An Integrative Review of the Barriers and Facilitators to Nurse Engagement in Quality Improvement in the Clinical Practice Setting

An Integrative Review of Quality Improvement Competence and Engagement Among Frontline Nurses

BACKGROUND

Nurses providing direct care have firsthand knowledge of gaps in practice and thus must actively engage in quality improvement (QI) to enhance patient outcomes.

PURPOSE

This integrative review evaluated QI competence and engagement among frontline nurses.

METHODS

Using Souza et al's 6-step framework, literature on QI engagement and competence was synthesized using a rigorous search strategy and quality assessment.

RESULTS

Sixteen studies revealed generally low QI engagement and competence. Factors such as education, experience, and role influenced engagement, with higher levels of education and experience linked to higher QI involvement. Nurse leaders had higher engagement, underscoring the need for strong leadership in creating a culture of improvement.

CONCLUSIONS

Successful and sustainable QI programs and supportive environments enhance QI engagement and competence among frontline nurses.

Continuous quality improvement across a South Australian health service and the role it plays in a learning health system: a qualitative study

INTRODUCTION

Continuous quality improvement (CQI) initiatives are commonly used to enhance patient safety and quality of care. A novel South Australian Local Health Network (SALHN) Continuous Improvement Program (CIP009) has integrated a top-down model of executive-directed change initiatives, with a bottom-up approach of clinician designed interventions to address an organisational-wide goal of improved patient flow. This study evaluated the strengths and challenges of CIP009 implementation from the perspective of participants and deliverers.

METHODS

A qualitative study was conducted in 2023/2024 to evaluate the implementation of CIP009 and 12 associated quality improvement projects. Semi-structured interviews and focus groups were conducted with key stakeholders (executives, coaches and CIP009 fellows) and guided by the Consolidated Framework for Implementation Research (CFIR). A document review and observations of CIP009 team meetings were also conducted. Data were analysed inductively using thematic analysis, then deductively mapped against the five CFIR domains.

RESULTS

Thirty-one participants were interviewed individually or in focus groups, two presentation days and six team meetings were observed, and 78 documents were reviewed. Seven key themes were identified highlighting key challenges and strengths of CIP009 implementation within the SALHN setting. These included four key strengths: the CIP framework and culture (the flexible framework, common language, training, and a culture of flattened hierarchy); the benefits of support from a dedicated, internal improvement Faculty (wrap around support from coaches); the advantages of an enthusiastic team member disposition and incentives (vested interests to enhance workflow and patient outcomes); and effective teams and team composition (teams comprised of senior clinician change agents). Three key challenges included: workforce and organisation-level challenges (individual workloads, workforce capacity, and data access); team cohesion, logistics and stakeholder engagement challenges (issues in the way teams worked together); and training and support shortcomings (the training course, and the top-down nature of CIP009).

CONCLUSION

This evaluation identified that CIP009 was considered an effective multifaceted CQI program. The strengths of CIP009 support a learning health system (a data driven model, utilising systematic frameworks, with commitment from leadership, and a culture of continuous learning). Further integration of implementation science principles may support the program to overcome the key challenges identified. These findings will inform and guide improvement efforts within future iterations of CIP.

Impact of a Structured Nurse Mentoring Program on Organizational Engagement

Nursing leadership identified a significant decrease in measured nursing engagement at the 3- to 5-year tenure. Mentoring was chosen as an effective intervention to increase engagement and promote professional development in this Proficient-Expert group of nurses. The benefits of the implemented structured mentoring program include increased organizational engagement, increased perception of well-being support, and increased mentor competency.

Increasing Academic Output through Quality Improvement Educational Strategies

Introduction

Quality improvement (QI) work is imperative to support health systems in providing safe and effective care. Conflicting demands, including the need to complete standard work recognized for academic promotion, can hinder meaningful participation in QI work.

Methods

At our quaternary pediatric hospital, we completed a series of plan-do-study-act cycles around developing QI educational opportunities. Our outcome measure was the number of publications containing the phrase "Quality Improvement" with at least 1 author from our institution. Our process measures included the cumulative number of employees trained in QI methods or writing.

Results

The number of publications increased significantly from an average of 3.4 to 12.5 per quarter. The total number of employees trained in QI methods and QI writing increased throughout the study period.

Conclusions

A series of interventions designed to increase the QI fluency of our workforce were associated with an increase in the number of QI publications at our institution.

Quality Improvement Interventions for Peripheral Intravenous Catheter Nursing Practices: A Systematic Review

BACKGROUND

The use of peripheral intravenous catheters (PIVC) is a crucial nursing practice for ensuring patient safety.

PURPOSE

This systematic review assessed quality improvement (QI) articles focused on nursing insertion and management practices related to PIVCs.

METHODS

A comprehensive search was performed. The Quality Improvement Minimum Quality Criteria Set (QI-MQCS) was used to appraise the quality of QI studies by 2 independent reviewers.

RESULTS

A total of 27 studies were included. More than half of the studies did not meet the sustainability and spread QI-MQCS criteria. QI interventions focused on ultrasound-guided PIVC placement, PIVC dressing products or other catheter devices, and bundles for PIVC practices. The improvements in PIVC-related patient outcomes and nurses' capabilities were reported.

CONCLUSION

Further research is needed to identify detailed QI protocols for ensuring the sustainability and cost-effectiveness of interventions and to facilitate the application of QI in diverse types of hospitals.

How Well Are Surgical Quality Improvement Projects Planned? Review of 242 Surgical Improvement Efforts Across 5 American College of Surgeons Quality Programs

BACKGROUND

Structured preparation is necessary to conduct quality improvement (QI) strategies that are relevant to the problem, feasible, appropriately resourced, and potentially effective. Recent work suggests that improvement efforts are suboptimally conducted. Our goal was to determine how well preparation for surgical QI is undertaken, including detailing the problem, setting project goals, and planning an intervention.

STUDY DESIGN

This retrospective cross-sectional study included QI efforts submitted in 2019 to the American College of Surgeons (ACS) during review for accreditation across 5 ACS Quality Programs: Children's Surgery Verification, the Commission on Cancer, the MBSAQIP, the National Accreditation Program for Breast Centers, and the Trauma Verification Program. Projects were scored for alignment with three components of the preconduct phase of the ACS Quality Framework: problem detailing, goal specification, and strategic planning.

RESULTS

A total of 242 projects satisfied inclusion criteria and were scored. Most projects in the final cohort were from MBSAQIP (36%), Commission on Cancer (31%), or National Accreditation Program for Breast Centers (29%) programs. The average overall preconduct score was 52% (SD 17). On average, projects performed best in the "goal specification" component (65%, SD 27), followed by "problem detailing" (52%, SD 16), and "strategic planning" (44%, SD 25). Within these components, identification of possible limitations (5%) and consideration of contextual issues (12%) were among the least frequently reported items.

CONCLUSIONS

Thorough planning is a critical component of effective QI, and our study reflects significant opportunity for its improvement. The ACS Quality Framework may serve as a guide to improve QI planning, thereby promoting efficiency and effectiveness of these efforts.

Experiences of Newly Qualified Nurses' Engagement with Quality Improvement in Practice: A Qualitative Follow-Up Study

BACKGROUND

Nurse education plays an essential role in preparing future nurses to engage with quality improvement (QI) initiatives in their organisations and improve patient care. However, frontline nurses continue to report that a lack of QI knowledge hinders their abilities to engage in improvement work. In the UK, student nurses are now trained in QI within their degree to enable them to contribute to improvements once qualified.

OBJECTIVES

This qualitative follow-up study investigated the sustainability of QI engagement in nurses who undertook QI training and a QI project during their degree and explored the factors influencing their engagement in QI once qualified.

METHODS

This paper followed the COREQ criteria to report upon 10 semi-structured interviews undertaken with registered nurses and focuses on their experiences of QI engagement post-registration. The data were investigated using an inductive thematic analysis and Nvivo 14.

FINDINGS

Five themes emerged: transition to a newly qualified nurse, QI knowledge decline, influencing factors (hierarchy, leadership, COVID-19 pandemic, data access and location), and skill transferability.

CONCLUSIONS

This study showed that qualified nurses can sustain their QI knowledge and remain engaged with QI where they experience positive QI leadership and were exposed to ongoing QI activity in their preceptorship year. However, a lack of QI opportunities and a culture which does not consider QI a responsibility of new nurses is seen to hinder engagement. Educational institutions and practice partners require careful collaboration to assess and develop ongoing QI learning activities that support new nurses to engage in QI.

How to Design Effective Audit and Feedback Interventions With Nurses: A Set of Hypotheses Based on Qualitative and Quantitative Evidence

OBJECTIVE

To propose practical hypotheses on audit and feedback that support the effectiveness with nurses.

BACKGROUND

Audit and feedback interventions have been mainly studied with physicians; however, the processes have been practiced by nurses for years. Nurses' response may differ from that of physicians and other healthcare disciplines because of their roles, power, and the configuration of nursing activities.

METHODS

A comparative analysis of the Clinical Performance Feedback Intervention Theory was conducted using nursing-specific empirical data from: 1) a mixed-methods systematic review and 2) a pilot study of audit and feedback with a team of primary care nurses.

RESULTS

Researchers hypothesize that audit and feedback interventions are more effective when: 1) feedback emphasizes how it relates to the relational aspect of nursing; 2) indicators are measured and reported at team level; and 3) feedback is provided in a way that highlights benefits to nurses' practice, such as the potential to reduce workload.

CONCLUSION

These proposed hypotheses provide concrete guidance to researchers and managers for an effective use of audit and feedback as a quality improvement strategy with nurses.

Self-efficacy in Quality Improvement Competency of Frontline Acute Care Registered Nurses

BACKGROUND

Registered nurses (RNs) are attuned to health care quality and safety concerns but may lack competency in quality improvement (QI) to advance care quality.

PURPOSE

To describe frontline acute care RNs' self-efficacy in QI competencies, evaluate differences based on educational attainment, and evaluate relationships based on years of RN experience.

METHODS

The study used a descriptive, quantitative, correlational, comparative cross-sectional survey design to evaluate RNs' self-efficacy in QI competency using the 2021 American Association of Colleges of Nursing The Essentials : Core Competencies for Professional Nursing Education .

RESULTS

Frontline RNs' overall QI self-efficacy showed variability in knowledge, skills, and attitudes, with no relationship between self-efficacy and years of RN experience, nor difference based on educational attainment.

CONCLUSIONS

Insufficient self-efficacy signals the need for further QI focus in nursing education, nursing practice, and health care policy to harness RNs' ability to advance care outcomes.

Assessing Barriers and Facilitators to Participation in a Nurse-Driven, Opt-Out HIV Screening Program in the Emergency Department

Emergency department (ED) HIV screening is a key component of the strategy to end the HIV epidemic, reaching populations with limited access to care for screening and early diagnosis. Many screening programs rely primarily on participation from ED nurses; however, little is known about the factors affecting nurse participation in screening. Guided by the Consolidated Framework for Implementation Research, 20 semi-structured interviews were conducted with ED nurses to explore perceptions of HIV screening, barriers and facilitators to participation, and implementation insights. Nurses were categorized as either high adopters or low adopters based on the number of HIV tests ordered 3 months prior to interviews. The Stanford Lightning Report Method, a rapid qualitative analysis approach, was used to analyze field notes. All participants generally agreed that the ED was an appropriate location for screening and that frequent, multimodal education about screening was needed. Integration of screening into standard workflows, education about the public health impact of screening, and the use of peer champions and mentors were identified as important strategies to increase participation. By incorporating these findings into implementation strategies, EDs may be able to increase nurse participation in screening, addressing important health equity issues in HIV diagnosis.

Increasing nursing and midwifery research leadership: impact evaluation of the National Institute for Health and Care Research Senior Nurse and Midwife Research Leader Programme at 1 year

Background

Although nurses and midwives make up the largest sector of the National Health Service (NHS) workforce, studies have identified a lack of knowledge, skills and confidence to engage and lead research. In 2018, the National Institute for Health and Care Research (NIHR) invested in the development of a 3-year Senior Nurse Midwife Research Leader (SNMRL) Programme aimed at developing nursing and midwifery research capacity and capability. This review was conducted at the end of year one as part of an ongoing impact evaluation of the programme.

Aim

To evaluate the impact of activities undertaken by NIHR SNMRL at the end of year one of the programme.

Method

The content of anonymised end-of-year one activity, self-reported by SNMRL, was coded independently and deductively analysed by a project team using the modified Visible ImpaCT Of Research framework (VICTOR). Exemplar case studies were selected by the team to illustrate activity within domains. Working group members coded two reports independently then compared them in pairs to increase inter-rater reliability and the quality and consistency of coding.

Results

Reports from 63 of 66 SNMRL were submitted and included for analysis. Reporting reflected progress towards NIHR programme objectives. These included acting as a programme ambassador, creating a vibrant research culture, supporting staff recruitment and retention, enhancing organisational reputation and clinical academic outputs. Networking and collaboration locally, regionally and nationally were widely reported.

Conclusions

The SNMRL cohort reported initiating multiple initiatives aimed at influencing organisational research culture, service provision and supporting nursing/midwifery engagement with research. Evaluation indicated progress to address barriers to research engagement within NHS Trusts.

Original Research: Exploring Frontline Nurses' Self-Perceived Levels of QI Engagement and QI Competence

BACKGROUND AND PURPOSE

Nurse engagement in quality improvement (QI) is critical in the delivery of safe high-quality care, yet few studies have evaluated frontline nurses in this area. The purpose of this study was to identify and compare levels of self-reported QI engagement and QI competence among frontline nurses and nurse leaders.

METHODS

This study used a cross-sectional descriptive design. A convenience sample of frontline nurses (bedside RNs and advanced practice nurses) and nurse leaders from acute and ambulatory care sites completed the Nursing Quality Improvement in Practice (NQuIP) tool, which measures engagement and competence (knowledge, skills, and attitudes) in QI.

RESULTS

Data from 6,351 surveys completed by frontline nurses and nurse leaders representing 66 sites nationwide were analyzed. Only 52.5% of all respondents reported participating in QI. Knowledge scores were relatively high, while skills scores-especially those related to using QI tools-were low. Overall attitudes toward QI were positive. Nurse leaders scored significantly higher in engagement and competence than the frontline nurses they supervise.

CONCLUSIONS

The study findings indicate that nurse engagement in QI is limited. Although nurses' knowledge levels appear to be high, their limited competency in QI-related skills may contribute to low QI engagement. Leaders must make efforts to increase nurse engagement in order to attain high-quality outcomes. Using the NQuIP tool will allow leaders to evaluate nurses' self-perceived QI competence and engagement, which will aid in identifying target areas and developing effective strategies for improvement.

Examining QI Knowledge Among Frontline Nurses and Nurse Leaders

BACKGROUND

Frontline nurses deliver direct patient care and by participating in quality improvement (QI) can have an impact on health care quality and safety. Unfortunately, nurses are not participating in QI, which may be due to a lack of QI knowledge.

PURPOSE

The purpose of this study was to evaluate nurses QI knowledge utilizing the revised Quality Improvement Knowledge Application Tool (QIKAT-R), with newly created nursing scenarios, among frontline nurses and nurse leaders.

METHODS

Using a cross-sectional design, this study evaluated nurses QI knowledge utilizing the QIKAT-R.

RESULTS

Overall, QI knowledge among nurses was low. The frontline nurses (n = 44) scored higher than nurse leaders (n = 11) on overall QI knowledge scores, although not significant. Frontline nurses scored higher in QI knowledge related to aim and measure, whereas nurse leaders scored higher in change.

CONCLUSIONS

Understanding frontline nurses QI knowledge, such as with the QIKAT-R with newly created nursing scenarios, can assist with creating targeted strategies for improving overall engagement in QI.

The Evaluation of an Interprofessional QI Program: A Qualitative Study

Background: Quality Improvement (QI) is the key for every healthcare organization. QI programs may help healthcare professionals to develop the needed skills for interprofessional collaboration through interprofessional education. Furthermore, the role of diversity in QI teams is not yet fully understood. This evaluation study aimed to obtain in-depth insights into the expectations and experiences of different stakeholders of a hospital-wide interprofessional QI program. Methods: This qualitative study builds upon 20 semi-structured interviews with participants and two focus groups with the coaches and program advisory board members of this QI program. Data were coded and analyzed using thematic analysis. Results: Three themes emerged from the analysis: "interprofessional education", "networking" and "motivation: presence with pitfalls". Working within interprofessional project groups was valuable, because participants with different experiences and skills helped to move the QI project forward. It was simultaneously challenging because IPE was new and revealed problems with hierarchy, communication and planning. Networking was also deemed valuable, but a shared space to keep in contact after finalizing the program was missing. The participants were highly motivated to finish their QI project, but they underestimated the challenges. Conclusions: A hospital-wide QI program must explicitly pay attention to interprofessional collaboration and networking. Leaders of the QI program must cherish the motivation of the participants and make sure that the QI projects are realistic.

Quality improvement engagement: Barriers and facilitators

A comparison of frontline nurses, advanced practice nurses, and nurse leaders.

Qualitative Study on Barriers and Facilitators of Quality Improvement Engagement by Frontline Nurses and Leaders

AIM

To understand the facilitators and barriers of quality improvement (QI) from the perspective of nurses and leaders at the frontline.

BACKGROUND

Nurse engagement in QI has been associated with quality care and improved patient outcomes, yet nurse reported participation is low.

METHODS

A descriptive qualitative design and purposive sampling was used to examine barriers and facilitators of nurse engagement.

RESULTS

Facilitators 1) A leader's influence on a QI culture. Sub themes: creating buy-in, support of a just culture and working in partnership with nurses. Barriers 1) Barriers in organizational culture for nurses to lead QI. Sub themes: hierarchy, absence of a just culture, nurses' role not valued, lack of accountability for QI in nursing role, and resistance to change 2) Barriers in organizational structure for nurses to lead QI. Sub themes: manager disengagement, time pressure, lack of access to timely data, lack of QI knowledge, siloed departments, and lack of QI experts.

CONCLUSION

Barriers to QI engagement prevent nurses from fully engaging in QI. Creating a just culture and building the infrastructure to support nurse engagement is critical for success.

IMPLICATIONS FOR NURSING MANAGEMENT

Specific facilitators and barriers were identified that nurse leaders can assess in their practice setting and use relevant strategies to support engagement in QI.