The Quality and Safety Education for Nurses (QSEN) competencies emphasize behaviors consistent with patient-centered care, collaboration with members of the health care team, the use of evidence-based practice, quality improvement, deliberate efforts to ensure patient safety, and the integrated use of informatics to support patient care (Cronenwett et al., 2007). These six competencies mirror the Institute of Medicine (now the National Academy of Medicine) competencies (2003), which are an expectation for all health care professionals. Using language that describes nursing actions, the knowledge, skills, and attitudes that support the QSEN competencies define the requirements of competent clinical nursing practice.
Clinical educators can frame their work with staff in the QSEN competencies when they serve as a resource and coach for quality and safety-focused projects. Supporting direct care nurses to competence with evidence-based practice (EBP) projects and quality improvement (QI) initiatives supports the work of the institution, empowers staff to know they can make a difference, and creates an environment where patient safety and QI are central tenets of the work. The Institute for Healthcare Improvement identifies two interdependent roles for everyone working in health care: one is doing the work, and the other is improving the work (Scoville et al., 2016). To that end, the clinical educator holds a vital role as coach, influencing immediate problem solving at the point of care and impacting longer range problem solving through identification and planning of opportunities for improvement in practice processes.
Direct care nurses are frequently motivated to enhance practice processes but do not always understand the sequential steps that create sustainable improvement. Serving as a coach, clinical educators can support direct care nurses to develop knowledge, skills, and attitudes needed for effective EBP and QI projects by facilitating education that simultaneously addresses important patient care issues for the institution while teaching the fundamentals of and connection between the two. Implementing a learning activity focused on a clinical problem that nurses experience daily, and working through it as a team, empowers direct care nurses to learn skills that will help them to initiate and conduct impactful evidence-based improvement work. Although this teaching activity requires some preparation by the clinical educator, its effect can be far reaching as it supports competency in teamwork and collaboration, EBP, and QI.
To begin, the educator needs to gather initial facts about a local clinical problem and perform a cursory literature review to obtain at least one pertinent study so that the fundamentals of critiquing evidence can be practiced during the learning activity. Creating a worksheet that introduces the clinical problem and outlines the improvement process provides structure for learners and helps them to anticipate the next steps. Focusing on a clinical problem that direct care nurses are affected by makes the education meaningful. Teaching in groups of eight to 10 promotes discussion and teamwork, bringing divergent views to the problem solving process, a significant feature of improvement work.
An example of a problem-focused learning activity is shown in Table 1. The local problem is introduced, stating the unit has a catheter-associated urinary tract infection rate of 4.2 per 1,000 catheter-days, well above the hospital's benchmark of 1.4 per 1,000 catheter-days. Additional information the educator provides is that nurses are hesitant to follow the nurse-driven protocol to remove unnecessary urinary catheters for fear of reprimand by the ordering physician. Many are waiting for a physician's order or approval, despite having well-defined criteria for discontinuation. To address the catheter associated urinary tract infection rate, processes are needed to ensure adherence to the nurse-driven protocol, which is the focus for improvement with this learning activity. The educator assumes the role as coach to guide learners through the process.
Problem-Focused Learning Activity: Conducting an Evidence-Based Quality Improvement Project
Following the steps of the work-sheet, learners begin by recognizing data that validate there is a problem, considering the root cause of the problem, and identifying which members of the health care team should work to find a solution. Establishing that the eight to 10 learners are the team, they move on to formulate a PICOT question to guide their literature search so that the solution is evidence based. PICOT is an acronym that stands for Population of concern, Intervention or issue, Comparison, Outcome, and Time frame. As coach, the educator assists the team to understand the value of having a clear and precise PICOT question, as there are many approaches a team can take to address a problem; the PICOT question clarifies the approach so that appropriate literature can be gathered.
Because this is a learning experience that does not allow time for a literature search, the clinical educator provides the team with at least one pertinent research study, preferably a systematic review. The educator coaches the group through the critique of the study, reviewing levels of evidence and features such as statistical significance and implications of sample size. If the institution uses a standardized form to critique evidence, this provides a good opportunity for the educator to review the form and support learners to complete it accurately. The team then approaches the next step in the process, discussing how literature is organized into a table of evidence. The clinical educator can share an example of a table of evidence, demonstrating how it lists pertinent facts related to each study reviewed.
Considering the findings from the literature search contained in the table of evidence, the input of direct care nurses regarding the local problem, and patient preferences, the team determines the practice change. It is at this point that EBP and QI intersect, as the team now needs a plan to put the evidence-based change into action. One of the most effective methods to bring about change is the implementation of Plan-Do-Study-Act (PDSA) cycles (Institute for Healthcare Improvement, 2019; Taylor et al., 2014). Three questions drive this process:
- What are we trying to accomplish?
- How will we know a change is an improvement?
- What change can we make that will result in improvement?
The Plan stage consists of the team identifying what can be changed that will lead to improvement and creating a blueprint for the change. In the Do stage, the plan is carried out, data are collected, and observations are made. During the Study stage, team members analyze the data obtained from observations to determine the effectiveness of their implementation. Finally, the Act stage is where adjustments are made based on the collected data in preparation for the next PDSA cycle. Iterations of the PDSA cycle continue until the goal of implementing the change in a sustainable way is achieved.
Using this model, the clinical educator moves the team through the learning activity by coaching them as they establish an aim statement for what they want to accomplish, plan how the changes will be implemented and measured, and discuss how they will know the improvement is achieved. Throughout this educational activity, the clinical educator can emphasize strategies for bringing coworkers into the process through consensus building. The value of a clinical educator as coach is clear in supporting direct care nurses to achieve competency in conducting EBP and QI. Although nothing can replace the coaching a clinical educator provides through an actual project, this hands-on learning activity can be completed in 2 hours and serves as an introductory or reinforcing exercise to help direct care nurses understand their role in and ability to achieve quality and safety competencies.
- Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P. & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
- Institute for Healthcare Improvement. (2019). Plan-do-study-act worksheet. Retrieved from http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx
- Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press.
- Scoville, R., Little, K., Rakover, J., Luther, K. & Mate, K. (2016). Sustaining improvement. Retrieved from http://www.ihi.org/resources/Pages/IHIWhitePapers/Sustaining-Improvement.aspx
- Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. & Reed, J.E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23, 290–298. doi:10.1136/bmjqs-2013-001862 [CrossRef]
Problem-Focused Learning Activity: Conducting an Evidence-Based Quality Improvement Project
|General Process Information|
Identify the problem; assemble a team; gather data to identify root cause of problem
Develop a PICOT (Population of concern, Intervention or issue, Comparison, Outcome, and Time frame) question to steer literature review/search
Conduct a literature review; gather information about the problem and potential solutions/research (Plan)
Critique the available evidence; create a table of evidence (Plan)
Formulate a plan of action; identify a clear measure for the action; seek the input of staff to build consensus for the practice change; provide any needed education (Plan)
Implement the plan and measure; ongoing educational support (Do)
Analyze the measured results; evaluation (Study)
Adjust the plan and begin a new PDSA cycle (Act)
|Problem: There are elevated catheter associated urinary tract infection rates (4.2 per 1,000 catheter-days) in third and fourth quarter for this medical–surgical unit—greater than the hospital benchmark (1.4 per 1,000 catheter-days). Currently, the hospital has a nurse-driven urinary catheter removal protocol. However, staff does not consistently implement expeditious catheter removal.|
|Background information: This nurse–driven protocol (NDP) was introduced in 2009. There is a physician order set for insertion of an indwelling urinary catheter (IUC) and includes the prechecked IUC removal NDP.|
|The NDP order has three parts:|
|1: Insertion 2. Maintenance and education 3. Discontinuation.|
|The order set is available and encouraged to be used for all patients. If a physician or surgeon does a procedure on a patient involving insertion of an IUC but does not want the nurse to remove it, he/she have been instructed to uncheck the discontinuation part of the order set. The problem has occurred because a surgeon never unchecked that part and when the nurse went to use the protocol several days later thinking there was no indication for the IUC, the nurse was reprimanded by the surgeon. Word spread that it is always better to ask the doctor first before pulling, which defeats the intentionality of the protocol.|
|Processes are needed to ensure protocol adherence.|
| How do you know it is a problem? What data supports that it is a problem?|
| What is the root cause? How can you find out?|
| Who should work on addressing the problem?|
|Develop a PICOT question to steer the literature search|
|Conduct a literature search|
| What would make you include an article?|
| What would make you exclude an article?|
|Critique the strength of evidence using the medical center's standardized form|
| Is it a randomized controlled trial? Descriptive? Correlational?|
| Does it use a sound methodology?|
| Is there statistical significance (p <.05)?|
| Is the sample adequate? Was it conducted at multiple sites? Larger sample size supports generalizability of findings.|
| Does the study make sense?|
| Do you see anything that makes you suspicious of the findings? Conflict of interests?|
| Do the findings help you solve your problem?|
|Create a table of evidence for the studies you are including as evidence|
|Consider current unit catheter associated urinary tract infection prevention practices; consider staff input regarding the problem|
|Consider the patient perspective regarding urinary catheters|
|Formulate a plan for the practice change with your team|
| How will you measure the change?|
| How will you know it is an improvement? What will be your measure?|
| How will you get staff buy-in? Can they give input to improve your process?|
| Do you need to provide education?|
| How will you support staff in making the change?|
|Implement and measure the practice change|
| When is the roll out?|
| How will you support staff through the roll out?|
| How long will you measure?|
| Who keeps the data?|
| Who reports the data to staff?|
|Analyze the data/evaluation of the practice change|
| What do these data indicate?|
| What adjustments to the plan can be made?|
|Initiate new PDSA cycle.|