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New Nurses Feel Unprepared to Focus on Quality Improvement

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By Debra Wood, RN, contributor

Jan. 5, 2010 - Although nursing administrators and other health care leaders have placed a strong emphasis on quality improvement, many new nurses enter the profession feeling "poorly" or "very poorly" prepared by their nursing education programs to implement quality improvement measures, according to new research findings.  In fact, 12.6 percent reported never having heard of the widely-used term now at the forefront of health reform discussions.

Christine Kovner, PhD, RN, FAAN
Christine Kovner, PhD, RN, FAAN, said she was surprised by the number of new nurses who felt unprepared to participate in quality improvement initiatives.

"I see this as a wake-up call and a piece of evidence," said Christine Kovner, Ph.D., RN, FAAN, a professor at New York University's College of Nursing and lead author of a study published in the January 2010 issue of The Joint Commission Journal on Quality and Patient Safety.

The research team received support from the Robert Wood Johnson Foundation (RWJF). They surveyed and analyzed responses from 436 newly licensed registered nurses from 34 states and the District of Columbia. The authors defined quality improvement (QI) as the "use of data to monitor the outcomes of care processes and use of improvement methods to design and test changes to continuously improve the quality and safety of health care systems."

Overall, 38.6 percent of new, bachelor's and associate's degree-prepared nurses responding said they thought that they were "poorly" or "very poorly" prepared about or had "never heard of" QI.

Participants views about their preparation varied with some feeling "very prepared" in patient-centered care, yet half of participants felt they were "not at all prepared" to utilize specific QI techniques, such as root-cause analysis. In addition, 41.7 percent said they were "not at all prepared" to use national patient safety resources, such as the National Quality Forum.

"All nursing education programs should do more to assess the performance of their graduates, measure change and address deficiencies," said co-principal investigator Carol S. Brewer, Ph.D., RN, professor in the School of Nursing at the University at Buffalo, New York, in a written statement. "This is about the patient and improving health outcomes, and quality improvement is an integral part of our ability to succeed."

Beverly Malone, Ph.D., RN, FAAN, chief executive officer of the National League for Nursing, an association dedicated to nursing education, agrees that nurses must understand quality improvement to ensure safe, quality care.

"There is no way you can do nursing without being able to do quality improvement, even if you might not call it that," Malone said. "But it would have to be there to evaluate whether you are giving safe, quality care."

Kovner indicates some controversy exists related to who should be responsible for teaching nurses about QI--nursing schools or employers--but there are opportunities for everyone. The authors call on hospitals, nurse education programs and nursing program accrediting bodies to make QI education their highest priority.

"I think both of them have a responsibility," Kovner said. "Nursing programs have the responsibility to teach the concept, and the employers have a responsibility, given the assumption the people they hire have a basic knowledge, to help them apply that knowledge in the workplace."

Only 23.3 percent of survey respondents called their employer-provided QI training "very helpful." QI officers, Kovner added, can use the study results to ask their administrators what their organizations are going to do about it.

Kovner indicated that the National League for Nursing Accrediting Commission and the American Association of Colleges of Nursing have standards that state schools should be teaching content about QI.

"I hope the accreditors would use this and that would put some pressure on the schools," Kovner said.

A separate Quality and Safety Education for Nurses initiative survey of 195 nursing schools, also funded by the RWJF, found that fewer than 18 percent of the educational programs had a dedicated QI course. Most include such content in clinical rotations or other courses.

"If we are not clear about quality improvement and the issue of errors at the system level, we have missed the mark," said Malone, adding that most system discussion takes place during master's degree coursework. "There must be more of a system perspective, looking from the beginning to the end. … It's where we need to go."

Kovner hypothesized that many faculty members are older and when they went to nursing school, 30 or more years ago, they did not learn about quality improvement measures.

"We have this expectation that faculty will talk about QI," Kovner said. "But I think it is likely that many faculty don't know that content."

Kovner acknowledges that the students surveyed may have been taught QI content but do not remember it.  "I don't think that's likely, but I think it is possible," she said.

New nurses also may have been taught quality improvement techniques that were referred to with different terminology. However, nurses need to know the accepted lingo.

The results of the survey were called "disturbing" by researcher Peter I. Buerhaus, Ph.D., RN, the Valere Potter Professor at the Vanderbilt University School of Nursing, Nashville, Tennessee, in an accompanying editorial. He said the research can serve as a baseline to measure improvement over time and urged educators and employers to do a better job of instilling the importance of QI in the training of the country's newest nurses.

"More needs to be done," Malone added. "Quality improvement is the heart of nursing."

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