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

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.

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.