The Journal of Continuing Education in Nursing

CNE Article 

A Multi-State Assessment of Employer-Sponsored Quality Improvement Education for Early-Career Registered Nurses

Maja Djukic, PhD, RN; Christine T. Kovner, PhD, RN, FAAN; Carol S. Brewer, PhD, RN, FAAN; Farida K. Fatehi, MS, BDS; Joanna R. Seltzer, BSN, RN

Abstract

How To Obtain Contact Hours By Reading This Issue

Instructions: 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com. In order to obtain contact hours you must:

Read the article, “A Multi-State Assessment of Employer-Sponsored Quality Improvement Education for Early-Career Registered Nurses,” found on pages 12–19, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.
Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

 

This activity is valid for continuing education credit until December 31, 2014.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Objective

Review the results of a descriptive study that assessed employer-sponsored quality improvement (QI) education and registered nurses’ preparedness across a wide range of QI steps and processes.

Do you want to Participate in the CNE activity?


Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

Background: Increasing participation of registered nurses (RNs) in quality improvement (QI) is a promising strategy to close the health care quality chasm. For RNs to participate effectively in hospital QI, they must have adequate QI knowledge and skills.
Methods: This descriptive study assessed employer-sponsored QI education and RNs’ preparedness across a wide range of QI steps and processes. RNs from 15 U.S. states who were employed in hospitals and were initially licensed to practice in 2007 to 2008 were surveyed.
Results: Fewer than one third of respondents reported being very prepared across all measured QI topics. More than half reported receiving zero hours of training in these same topics in the last year. Lack of educational offerings on the topic was the top reason respondents gave for not obtaining QI training.
Conclusion: The QI education offered by employers to RNs could be substantially improved. Nurse educators play a critical role in making these improvements.

Dr. Djukic is Assistant Professor, Dr. Kovner is Professor, and Ms. Seltzer is Research Assistant, New York University College of Nursing, New York, New York. Dr. Brewer is Interim Associate Dean for Academic Affairs and Professor, University at Buffalo School of Nursing, Buffalo, New York. Ms. Fatehi is Research Analyst, New York University College of Dentistry, New York, New York.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Funding for this study was provided by the National Council of State Boards of Nursing Center for Regulatory Excellence and the Robert Wood Johnson Foundation.

Address correspondence to Maja Djukic, PhD, RN, Assistant Professor, New York University College of Nursing, 726 Broadway, 10th Floor, New York, NY 10003. E-mail: md1359@nyu.edu.

Received: August 08, 2012
Accepted: October 02, 2012
Posted Online: November 26, 2012

Abstract

How To Obtain Contact Hours By Reading This Issue

Instructions: 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com. In order to obtain contact hours you must:

Read the article, “A Multi-State Assessment of Employer-Sponsored Quality Improvement Education for Early-Career Registered Nurses,” found on pages 12–19, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.
Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

 

This activity is valid for continuing education credit until December 31, 2014.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Objective

Review the results of a descriptive study that assessed employer-sponsored quality improvement (QI) education and registered nurses’ preparedness across a wide range of QI steps and processes.

Do you want to Participate in the CNE activity?


Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

Background: Increasing participation of registered nurses (RNs) in quality improvement (QI) is a promising strategy to close the health care quality chasm. For RNs to participate effectively in hospital QI, they must have adequate QI knowledge and skills.
Methods: This descriptive study assessed employer-sponsored QI education and RNs’ preparedness across a wide range of QI steps and processes. RNs from 15 U.S. states who were employed in hospitals and were initially licensed to practice in 2007 to 2008 were surveyed.
Results: Fewer than one third of respondents reported being very prepared across all measured QI topics. More than half reported receiving zero hours of training in these same topics in the last year. Lack of educational offerings on the topic was the top reason respondents gave for not obtaining QI training.
Conclusion: The QI education offered by employers to RNs could be substantially improved. Nurse educators play a critical role in making these improvements.

Dr. Djukic is Assistant Professor, Dr. Kovner is Professor, and Ms. Seltzer is Research Assistant, New York University College of Nursing, New York, New York. Dr. Brewer is Interim Associate Dean for Academic Affairs and Professor, University at Buffalo School of Nursing, Buffalo, New York. Ms. Fatehi is Research Analyst, New York University College of Dentistry, New York, New York.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Funding for this study was provided by the National Council of State Boards of Nursing Center for Regulatory Excellence and the Robert Wood Johnson Foundation.

Address correspondence to Maja Djukic, PhD, RN, Assistant Professor, New York University College of Nursing, 726 Broadway, 10th Floor, New York, NY 10003. E-mail: md1359@nyu.edu.

Received: August 08, 2012
Accepted: October 02, 2012
Posted Online: November 26, 2012

At more than 3 million strong, registered nurses (RNs) make up the largest segment of the U.S. health care work force (Health Resources and Services Administration [HRSA], 2010) and have a robust presence in direct patient care. As a result, RNs can contribute to closing the nation’s persistent health care quality chasm (Agency for Healthcare Research and Quality [AHRQ], 2012) by leading and participating in quality improvement (QI), which is defined as a range of formal approaches to analyzing the quality of patient care and implementing systematic efforts to improve it.

The value and importance of implementing QI, especially clinicians’ involvement in improvement initiatives, is evident from a number of reports. Involving a higher percentage of hospital staff in QI is associated with better performance on several hospital-level quality indicators, such as acute myocardial infarction, congestive heart failure, stroke, and pneumonia-related mortality (Weiner et al., 2006). Higher participation of staff RNs is related to better perceptions of the quality of patient care as reported by hospital quality managers (Cohen et al., 2008). Also, based on the analysis of data from 10 hospitals that participated in the Transforming Care at the Bedside (TCAB) (Hassmiller & Bolton, 2009) initiative, Unruh, Agrawal, and Hassmiller (2011) estimated that front-line RNs’ involvement and leadership in process improvement resulted in savings of $625,603 per clinical unit during a 3-year period. Further, recent changes in the Centers for Medicare and Medicaid Services (CMS) payment policy specific to measuring nursing-sensitive quality outcomes, such as falls, pressure ulcers, catheter-associated urinary tract infections, and central-line-associated infections (CMS, 2011a), and participating in a nursing-sensitive quality indicators database (CMS, 2011b) are likely to create even greater value for QI. RNs must be equipped with the necessary knowledge and skills to participate in and lead QI.

Despite these findings and payment policies, the lack of RNs’ educational preparedness in QI is a major obstacle to their participation in this area (Draper, 2008; Institute of Medicine [IOM], 2003). Based on data from a national sample of U.S. RNs who were licensed to practice for the first time in 2004 and 2005, fewer than one fourth reported being very prepared in essential QI activities, such as data collection, data analysis, measurement, and flowcharting processes on graduating from their basic nursing education programs (Kovner, Brewer, Yingrengreung, & Fairchild, 2010). This finding suggests that employers are left to pick up the slack, providing RNs with continuing education so that they can participate in and help lead health care improvements.

In response to the IOM report, Health Professions Education: A Bridge to Quality (IOM, 2003), leaders in nursing and other health professions have worked to bolster RNs’ QI preparedness. The Quality and Safety Education for Nurses (QSEN) initiative, which began in 2005, created a website to disseminate tools and resources to help nursing schools and health care organizations develop the competencies necessary for effective RN participation and leadership in QI (Cronenwett et al., 2007). Additionally, the Institute for Healthcare Improvement (IHI) Open School for Health Professions (2012) and Clinical Microsystems (2011) offer many web-based QI resources that can be accessed by students and clinicians across educational and clinical settings. Useful learning frameworks and principles have also been developed to help educators in a variety of settings structure successful QI learning experiences at different levels, from novice to proficient practitioner (Armstrong, Headrick, Madigosky, & Ogrinc, 2012; Cooke, Ironside, & Ogrinc, 2011). Furthermore, programs such as the Magnet Recognition Program® (American Nurses Credentialing Center, 2012), TCAB, the Integrated Nurse Leadership Program, the Clinical Scene Investigator (CSI) Academy (Kliger, Lacey, Olney, Cox, & O’Neal, 2010), Nurses Improving Care for Healthsystem Elders (NICHE) (2012), and other innovative organizational-level initiatives, such as those described by Albanese et al. (2010), have been adopted by some hospitals, creating opportunities for RNs to engage in and learn about QI. Despite the plethora of resources and programs designed to facilitate QI learning for RNs, a systematic assessment of how well early-career RNs are prepared by their employers in QI and the types, effectiveness of, and barriers to participating in employer-sponsored QI education is lacking. This gap in knowledge hampers strategic development and planning for effective employer-sponsored QI education.

This study was conducted to assess QI education and participation in a cohort of early-career RNs who were licensed to practice for the first time in 2007 and 2008 in 15 U.S. states. Early-career RNs, defined in this study as RNs who have practiced for less than 5 years, represent approximately one fourth of the U.S. hospital nursing work force (U.S. Department of Health and Human Services, 2010). Thus, they play an important role in improving health care quality. This article reports RNs’ assessments of their employer-sponsored QI education. The research questions were:

  1. How well prepared are RNs by employer-sponsored QI education?

  2. What is the participation of RNs in employer-sponsored QI education?

  3. What are the types, effectiveness of, and barriers to employer-sponsored QI education?

 

The results of this study show the experiences of early-career RNs with employer-sponsored QI education. As hospitals strive to meet quality benchmarks for nursing-sensitive quality indicators, these data can help guide the planning of effective educational programming to stimulate RNs’ participation in health care improvements.

Methods

Permission to conduct the study was granted by the institutional review boards from the participating institutions.

Research Design

This study used a cross-sectional, descriptive design and multiple data sources. The authors obtained and merged demographic data from a survey administered in 2009 with a sample of RNs licensed for the first time in 2007 and 2008 (Kovner et al., 2007, 2010). To collect QI data from the same sample, in 2010, the authors administered a mixed-mode mailed paper and web-based survey to a subset of respondents to the 2009 survey. Multiple mailings were sent to nonresponders, following the Dillman Tailored Design method (Dillman, 2000).

Sampling

Between January and March 2009, random sampling was used to survey RNs who were licensed to practice for the first time between August 1, 2007, and July 31, 2008, in 15 states (Alabama, Kentucky, Maryland, Michigan, Nevada, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, and West Virginia), from 25 metropolitan statistical areas and two rural counties, about personal and work characteristics. The authors chose these states because they had the most accessible and accurate lists of newly licensed RNs. In 2009, a total of 3,216 surveys were sent, with 1,765 respondents completing the survey (57% response rate). Of the respondents, 1,496 reported working in hospitals. From this group, 1,113 RNs were randomly selected to participate in the QI survey between October 2010 and February 2011. Of those, 475 returned the survey (47% response rate), 6 were dropped as outliers for reporting more than 100 hours of QI training during 12 months, 32 did not report their work setting, 13 reported not working in a hospital, and 24 reported working in a capacity other than as a staff RN. This left 400 respondents in the analytic sample.

Instrument

Data on QI activities were collected using a survey containing 35 questions, with a total of 95 items. The survey questions about QI were developed based on the QSEN framework (Cronenwett et al., 2007). The face validity of these questions was established by a five-member expert panel. Five staff RNs who worked in hospitals pilot tested the survey to ensure its readability and ease of use. This article describes RNs’ reports of 17 items on the degree of employer-sponsored preparation in several QI models and activities using a Likert-type scale with three response options: “not at all prepared,” “somewhat prepared,” and “very prepared.” It also reports 14 items related to hours of training in these QI activities during the last 12 months and 6 items related to the types, effectiveness of, and barriers to QI training.

Data Analysis

Descriptive statistics were used to examine responses to each survey question.

Results

Demographics

Table 1 shows the demographic characteristics of the survey respondents. The majority of respondents were female (92.8%) and White (81.9%), with an average age of 34.4 years (SD = 9.0). More than half (58.2%) had earned a diploma or an associate’s degree as their basic nursing degree and most (92.0%) worked full-time in an inpatient hospital setting (93.5%). Approximately one third (36.3%) worked on medical-surgical units. Fewer than one fourth (17.8%) reported working at a Magnet® hospital. Respondent RNs had an average of 30.3 months (SD = 3.8) of work experience.

Sample Demographics (N = 400)

Table 1: Sample Demographics (N = 400)

Nurses’ Preparation in Quality Improvement by Employers

Table 2 shows RNs’ reported preparation by their employers in various QI models and activities. Of the five QI models measured, the greatest percentage of RNs reported being “very prepared” in Continuous Quality Improvement (26.8%). This was followed by Plan, Do, Study, and Act (17.8%); Focus, Analyze, Develop, Execute, and Evaluate (16.5%); Total Quality Management (16.1%); and Six Sigma-DMAIC/DMADV (Define, Measure, Analyze, Improve, and Control/Define, Measure, Analyze, Design, and Verify) (13.2%).

Quality Improvement Preparedness by Employers (N = 400)

Table 2: Quality Improvement Preparedness by Employers (N = 400)

For the 12 QI activities, nearly one third of RNs reported being “very prepared” in flowcharting processes, (32.1%), measuring current performance (29.2%), data collection (27.7%), and using tools and methods to improve performance (26.8%). Approximately 25% of the respondents reported being “very prepared” in measuring changes resulting from QI (24.0%), data measurement (23.3%), project implementation (21.4%), and assessing gaps in current practice (20.9%). Fewer than one in five reported being “very prepared” in repeating QI steps until the desired outcome is achieved (19.6%) and monitoring the sustainability of QI changes (17.8%).

Participation in Employer-Sponsored Quality Improvement Education

Table 3 shows the reported hours of employer-sponsored QI training in the past 12 months. On average, more than 50% of RNs reported not receiving any training across all of the 14 measured QI activities, with a high of 76.5% of RNs reporting that they had received no training in monitoring sustainability and a low of 46.1% of RNs reporting that they had received no training in working as a team.

Participation in Employer-Sponsored Quality Improvement Education in the Past 12 Months (N = 400)

Table 3: Participation in Employer-Sponsored Quality Improvement Education in the Past 12 Months (N = 400)

Types, Effectiveness, and Barriers to Employer-Sponsored Quality Improvement Education

Table 4 shows RNs’ responses about their participation in an employer-sponsored QI course, conference, or online training in the past 12 months; RNs’ perceptions of the effectiveness of these educational offerings; and the major barriers to participation. Approximately one fourth of the RNs reported being sent by their employer to a QI training course or conference (25.4%), and nearly one third reported participating in an online QI course (31.7%). Of those who attended a QI course or conference, 43.9% found the training “very effective” and 52.0% found it “somewhat effective” in helping them improve patient care on their unit. Slightly more than one third of those who participated in online training (38.1%) found it “very effective” and 56.8% found it “somewhat effective” in helping them improve patient care. The primary reason reported for not participating in online training and for not attending courses or conferences was that they were not offered (42.2% and 43.4%, respectively). The second most common reason was the time commitment (25.2% and 25.1%, respectively). Respondents could select multiple reasons for not attending.

Effectiveness of and Barriers to Employer-Sponsored Quality Improvement Education (N = 400)

Table 4: Effectiveness of and Barriers to Employer-Sponsored Quality Improvement Education (N = 400)

Discussion

The confluence of several factors will require health care organizations to invest in and improve the readiness of the nursing work force to engage in QI: (1) CMS payment reforms in nursing care quality (CMS, 2011a, 2011b); (2) research evidence that shows the financial (Unruh et al., 2011) and health care quality benefits (Cohen et al., 2008) of nurse-led QI; (3) a new professional mandate for RNs to lead quality and safety efforts (Cronenwett et al., 2007; HRSA, 2010); and (4) remaining deficiencies in the quality of health care (AHRQ, 2012). As a result, health care organizations will need to move beyond the typical strategies for managing quality that are often associated with the performance improvement paradigm. These strategies focus on work force-related causes and solutions (e.g., implementation of clear job expectations, performance feedback, motivation, and incentives). Instead, health care organizations need to incorporate a more systematic and comprehensive set of improvement strategies, common to the QI framework, which focus on improvements in the care environment and care processes to support better work force performance and ultimately better patient outcomes (Bornstein, n.d.).

This study examined the experiences with employer-sponsored education of early-career RNs working in hospitals in various QI knowledge topics and skills that would enable RNs to lead improvements in care systems and processes. Fewer than one third of respondents reported being very prepared across all measured QI topics, whereas more than half reported not receiving any training in these same topics in the previous year. As might be expected for novice practitioners, more RNs reported being very prepared in what might be considered less complex QI skills. For example, approximately one in three early-career RNs reported being very prepared in data collection, flowcharting, and measuring current performance. In comparison, fewer than one in five reported being very prepared in data analysis, using project monitoring tools, and monitoring the sustainability of improvement efforts. Few respondents reported attending an employer-sponsored QI training course or conference or completing online QI training. Yet, most of those who received training found it very or somewhat effective in helping them to improve patient care on their unit, regardless of whether the training was received at a conference or online. The major reason that RNs gave for not obtaining QI education was lack of offerings on the topic, a finding that has substantial implications for hospital nurse educators.

Hospital nurse educators can play a key role in facilitating RNs’ QI education. However, developing QI education programs can be daunting for clinical educators who themselves might lack fundamental QI knowledge and skills. To overcome this barrier, nurse educators can assume the roles of co-learner and facilitator instead of the more traditional role of imparter of knowledge. Cooke et al. (2011, p. i80) defined co-learning as “teachers, students, clinicians, patients, and families learning together,” which enables educators to learn with clinicians about QI. In the facilitator role, the educator is “designing a pattern of learning experiences” and is “concerned with providing procedures and resources for helping learners acquire information and skills” instead of being “concerned with transmitting information and skills” (Knowles, Holton, & Swanson, 2005, p. 115).

Nurse educators can use existing frameworks that outline learning outcomes and related activities that are appropriate for different levels of learners (Armstrong et al., 2012). Expert consultants (QSEN, 2012) can help identify resources and learning experiences that best facilitate RNs’ self-directed learning of basic QI principles. Examples of available resources include the IHI’s Open School web-based learning modules (IHI, 2012) and Clinical Microsystem’s virtual, action-oriented eCoach-The-Coach (eCTC) program (Clinical Microsystems, 2011). This 6-month program includes four virtual sessions and one 3-day in-person session and is designed to provide participants with knowledge of improvement principles. Participants then have an opportunity to apply these principles in their work settings through guided implementation of QI projects (Clinical Microsystems, 2011). Both the IHI and the Clinical Microsystems websites offer free access to many helpful tools and ideas for structuring unit-based QI projects. Examples of tools include workbooks to guide improvement work, reading lists, books, improvement stories, case studies, videos, and webinars.

However, learning about QI without having an opportunity to practice is not sufficient for building QI competency (Armstrong et al., 2012). Therefore, nurse educators can partner with unit-level and organizational-level quality champions to create opportunities for RNs to engage in ongoing QI initiatives to apply didactic knowledge to real-life improvement projects (Armstrong et al., 2012; Clinical Microsystems, 2011). Three examples of programs that nurse educators can help to implement in their local organizations to engage RNs in improvement efforts are TCAB, the Integrated Nurse Leadership Program, and the CSI Academy. These programs promote projects led by staff RNs and partnerships between senior executives and front-line staff to accomplish several goals (Kliger et al., 2010), including the following:

  • Teach staff nurses new skills and competency in leading change and quality improvement.
  • Empower nurses to engage in problem solving and find solutions.
  • Use bottom-up organizational change theory.

 

Other ideas for nurse educators who are interested in facilitating QI learning include designing programs that allow staff RNs who are more experienced in QI to mentor novice RNs; introducing QI principles, tools, and ongoing organizational improvement projects during orientation or new nurse residency programs; and advocating for the design and implementation of clinical, unit-level dashboards that track and visually display real-time performance data to provide feedback to staff nurses on how their unit is doing in patient metrics affected by nursing care (Albanese et al., 2010).

The results of this study suggest that employer-sponsored QI education for early-career RNs could be substantially improved. Nurse educators can be the main catalysts for this improvement. These efforts must also be supported by those in top leadership positions, who can commit financial resources to the development of QI educational programs and make QI an organizational priority. The generalizability of these findings is limited to early-career RNs working in hospitals in the geographic areas in which responders were located, and the validity of the findings might be affected by nonresponse bias and reliance on self-reported data, as opposed to more objective measures of RNs’ knowledge of and participation in QI.

Conclusion

The results of this study reflect QI education trends in a diverse sample of early-career RNs, but nurse educators who are responsible for continuing education programming can use similar survey tools to assess local RNs’ preparedness across a range of QI topics. Nurse educators can use the resources available to them to create personalized staff development programs to best meet the learning needs of RNs and to help cultivate a more QI-ready nurse work force. Given the higher costs associated with attending a conference compared with obtaining education online, web-based programs may be a more economical approach for employers to increase the number of RNs receiving QI training without sacrificing the quality of the education.

References

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  • Kliger, J., Lacey, S. R., Olney, A., Cox, K. S. & O’Neal, E. (2010). Nurse-driven programs to improve patient outcomes: Transforming care at the bedside, Integrated Nurse Leadership Program, and the Clinical Scene Investigator Academy. Journal of Nursing Administration, 40(3), 109–114. doi:10.1097/NNA.0b013e3181d042ac [CrossRef]
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  • Weiner, B., Alexander, J. A., Shortell, S. M., Baker, L. C., Becker, M. & Geppert, J. J. (2006). Quality improvement implementation and hospital performance on quality indicators. Health Services Research, 41(2), 307–334. doi:10.1111/j.1475-6773.2005.00483.x [CrossRef]

Sample Demographics (N = 400)

Variable n (%)
Mean age in years (SD) 34.4 (9.0)
Mean opportunity to work since passing the NCLEX in months (SD) 30.3 (3.8)
Gender
  Male 29 (7.2)
  Female 371 (92.8)
Marital status
  Married 208 (52.8)
  Not married 186 (47.2)
First basic nursing degree
  Diploma/associate’s degree 227 (58.2)
  Baccalaureate degree or higher 163 (41.8)
Ethnicitya
  White 321 (81.9)
  Black 33 (8.4)
  Asian 18 (4.6)
  Other 20 (5.1)
Work status
  Full-time 368 (92.0)
  Part-time 32 (8.0)
Work setting
  Hospital inpatient 374 (93.5)
  Hospital outpatient 26 (6.5)
Unit typeb
  ICU 87 (21.8)
  Step-down 38 (9.5)
  General/medical-surgical 145 (36.3)
  Other 129 (32.3)
Magnet®
  Yes 61 (17.8)
  No 281 (82.2)

Quality Improvement Preparedness by Employers (N = 400)

Variable Not at All Prepared Somewhat Prepared Very Prepared

n (%) n (%) n (%)
FADE improvement model 207 (54.3) 111 (29.1) 63 (16.5)
PDSA improvement model 197 (51.4) 118 (30.8) 68 (17.8)
Six-Sigma-DMAIC/DMADV 219 (57.6) 111 (29.2) 50 (13.2)
CQI 124 (32.3) 157 (40.9) 103 (26.8)
TQM 203 (53.7) 114 (30.2) 61 (16.1)
Data collection 112 (28.7) 170 (43.6) 108 (27.7)
Data analysis 120 (30.8) 176 (45.2) 93 (23.9)
Data measurement 120 (31.0) 177 (45.7) 90 (23.3)
Project implementation 120 (31.0) 184 (47.5) 83 (21.4)
Use of data analysis or project monitoring tools 138 (35.9) 170 (44.3) 76 (19.8)
Flowcharting processes 111 (28.8) 151 (39.1) 124 (32.1)
Measuring current performance 95 (24.8) 176 (46.0) 112 (29.2)
Assessing gaps in current practice 114 (29.5) 192 (49.6) 81 (20.9)
Using tools and methods to improve performance 92 (23.7) 192 (49.5) 104 (26.8)
Measuring resulting changes 117 (30.2) 178 (45.9) 93 (24.0)
Repeating steps until desired outcome is achieved 126 (33.0) 181 (47.4) 75 (19.6)
Monitoring sustainability 133 (34.7) 182 (47.5) 68 (17.8)

Participation in Employer-Sponsored Quality Improvement Education in the Past 12 Months (N = 400)

Variable 0 Hours 1 to 10 Hours > 10 Hours

n (%) n (%) n (%)
Data collection 247 (69.0) 90 (25.2) 21 (6.1)
Data analysis 260 (72.6) 80 (22.3) 18 (5.2)
Data measurement 261 (72.9) 82 (22.9) 15 (4.2)
Working as a team 165 (46.1) 140 (39.2) 53 (14.8)
Project implementation 213 (59.5) 121 (33.7) 24 (6.8)
Quality improvement data analysis or project monitoring tools 248 (69.3) 91 (25.5) 19 (5.4)
Flowcharting processes 240 (67.0) 95 (26.5) 23 (6.6)
Identifying good care from scientific evidence 198 (55.3) 131 (36.7) 29 (8.3)
Measuring current performance 203 (56.7) 134 (37.4) 21 (6.1)
Assessing gaps 262 (73.2) 84 (23.4) 12 (3.4)
Applying tools and methods to improve performance 193 (53.9) 134 (37.4) 31 (8.8)
Measuring resulting changes 244 (68.2) 94 (26.3) 20 (5.7)
Repeating steps until desired performance is achieved 268 (74.9) 71 (19.9) 19 (5.4)
Monitoring sustainability 274 (76.5) 69 (19.3) 15 (4.2)

Effectiveness of and Barriers to Employer-Sponsored Quality Improvement Education (N = 400)

Variable n %
Has your employer sent you to a QI course or conference during the past 12 months?
  Yes 100 25.4
  No 294 74.6
How effective was the QI education in helping you to improve patient care?
  Very effective 43 43.9
  Somewhat effective 51 52.0
  Not very effective 4 4.1
If you did not attend, the primary reason was:
  Time commitment 67 25.1
  Inconvenient 27 10.1
  Not offered 116 43.4
  Lack of evidence of effectiveness 3 1.1
  Too expensive 22 8.2
  Other 32 12.0
Have you participated in online QI training in the past 12 months?
  Yes 119 31.7
  No 256 68.3
How effective was this training in helping you to improve patient care?
  Very effective 45 38.1
  Somewhat effective 67 56.8
  Not very effective 6 5.1
If you did not participate, the primary reason was:
  Time commitment 58 25.2
  Inconvenient 18 7.8
  Lack of evidence of effectiveness 6 2.6
  Too expensive 16 7.0
  Other 29 12.6
  Not offered 97 42.2
  Lack of access to a computer 6 2.6

Key Points

Quality Improvement

Djukic, M., Kovner, C. T., Brewer, C. S., Fatehi, F. K. & Seltzer, J. R. (2013). A Multi-State Assessment of Employer-Sponsored Quality Improvement Education for Early-Career Registered Nurses.The Journal of Continuing Education in Nursing, 44(1), 12–19.

  1. By using quality improvement (QI) tools and resources, nurses, who make up the largest segment of the U.S. health care work force, can play a substantial role in closing the nation’s health care quality chasm.

  2. Fewer than one third of registered nurses (RNs) reported being very prepared across all QI topics measured by employer-sponsored education, and more than half reported receiving zero hours of QI training in the past year through employer-sponsored education.

  3. Hospital nurse educators, with the support of nursing C-suite executives, are uniquely positioned to improve the QI education that RNs receive in the workplace, thus helping to cultivate a QI-ready work force that can improve the quality of patient care.

  4. Many high-quality, easily accessible QI tools and resources, such as Transforming Care at the Bedside, the Institute for Healthcare Improvement, Quality and Safety Education for Nurses, Nurses Improving Care for Healthsystem Elders, and Clinical Microsystems, are available to support hospitals in their efforts to educate RNs about QI.

10.3928/00220124-20121115-68

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