board of the healthcare facility should be consulted. [21] Many institutions require the institutional review board to review proposed quality improvement projects. [21] QI projects that involve vulnerable populations are more likely to be classified as research.

Quality improvement projects often utilize PDSA cycles. At least several iterations of PDSA are used during a QI project, which often reveals new inefficiencies and tests creative potential solutions. These results can be published to aid in the improvement of similar facilities. However, every system and facility is different, and initiatives may not have the same outcomes in other facilities. Any ethical concerns associated with the publication of QI need to be addressed with the appropriate institutional review board. Suppose a new tool is developed as an outcome of the quality improvement project. In that case, it becomes a part of the institution's intellectual property and ideally needs to be copyrighted. [22]

It should be noted that continuous improvement is the goal of QI. [23] Projects should start with an exploration of the system and process to gain a clear understanding of the current status of the process, then plan an intervention and state a clear hypothesis about the result of the intervention. [23] Metrics should be defined to determine whether the intervention would result in the indicated improvement. Interventions should start with a small, pre-determined target population, and results should be evaluated before scaling out the intervention as confidence grows. [23] After assessing the results of the intervention, further action should be determined based on the effects of the prior intervention. [23] Data collected as part of the intervention should be carefully documented. [23] It has been noted that few published studies adhere to these principles. [23] However, adherence allows the process to be driven by data and based on the scientific method.

  • Clinical Significance

QI projects are crucial for improving processes and practices at an institution. Evidence-based medicine (EBM) has formed the basis of many quality improvement projects, such as those focused on reducing rates of venous thromboembolism [24] and bloodstream infections related to catheters. [25] EBM has also been applied to ventilator-associated pneumonia and other hospital-acquired infections. [26]

A significant number of deaths result from medical errors; it is estimated to be the third leading cause of death in the US. [27] Medication errors have been estimated to cause every 1 in 131 outpatient and 1 in 184 outpatient deaths. [28]   Reducing over-expenditure has been the focus of high-value care in healthcare. Choosing wisely is an essential resource created by the ABIM to provide physicians with a framework to reduce wasteful expenditure, provide cost-effective care, and reduce harm. [29] Unnecessary medical tests can cause harm rather than provide effective and efficient care. Although the Choosing Wisely campaign has been widely publicized, it has been noted that this has not been enough to change practice in many instances. [30] Quality improvement projects led by local leaders that can craft interventions specific to specific hospitals and situations are imperative to effect change.

Clinical evidence must be used to develop and apply adaptive work in healthcare. Barriers to implementing EBM at an institutional level are analyzed in quality improvement projects. An essential strategy for improving adaptive work has been storytelling. The involvement of patients' families and their perspectives contribute to quality care and help develop quality improvement projects  [31] . Anecdotal evidence and narrating stories about a given intervention and how it can prevent harm in a particular scenario can help engage stakeholders. Outlining the processes involved in a quality project, team-building exercises, and communication boards can help adapt an intervention. PDSA cycles employed by leaders and frontline practitioners can identify strategies that can improve outcomes. [12]

A cross-sectional survey of physicians found that 85.7% expressed interest in being involved in quality improvement initiatives, but only 68.6% had been in the last year. [32] Physicians cite a lack of participation due to scarcity of time and heavy clinical loads. [32] Physicians have responsibilities in varied areas, and quality initiatives of hospitals or other healthcare organizations may not align with the quality issues physicians face. Physician involvement can increase by streamlining processes to perform QI and prioritizing issues that directly affect physicians and their patients. [33] Patient and family involvement helps identify improvement opportunities and potential solutions and persuade healthcare providers. [34]   Via participation of multiple stakeholders, QI efforts aim at continuous process improvement to reduce variations and improve outcomes at the institutional level.

  • Nursing, Allied Health, and Interprofessional Team Interventions

Quality improvement initiatives must, of necessity, include all staff members, not just the clinicians. This means that nursing and other allied health professions that comprise the interprofessional healthcare team must be included in the initiative, not only as it applies to enacting decisions for quality improvement, but also these team members must be empowered to contribute to developing these initiatives. All persons working in the system have valuable insights and vital contributions to make. Participation and understanding by all staff members ensure that quality improvement initiatives have the highest chance of success possible. To increase participation, the rationale for proposed changes and the value to the patient must be made clear to all involved.

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Disclosure: Isha Puri declares no relevant financial relationships with ineligible companies.

Disclosure: Caitlyn Hollingshead declares no relevant financial relationships with ineligible companies.

Disclosure: Prasanna Tadi declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

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