One of the most challenging aspects of the nurse educator role is to make choices about what constitutes fundamental content in a baccalaureate nursing curriculum. These choices are driven, in part, by initiatives from the Institute of Medicine (IOM, 2010), the Carnegie Foundation (Benner, Sutphen, Leonard, & Day, 2010), and the Robert Wood Johnson Foundation (RWJF, 2010) that address the need to prepare nurses who can function safely and effectively in a fast-paced, rapidly changing, nonlinear complex care environment with “expanded expectations for today's nursing practice” (Benner et al., 2010, p. 19). Simultaneously, Ironside and McNelis (2011) and Tanner (2010) have questioned the traditional view of fundamental nursing skills by recommending that educators focus on teaching students to find and use information, give them the tools necessary to participate in quality improvement (QI) activities, encourage participation in interprofessional teams, expand their understanding of the culture of health care, and introduce systems thinking in order to increase their “adaptive capacity” to identify errors and safety risks and, more importantly, intervene (Ironside & McNelis, 2011, p. 124).
These calls suggest the need for nurses who can “see practice differently” by learning about systems thinking and QI (Ironside & McNelis, 2011, p. 123). Systems thinking is “the ability to recognize, understand, and synthesize the interactions and interdependencies in a set of components designed for a specific purpose” (Dolansky & Moore, 2013, para. 7) and QI “first measures variance between ideal and actual [processes], and then implements strategies to close any gaps” (Sherwood & Zomorodi, 2014, p. 19). These two concepts are embraced by both academic- and practice-centered professional nursing organizations. For instance, the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice (2008) calls for “baccalaureate graduates [who] will understand and use quality improvement concepts, processes, and outcome measures…within a larger system of care” (p. 13). Similarly, the American Organization of Nurse Executives (AONE) lists performance improvement (using quality metrics) and systems thinking as competencies required of today's nursing leaders (AONE, 2015). Other organizations are also embracing this movement by providing resources to facilitate the required education of both new and experienced nurses. For example, Quality and Safety Education for Nurses (QSEN) identifies QI as one competency for nurses (Cronenwett et al., 2007) and offers resources for enhancing systems thinking in educational activities (e.g., Capper, 2017; Wisser, 2016). The Institute for Healthcare Improvement (IHI) offers a variety of educational resources through their Open School to advance and support interprofessional approaches to systems thinking and QI in health care.
Despite these recommendations and resources, nursing programs have been slow to fully integrate systems thinking and QI principles (Tschannen, Aebersold, Kocan, Lundy, & Potempa, 2015). The most prevalent models for incorporating these concepts include integration within a single course, a learning module, or case studies (Gjessing, Torgé, Hammar, Dahlberg, & Faresjö, 2014; Heflin et al., 2014; Machin & Jones, 2014; Pelayo, 2013; Teeley, Lowe, Beal, & Knapp, 2006). However, D'Eramo and Puckett (2014) challenge educators to expand beyond these singular, predominately didactic experiences by providing opportunities for students to participate in real QI initiatives with clinical partners.
The purpose of this article is to showcase a holistic approach to embedding systems thinking and QI content across a 4-year Bachelor of Nursing (BSN) curriculum. Not only does this approach bridge the gap between education and practice, it also supports the culture of patient safety. This approach is innovative in that it (a) integrates systems thinking and QI with traditional course content, (b) builds increasing competency in systems thinking and QI across the curriculum, (c) provides collaborative team experiences with practice partners, representing multiple professions, to address real-world systems and QI issues, and (d) demonstrates a mechanism to keep nursing education current with practice trends.
Infusing Systems Thinking and Quality Improvement Into the BSN Curriculum
As our faculty embarked on a substantive BSN curricular revision, input from both the national and local levels was sought. At the local level, practice partner leadership input was solicited via the question “What knowledge, skills, and abilities would make our students standout and contribute to the mission and vision of your organization?” The answer was specific and immediate: systems thinking and QI. These thought leaders aligned with the aforementioned national-level calls for action as they articulated the value added to their organizations when new graduates enter the workforce with these skills.
Based on this input, faculty determined that integrating basic systems thinking and QI content was essential in the revised undergraduate curriculum. The expectation was for students to appreciate that QI takes place in the context of a “wider dynamic system” (de Savigny & Adam, 2009, p. 33). However, one of the challenges was determining the scope of learning experiences that would generate relevant outcomes for BSN graduates and differ from the expectation for Doctor of Nursing Practice (DNP) graduates.
Our faculty focused at both the conceptual and operational levels as they worked to distinguish expected outcomes for the program levels. At the conceptual level, DNP graduates focus on “creating and sustaining changes” (AACN, 2006, p. 19) based on identified trends across organizational levels and care settings, whereas BSN graduates engage in continuous QI activities that build “basic organizational and systems leadership for patient safety and quality care” (AACN, 2008, p. 3). In particular, faculty agreed that BSN students need to appreciate that work place challenges (a) are rarely a single instance of a problem; (b) may be solved with temporary workarounds, but simultaneously require reporting the issues and undertaking systematic investigations into the root causes; and (c) when addressed in isolation, may result in solutions that have unforeseen reverberations throughout the organization. At an operational level, DNP students are expected to function with independence and autonomy as they scope, develop, and execute their practice inquiry projects. Alternatively, at the BSN level, faculty scope and develop projects for student teams to execute.
To achieve this vision, we focused on four specific areas: (a) integrating systems thinking and QI content into the curriculum, (b) fostering faculty involvement and building faculty competency around these concepts, (c) cultivating relationships with practice partners, and (d) designing sustainable approaches.
Faculty agreed that early introduction of these skills, followed by repeated and increasingly sophisticated learning activities, would emphasize to the students that systems thinking and QI were important skills for practicing nurses. Faculty-directed activities help students embrace a progressively sophisticated systems thinking perspective through (a) didactic instruction (e.g., teaching seniors to identify the users and stakeholders of the systems they are investigating who may not all be immediately obvious); (b) project activities (e.g., encouraging students to work with practice partner liaisons and faculty to observe antecedents and consequences of the processes they are investigating), (c) written and verbal discussions and reflections (e.g., requiring students to self-evaluate participation in QI activities), (d) group papers and presentations (e.g., crafting assignments where students must articulate potential influences of their efforts beyond the immediate solution).
Concurrently, we integrated the QI content cross all levels into the already long list of required nursing coursework (Table). At the freshmen level, a basic introduction to systems thinking and QI occurs using an exercise available for free from the IHI Open School ( http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/WilliamsPotatoHead.aspx). At the sophomore level, the power of systems thinking and QI is demonstrated as students tackle basic projects addressing systems problems at their hospital- or community-based clinical sites that practitioners simply do not have time to complete, thereby giving back to the practice partners who help them learn the skills of their profession (for more detail, see Karagory & McComb, 2014; Kirby & Karagory, 2014). At the junior level, small groups of students complete projects on their clinical units that require them to use evidence-based practice, and collect, analyze, and present data as they drill down about a concept applicable to the medical–surgical setting (for more detail, see Simpson, McComb, & Kirkpatrick, 2015; Young et al., 2014). At the senior level, students enrolled in the leadership course complete semester-long projects for a practice partner that provide them with an opportunity to hone not only their systems thinking and QI skills, but also leadership skills including teamwork, delegation, and conflict resolution (for more detail, see Karagory, McComb, & Kirkpatrick, 2016). This scaffolded approach offers students increasingly complex opportunities to practice systems thinking and QI skills.
Scaffolding Learning About Quality Improvement
In attempting to practice what we preach, the School of Nursing faculty continually look for improvement opportunities. For example, we have experimented with intraprofessional collaboration by having sophomore and junior clinical students collect data for the senior leadership team projects. As well, some projects have embraced interprofessional collaboration by partnering with technology students designing medical equipment. Regardless of operationalization, this repeated exposure across the years helps to reinforce the importance and significance of systems thinking and QI in today's complex health care environment. Through this process, students see that, as one of our local nurse executives simply stated, “It's what we do.”
Faculty Input and Professional Development
Full faculty involvement in curricular innovation, such as the one described herein, is mandatory. Further, it requires commitment to the process, champions, and expert support, all of which were present during this transition period. First, the entire faculty was instrumental in the curricular revision. Over the course of one academic year, the faculty held a series of meetings to redesign the BSN curriculum. These meetings included conducting a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis, reviewing current literature, and analyzing learning experiences. Given that systems thinking and QI are infused into every level, all faculty were involved in the development and implementation of this innovation. Second, the School of Nursing leadership invested in the professional development of 10 faculty champions, who teach across the curriculum, by funding their efforts to increase their QI knowledge and obtain Lean Six Sigma yellow belt certification. Third, to further build competency within the faculty, the School of Nursing hired an industrial engineering professor in 2011, who has been instrumental in working with nursing colleagues as they incorporate systems thinking and QI into various courses.
Practice Partner Commitment
Building practice partner commitment requires attention and significant stewardship by the School of Nursing faculty and students. One of the more successful strategies for garnering commitment from our practice partners was to invite their CEOs and CNOs to our formal, end-of-semester presentations in the Senior Leadership in Nursing course. Multiple positive outcomes transpired because these senior executives attended the presentations. First, the mutual benefit of the overall learning approach became apparent. As one local CEO stated, these projects “help us to better define and analyze the problem and bring innovative solutions to our QI initiatives. We have implemented many of the ideas and recommendations presented by the students and are already seeing progress and improved patient outcomes.” Second, these leaders recognized the students' professionalism and the high caliber of their presentations and project outcomes. Another local CEO observed that, “The LEAN QI deliverables to the hospital and clinic settings have been significant, novel and meaningful to our ongoing improvement efforts and of comparable quality to the work produced by our current leadership team.” Third, those executives who had not yet participated became excited by the potential of collaborating on future projects. Indeed, we now have a waiting list of practice partners who wish to collaborate with our students, which also helps to ensure that no one practice partner becomes overburdened with helping to identify real-world projects for our students.
Sherwood (2015) noted that the culture of the organization and the skills of the nursing staff influence readiness to embrace QI practices. The readiness gap was addressed in the School of Nursing by the aforementioned professional development activities. Concurrently, many of our practice partners were on their own journey to build capacity in systems thinking and QI. However, the collaborative culture required to successfully sustain our curricular implementation required enthusiastic champions from both academia and practice who demonstrated to others the potential and importance of this work.
Sustainability can be threatened by the painful reality of turnover. Therefore, one of the most critical aspects of sustainability planning is identifying how to energize the current players and foster the next generation of champions. While we are still seeking innovative approaches to address this challenge, we continually attempt to keep these concepts in focus and demonstrate relevance. One initiative we have implemented is hosting conferences where students, faculty, and practice partners learn about key advances in systems thinking and QI from thought leaders, such as Dr. Linda Aiken, known for her groundbreaking research that has influenced how hospital staff nurses care for patients, and Dr. Doris Quinn, a process improvement and quality expert.
To date, approximately 500 students have been exposed to systems thinking and QI via our BSN curriculum. Each year, approximately 48 projects are completed (i.e., 16 each at the sophomore, junior, and senior levels). Of these projects, many have been implemented by our practice partners. As examples, one sophomore group designed a sustainable training program for public school system employees to manage children's severe allergic reactions, and two teams of seniors designed the content and distribution process, respectively, for a real-time patient satisfaction survey that captures data useful to nurses as they provide care in the emergency department.
As documented in the Practice Partner Commitment section of this article, student projects are influencing our practice partners in positive ways. Students are also reporting the significance of these efforts on their careers, the field of nursing, and health care. For instance, one student reported:
The project gave me the chance to enhance my own learning while working with a team toward an end product that made us all proud. For my internship this summer, I had to complete another QI project, and having the previous QI project experience, I felt confident with my abilities before even tackling the project.
A second student demonstrated how life-changing this paradigm shift can be by stating:
I never felt as though I was making a lasting difference in community healthcare until our QI project…. This single project changed the dynamic of my nursing career before it has even started by giving me confidence and showing me that I have the capability to make a significant impact. Thanks to the lessons learned through this process, I am ready to be a leader and a proactive member of the health care community.
A senior exit survey comment was “Now, I automatically think about things from a QI perspective… How can we do things differently to achieve better outcomes?”
The infusion of systems thinking and QI motivated us to launch an IHI Open School student chapter. This student organization, run by an interprofessional group of undergraduate students representing predominantly nursing and industrial engineering, offers opportunities that complement students' required academic preparation. First, students can choose to participate in chapter meetings where an interprofessional cadre of students interested in enhancing the systematic delivery of safe health care complete experiential exercises, hear speakers, and view clips and movies about patient safety and QI. Second, students can independently earn certification by completing the IHI Open School's safety and quality learning modules. Finally, the chapter engages in community service projects that require members to practice their systems thinking and QI skills.
Incorporating systems thinking and QI approaches into BSN programs is replicable. The tools (e.g., yellow belt certification for faculty and online resources from organizations such as the IHI Open School and QSEN) and resources (e.g., cooperative relationships with engineering and other professions interested in improving health care delivery) are available to faculty in schools of nursing. To foster replication, our faculty are disseminating results via journal articles (e.g., Karagory & McComb, 2014) and conference presentations (e.g., Karagory & McComb, 2013; Karagory et al., 2016; Kirby & Karagory, 2014; Simpson et al., 2015).
Change Is Hard
Convincing faculty and students that systems thinking and QI must be considered fundamental nursing content has not always been easy. As with all change, some faculty and students were resistant, whereas others served as in-house champions. However, this dichotomy promoted a spirited dialogue about the changes being proposed that resulted in a much stronger final product. Successful projects have spurred enthusiasm for the later adopters in both academia and practice.
Faculty Development and Support
Faculty development was, and continues to be, a key component to the success of incorporating systems thinking and QI into our curriculum. The health care industry has embraced this philosophical approach to continuously improve care delivery, quality, and safety; academia is still playing catch up. Investment in faculty champions who teach across the curriculum, via yellow belt certification, was critical to the initial implementation. The addition of an industrial engineer to our School of Nursing faculty has provided valuable in-house support for our initiatives and stimulated multiple innovations.
Incorporating systems thinking and QI into the curriculum is time intensive in many ways. First, time is required to cultivate relationships across professions, with practice partners, and among the faculty who will support partnerships and collaborations. Second, incorporating a culture of continuous improvement is inherently iterative, thereby necessitating ongoing cycles of evaluation and revision. Finally, faculty need time to develop and hone the skills and confidence to succeed with these initiatives.
Turnover in Provider Agencies
Partnerships and collaborations with champions in the provider agencies is critical to success. These individuals help scope student projects, promote student activities to their colleagues, and advocate for continued agency support. These individuals, however, turn over frequently requiring time to build relationships with their replacements or others within the provider agencies. We hope this issue will become less challenging as the nursing workforce becomes versed in systems thinking and QI. This expanded capacity may result from both pervasive adoption across the health care industry and increased integration of these principles in BSN programs.
Telling Our Story
Garnering support for our continued efforts requires continually telling our story to different constituencies. These stories include recognition of the faculty who are doing all the hard work to incorporate systems thinking and QI into our classes, celebrating successes, and highlighting how support (e.g., financial, access, project identification) will be used to continue improving our efforts. Students also tell our story as they interview for positions postgraduation and impress potential employers with their grasp of systems thinking and QI fundamentals, including how they are applied in practice.
Implications and Conclusions
Systems thinking and QI are no longer nice-to-know skills for baccalaureate nursing students; rather, they are need-to-know skills. As part of the intraprofessional nursing team, RNs at the point of care are essential in recognizing risk and preventing error; their work compliments the organizational change role frequently assumed by DNP graduates. Unfortunately, as Tschannen et al. (2015) articulated, nurse educators have been reluctant to incorporate the pedagogical changes required to meet these changing realities of practice.
Our journey may provide some insights into how this reluctance might be overcome. First, administrators of nursing education programs must be committed to building a cadre of faculty with the skills and confidence to champion these changes. Second, concerns about adding content to an already overloaded curriculum can be neutralized by incorporating repeated and increasingly sophisticated experiences across the curriculum within existing courses. Finally, everyone involved must recognize that change of this magnitude requires creating the educational infrastructure, building relationships with practice partners, and affecting the culture of schools of nursing. Ultimately, this approach to undergraduate nursing education has the potential to produce a generation of nurses who can think in terms of system-level implications of care and who fully expect QI to be a natural part of the nursing role. Further, they are ready to serve as effective members and leaders of interprofessional teams assembled to systematically improve health care delivery, quality, and safety.
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Scaffolding Learning About Quality Improvement
|Focus||Experiential learning activity to introduce the concept of process improvement||Service activity addressing a system problem in clinical or public health setting||Data-driven project for unit where they are completing their medical–surgical clinical experience||Semester-long project addressing a system problem with practice partners|
|Primary source of evidence||None||Literature||Data collected by students||Literature and data collected by students|
|Contact time||1 class period||1 clinical day + preparatory work||3–5 clinical days||1 credit of 3 credit course|
|Course||Introduction to Nursing Seminar||Essentials of Nursing Practice Clinical||Health Alternations in Adults Clinical||Leadership in Nursing Course|
|Teams||Ad hoc (n = 6–10)||Clinical group (n = 7–9)||Subgroup of clinical group (n = 2–4)||Teams (n = 4–7) constructed based on student attributes|
|Deliverable||None||An improved activity (e.g., best practices training, basic process improvement)||Data-driven report summarizing findings and making recommendations (e.g., root cause analysis, process map)||A structured project summary using DMAIC framework (in the form of an A3), project-specific deliverables (e.g., training tool, checklist, protocol)|
|Dissemination||None||Informal presentation of improvement to unit staff/organization personnel||Semiformal presentation of process and deliverable to unit leaders||Formal presentation of project background, methods, results, and deliverables to senior staff (e.g., CNO at partner facility)|
|Project examples||None||Organizing a supply room in a long-term care facility, developing a food allergy policy for a rural elementary school, designing a sustainable training program for public school system employees to manage children's severe allergic reactions, and redesigning the patient flow through a community child wellness day clinic||Determining barriers to changing intravenous tubes; evaluating the use, value, and effectiveness of rounding lights; conducting a root cause analysis of catheter-associated urinary tract infections; and mapping processes (e.g., the medication delivery process; a specimen labeling process) to identify barriers and opportunities for improvement||Developing both the patient and provider aspects of an online health care portal for a rural nurse-managed clinic, redesigning the process to reduce patient chair-to-bed falls, decreasing readmission for heart failure patients, recommending process improvements for transitions between acute care and a skilled rehabilitation unit, and implementing intensive care unit liberation bundles|