Implementing service improvement projects within pre-registration nursing education: a multi-method case study evaluation

How, and under what contexts, do academic-practice partnerships collaborate to implement healthcare improvement education into preregistration nursing curriculums: a realist review protocol

INTRODUCTION

Internationally, healthcare improvement remains a clinical and educational priority. Consensus in Europe, Canada and the USA to implement quality improvement (QI) education into preregistration nursing curricula ensures students become equipped with the skills and knowledge required to improve practice. Now, New Zealand and Australia are beginning to implement QI education into their nursing curricula. However, QI education is complex; comprising multiple components, each influenced by the contexts under which they are developed and implemented. Evaluation studies of QI education unanimously acknowledge that academic and practice partnerships (APPs) are essential to optimally embed QI into preregistration curricula, yet it is not understood how, and under what contexts, APPs collaborate to achieve this.

METHODS AND ANALYSIS

A realist review to determine how, and under what contexts, APPs collaborate to implement QI education in pre-registration nursing will be conducted using the Realist and Meta-narrative Evidence Syntheses: Evolving Standards Guidelines. International stakeholders will be consulted at each stage which includes (1) clarifying the scope of the review through empirical literature and tacit expert knowledge, (2) searching for evidence in healthcare and social science databases/grey literature, (3) appraising studies using the Evidence for Policy and Practice Information and Co-ordinating Centre weight of evidence framework and extracting data using Standards for QUality Improvement Reporting Excellence in Education Publication Guidelines, (4) synthesising evidence and drawing conclusions through the creation of context, mechanism and outcome configurations and (5) disseminating findings through conferences and peer-reviewed publications.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. Findings will be disseminated to international nurse educators, leaders and front-line staff implementing QI education within their own academic and practice contexts through conferences and peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021282424.

Partnering with healthcare organisations to teach pre-registration health professions students about quality improvement: A systematic review

AIMS AND OBJECTIVES

To describe what higher education and healthcare organisation partnerships can be identified in the published literature to teach pre-registration health professions students quality improvement and the impact of these partnerships.

BACKGROUND

Quality improvement has been gaining traction in the Western world and has been incorporated in varying degrees into the curricula for pre-registration health professions students. Providing quality improvement education in partnership with healthcare organisations has been found to be a valuable experiential learning solution, but the impacts of higher education and healthcare organisation partnerships have not been explored.

DESIGN AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was undertaken using the Ovid MEDLINE, Emcare, CINAHL, Scopus and Eric databases. Studies were subject to quality appraisal using the Critical Appraisal Skills Program validated tools and a thematic analysis and narrative synthesis was undertaken.

RESULTS

Eight studies were included in this review. Features of existing quality improvement partnerships included experiential learning, time pressures and barriers to successful quality improvement partnerships. The impacts of quality improvement partnerships were demonstrated by an increase in quality improvement knowledge and understanding, students leading change and the implementation of quality improvement projects.

CONCLUSION

Several key elements were identified that may act as barriers or enablers to successful implementation of quality improvement partnerships. This review advances understandings of the need for a shift in focus that pays attention to the culture of teaching quality improvement in education partnerships and how this can be achieved in a mutually beneficial way.

RELEVANCE TO CLINICAL PRACTICE

The development of quality improvement partnerships has been found to increase student knowledge and understanding, potentially improving patient outcomes, systems performance and professional development. More research is required on the establishment of quality improvement partnerships and the benefit these collaborations have on students, staff and patients.

Where You from? Examining the Relationship between Gang Migrants and Gang-Related Homicide

Research has frequently focused on the increased likelihood of violence and homicide among gang-involved individuals, as well as on the factors that contribute to this violence. Such work has examined the relationship between immigration and the frequency of crime, as well. However, there is a dearth of research examining the likelihood of gang-related homicide and the presence of both gang migrants from within the U.S. and those from abroad in a given community. The current paper utilizes National Youth Gang Survey data to examine the relationship between law enforcement perceptions of gang migrants in their jurisdiction and the frequency of gang-related homicide. The results reveal that gang-related homicides have a significant and negative association with the presence of gang migrants. These findings have important policy implications for understanding and addressing serious gang violence and homicide at the community level.

Change management experiences of nursing students in clinical practice: A phenomenological study

BACKGROUND

In healthcare services, nurses' roles and practices make them an integral component of the change process. Therefore, nurses should prepare for their change-creating roles during their education. However, little research regarding change management and the change creation process of nursing students is found in the literature.

OBJECTIVES

To identify the needs of undergraduate nursing students when initiating change in practice and to reveal their experiences during the planning and implementation process of change projects.

DESIGN

A descriptive, qualitative design using focus group was conducted.

PARTICIPANTS

The study includes third-year undergraduate nursing students enrolled in a nursing school in Turkey and were enrolled in the Management in Nursing and Clinical Practices courses.

METHODS

Six focus group were conducted with a total of 28 nursing students. Data were collected over one semester via a semi-structured form. The data were analyzed using thematic content analysis.

RESULTS

Regarding the change management experiences of the participants, five main themes ("changing world, changing necessities," "view from the perspective of change," "discovering resistance," "developing motivation against resistance," and "change in the perception of change"), and nine sub-themes were determined.

CONCLUSIONS

As a result of their change management experiences, nursing students might better contribute to the quality of patient care, think more critically and have more autonomy. Therefore, change process management should be extensively included in nursing education and should be systematically monitored.

Planning and implementing quality improvement projects in clinical practice: Third-year nursing students' learning experiences

AIMS AND OBJECTIVES

To evaluate the impact of an educational design to develop nursing students' competence to work systematically with quality improvement in clinical practice.

BACKGROUND

Competence in how to improve the quality and safety of healthcare services based on new knowledge is crucial for healthcare quality. Nursing education should give students opportunities to engage in quality improvement projects to gain this competence.

DESIGN

This project qualitatively evaluated the impact of the course on students' ability to plan and implement a quality improvement project in their clinical placement.

METHODS

Data from retrospective focus group interviews and written project reports were analysed by means of qualitative content analysis. Fifty-five students participated in the study. COREQ reporting guidelines were used.

RESULTS

Three themes were derived from the analysis: (a) the importance of anchoring the quality improvement project in the clinic; (b) experiencing the steps of a quality improvement project; and (c) challenging student role.

CONCLUSIONS

Course design that facilitates student-run small-scale quality improvement projects under supervision can enhance nurse students' competence in quality improvement work, as well as raise the students' awareness of the responsibility they will undertake as future nurses.

RELEVANCE TO CLINICAL PRACTICE

Nursing students work on quality improvement project in clinical placement may enhance their awareness and competence in developing quality and safety of healthcare services as future nurses.

Developing and sustaining nurses' service improvement capability: a phenomenological study

BACKGROUND

Service improvement to enhance care quality is a key nursing responsibility and developing sustainable skills and knowledge to become confident, capable service improvement practitioners is important for nurses in order to continually improve practice. How this happens is an under-researched area.

AIM

A hermeneutic, longitudinal study in Northern England aimed to better understand the service improvement lived experiences of participants as they progressed from undergraduate adult nursing students to registrants.

METHOD

Twenty year 3 student adult nurses were purposively selected to participate in individual semi-structured interviews just prior to graduation and up to 12 months post-registration. Hermeneutic circle data analysis were used.

FINDINGS

Themes identified were service improvement learning in nursing; socialisation in nursing practice; power and powerlessness in the clinical setting; and overcoming service improvement challenges. At the end of the study, participants developed seven positive adaptive behaviours to support their service improvement practice and the 'model of self-efficacy in service improvement enablement' was developed.

CONCLUSION

This study provides a model to enable student and registered nurses to develop and sustain service improvement capability.

Behavioural and operational outcomes of a Master's programme on improvement knowledge and leadership

PURPOSE

The purpose of this paper is to evaluate behavioural changes and operational outcomes resulting from a Master's programme on improvement knowledge and leadership in the Swedish welfare sector. The welfare sector is the collective term for tax-funded services the state, county councils and municipalities are responsible to provide.

DESIGN/METHODOLOGY/APPROACH

A survey combined open-ended and closed questions using a five-point Likert scale. The questions were based on the learning objectives of the Master's programme. The survey was sent to 139 graduates and achieved a response rate of 41 per cent (57 respondents). Responses were entered into a survey programme to enable the descriptive presentation of data; open-ended responses were analysed using conventional content analysis.

FINDINGS

Respondents reported their increased knowledge and changed behaviours had impacted operational outcomes, e.g. processes efficiency, compliance with guidelines and quality. They said the programme was of value to themselves and society but requested more leadership knowledge. All respondents recommended the programme to others.

ORIGINALITY/VALUE

By operationalizing the Kirkpatrick framework, the paper describes outcomes on levels three and four, and the use of numerous best practice techniques for adult learning. This is valuable knowledge for organisers of improvement knowledge educations.

Service improvement in health care: a literature review

Service improvements in health care can improve provision, make cost savings, streamline services and reduce clinical errors. However, on its own it may not be adequate for improving patient outcomes and quality of care. The complexity of healthcare provision makes service improvement a challenge, and there is little evidence on whether improvement initiatives change healthcare practices and improve care. To understand the concept of service development within health care, it is necessary to explore the national context and how the NHS has adopted improvement initiatives. To equip the nursing workforce with the skills necessary to make positive change, higher education institutions have developed courses that include the topic within their pre-registration programmes. However, service improvement is a learned skill that nurses need to practise in order to become competent.

A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England

Background

Schwartz Center Rounds®(Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care.

Objectives

How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care.

Design

(1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation).

Setting

(1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey).

Participants

(1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings.

Results

(1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p < 0.05) in Rounds attenders (25% to 12%) compared with non-attenders (37% to 34%). (4 and 5) Rounds were described as interesting, engaging and supportive; four contextual layers explained the variation in Rounds implementation. We identified four stages of Rounds, ‘core’ and ‘adaptable’ components of Rounds fidelity, and nine context–mechanism–outcome configurations: (i) trust, emotional safety and containment and (ii) group interaction were prerequisites for creating (iii) a countercultural space in Rounds where staff could (iv) tell stories, (v) self-disclose their experiences to peers and (vi) role model vulnerability; (vii) provide important context for staff and patient behaviour; (viii) shining a spotlight on hidden staff and patient stories reduced isolation and enhanced support/teamwork; and (ix) staff learned through reflection resulting in ripple effects and outcomes. Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and reported changes in practice. The impact of Rounds is cumulative and we have identified the necessary conditions for Rounds to work.

Limitations

Rounds outcomes relied on self-report, fewer regular attenders were recruited than desired, and it was not possible to observe staff post Rounds.

Conclusion

Rounds offer unique support for staff and positively influence staff well-being, empathy and compassion for patients and colleagues.

Future work

The adaptation of Rounds to new contexts and to increase reach needs evaluation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Professional practice-related training and organizational readiness for change facilitate implementation of projects on the national core value system in care of older people

AIM

To explore whether professional training contributed to implementation of the national core value system in practice in care of older people and to identify course participants' perceptions about factors that facilitated or obstructed them in implementing their projects. To identify participants' perceptions concerning factors that facilitate or obstruct implementation.

DESIGN

Descriptive and cross-sectional.

METHODS

Data were retrieved from 451 participants who had completed the course "Understanding and providing leadership based on the national core value system for older people" at Uppsala University during spring semester and autumn semester of 2018. Quantitative and qualitative data were obtained using a web-based questionnaire.

RESULTS

The results showed that the majority (73%) of project plans were initiated, although not always completed and sometimes interrupted. Organizational readiness in terms of management supporting and prioritizing these plans were two principle facilitators chosen by half of the respondents and consequently the absence of these factors was an obstacle. In addition, successful implementation required dedicated co-workers and certain resources, such as time and funds. Surprisingly, factors related to the project leader were reported to be of limited importance.

An evaluation of approaches used to teach quality improvement to pre-registration healthcare professionals: An integrative review

BACKGROUND

Improving the quality of healthcare remains central to UK and international policy, practice and research. In 2003, The Institute of Medicine's 'Health Professions Education: A Bridge to Quality', advocated quality improvement as a core competency for all healthcare professionals. As a result, developing capacity and capability of those applying improvement methodologies in the pre-registration population has risen, yet, little is known about the teaching approaches employed for this purpose.

OBJECTIVES

To describe and analyse educational approaches used to teach quality improvement to pre-registration healthcare professionals and identify enabling and impeding factors.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, PsychINFO, MEDLINE, ERIC, ASSIA, SCOPUS and Google Scholar were accessed for papers published between 2000 and 2016.

REVIEW METHODS

Publications where quality improvement education was delivered to pre-registration healthcare professionals were eligible. One author independently screened papers, extracted data using a modified version of the Reporting of Primary Studies in Education Guideline and evaluated methodological quality using the Weight of Evidence Framework. The Kirkpatrick Education Evaluation Model was used to explore the impact of teaching approaches. Enabling and impeding factors were thematically analysed. A narrative synthesis of findings is presented.

RESULTS

Ten papers were included, representing nursing, pharmacy and medicine from UK, Norway and USA. Studies comprised four quantitative, four mixed method, one qualitative and one cluster randomised trial, all allocated medium Weight of Evidence. Teaching approaches included experiential learning cited in all studies, didactics in seven, group work in four, seminars in three, self-directed learning in three and simulation in one. Most studies measured Level 1 of the Kirkpatrick Model (reaction), all but one measured Level 2 (skills, knowledge or attitudes), none measured Level 3 (behaviour) and one measured Level 4 (patient outcomes). Enabling and impeding themes included: Teaching Approaches, Clinical/Faculty support, Information Provision, Curriculum Balance and Data.

CONCLUSIONS

Evaluating quality improvement education is complex. Experiential learning combined with didactics is the favoured approach; however, attributing causality to educational intervention proves difficult in light of poor methodological rigour, lack of validated tools and complex clinical settings. Clarity regarding which quality improvement competencies are priority for this population would be useful to streamline future educational development and evaluation. Stronger collaboration between educators and clinicians is recommended to explore the multiple components and contextual factors associated with quality improvement education in practice. Ethnographic enquiry may be a logical next step to advance knowledge within the field.