Historically, frontline nurses in collaboration with nursing leadership have engaged in quality improvement (QI) initiatives to transform healthcare. Recently, however, reports indicate that engagement in QI is low among frontline nurses. Using a national sample, researchers identified barriers to and facilitators of engagement in QI by nursing role that may inform future engagement strategies.
Background
It's well documented in the literature that high-quality patient care is dependent on nurse engagement in QI.1 The Robert Wood Johnson Foundation and the Institute for Healthcare Improvement's Transforming Care at the Bedside (TCAB) program established the impact of frontline nurse engagement in QI, demonstrating that bottom-up environments, where frontline nurses identified practice gaps and tested solutions, resulted in improved patient safety, such as reduced falls, and better healthcare outcomes, such as reduced 30-day readmission, on medical-surgical units.2
Despite these positive outcomes, real-world practice and survey studies indicate that frontline nurses, such as RNs and advanced practice registered nurses (APRNs), remain underengaged in QI work.3-5 Reasons for this low engagement are unclear. The QI literature to date has identified perceived barriers to the implementation of QI and strategies to overcome these barriers without direct input from frontline nurses and nurse leaders.6 It's possible that the perceptions of factors impacting nurse engagement in QI by other members of the healthcare team are different than what's experienced by frontline nurses, which may explain in part why current efforts to engage nurses in QI are unsuccessful.
Nurses believe that they possess the clinical expertise to engage in QI, but organizational hierarchy, absence of a just culture, and nursing's role not being valued prevent full engagement.6 Common leadership strategies to increase nurses' engagement in QI involve providing resources and recognition for nurse participation in QI processes, yet frontline nurses perceive their own participation in QI projects and seeing the results to be much more influential on their engagement.7,8 It's important to further understand factors that impact frontline nurses' engagement in QI so nurse leaders and healthcare organizations can develop and test strategies that move toward effective bottom-up environments to support QI.
This descriptive survey study examined barriers to and facilitators of engagement in QI in a national sample of clinical nurses, APRNs, and nurse leaders. Study questions included:
1. To what extent do clinical nurses, APRNs, and nurse leaders rate known barriers and facilitators as influencing their ability to engage in QI initiatives?
2. What are the similarities and differences among clinical nurse, APRN, and nurse leader perceptions of barriers and facilitators impacting engagement in QI?
3. What additional barriers and facilitators were identified by respondents that weren't listed in the survey?
Methods
Design
This study is part of a larger study that used a descriptive survey design to measure nurses' knowledge, skills, and attitudes toward QI; levels of engagement in QI; and perceived barriers to and facilitators of engagement in QI. This report focuses on nurses' perceived barriers and facilitators. Institutional Review Board approval was obtained for each health system. In all systems, the study was deemed exempt.
Sample and setting
The study included nurses from a convenience sample of 66 healthcare sites representing the continuum of care in each US geographic region (10 Northeast, 17 Southeast, 35 Midwest, 4 West). Within each site, a convenience sample of nurses who deliver direct patient care in any specialty and their direct nurse leaders were asked to participate in the study. Direct patient care was defined as hands-on care by the nurse for the purposes of diagnosis, treatment, and monitoring in any clinical setting. The nurse role for this analysis included clinical nurses, care coordinators, nurse navigators, and case managers. The APRN role included NPs, nurse midwives, and certified registered nurse anesthetists. Lastly, nurse leader roles included nurse educators, clinical nurse specialists, supervisors, managers, and directors. Specialty areas ranged from critical care to general medical-surgical to ambulatory care.
Measures
The Nursing Quality Improvement in Practice (N-QuIP) tool, which assesses current knowledge, skills, and attitudes toward QI; levels of engagement in QI; and perceived barriers to and facilitators of engagement in QI, was utilized.9 For purposes of this study, research questions were answered using two items from the N-QuIP tool. Specifically, respondents were asked to "select all that apply" from a predeveloped list of potential barriers, such as time constraints, heavy workload, and knowledge deficit, and facilitators, such as access to data, adequate resources, and leadership support for their participation in QI.
The list of barriers and facilitators included on the N-QuIP tool was developed through an integrative review identifying common factors contributing to nurse engagement in QI.6 In the event that a perceived barrier or facilitator wasn't listed, respondents could provide a free-text response, thus capturing any additional factors that may influence engagement in QI. The tool has established validity and reliability.9
Procedures
A principal investigator or co-investigator was identified to oversee the study in each healthcare site. The investigator at each site sent nurses, APRNs, and nurse leaders an email invitation with the study description and link to the survey. A survey management system was used to capture all study data anonymously. Reminder emails were sent at weeks 2 and 3. Completion of the survey implied consent to the study.
Data management and analysis
All survey data relative to this analysis were subsequently downloaded into a comma-separated values file. The data were then cleaned, which included the removal of responses that didn't answer the questions of interest, and imported into a statistical analysis software program. Descriptive statistics, including frequencies and percentages by role, were computed. Differences in perceived barriers/facilitators were determined using Pearson chi-square tests. Post-hoc analysis was done using z-proportion tests with adjusted P values (Bonferroni method).10 When a respondent reported a barrier or facilitator not listed in the N-QuIP tool, the free-text responses were captured in a spreadsheet and reviewed.
Results
Table 1 displays the sample characteristics. Of the 5,973 respondents employed in 66 sites across the country, the majority were clinical nurses (n = 4,975, 83.3%), followed by nurse leaders (n = 794, 13.3%) and APRNs (n = 204, 3.4%). Respondents were more likely to have 1 to 5 years of experience (n = 2,167, 36.3%) and hold a bachelor's degree (n = 3,470, 58.1%). Most specialty areas were represented, with medical-surgical units having the highest representation (n = 1,872, 31.3%), followed by ORs and EDs (n = 1,106, 18.5%).
Barriers to QI engagement
Figure 1 displays the barriers to QI engagement reported by all nurses (percentages). Overall, nurses reported lack of time (n = 3,271, 54.8%), heavy workload (n = 3,174, 53.1%), and lack of adequate resources (n = 2,379, 39.8%) as the highest barriers to engagement in QI. A small group of nurses reported no barriers to QI engagement (n = 889, 14.9%).
Figure 1 also displays the barriers to QI engagement by role (colored bars). Although all roles frequently and consistently reported lack of time and heavy workload as barriers to engagement in QI, nurse leaders were more likely to report a lack of resources as a barrier (45.6%), compared with clinical nurses (39.2%) and APRNs (31.9%) [[chi]2(2, 5973) = 17.14, P < .001]. Other barriers that varied by role were a higher percentage of nurse leaders who identified difficulty in accessing and retrieving data (28.3%) and self-imposed barriers, such as resistance to change, disconnect between perception of QI and practice, and lack of enthusiasm (33.1%), compared with APRNs (13.7% and 13.2%, respectively) and clinical nurses (11.2% and 18.8%, respectively) ([[chi]2(2, 5973) = 172.81, P < .001], [[chi]2(2, 5973) = 93.36, P < .001], respectively).
In contrast, clinical nurses and APRNs were more likely to identify a lack of organizational culture supporting QI engagement (11.0%, clinical nurses; 12.8%, APRNs) and a lack of leadership support (12.5%, clinical nurses; 14.2%, APRNs) as barriers to engagement than nurse leaders (6.5% and 6.8%, respectively) ([[chi]2(2, 5973) = 16.58, P < .001] and [[chi]2(2, 5973) = 22.67, P < .001], respectively). Clinical nurses were more likely to state no barriers compared with APRNs and nurse leaders [[chi]2(2, 5973) = 6.74, P = .03].
Facilitators of QI engagement
Figure 2 displays the facilitators of QI engagement reported by all nurses (percentages). Overall, nurses reported dedicated time for QI (n = 3,958, 68.2%), adequate resources (n = 3,329, 57.4%), and access to a QI mentor (n = 2,730, 47.0%) as the highest facilitators of engagement in QI.
Figure 2 also displays the facilitators of QI engagement by role (colored bars). APRNs were more likely to report dedicated time for QI as a facilitator (73.8%), compared with nurse leaders (71.4%) and clinical nurses (67.5%) [[chi]2(2, 5804) = 7.73, P = .02]. Nurse leaders were more likely to report access to a QI mentor (51.2%) and access to data (47.4%) as facilitators of engagement in QI, compared with APRNs (44.5%; 42.6%) and clinical nurses (46.5%; 38.4%) [[chi]2(2, 5804) = 6.81, P = .03] for QI mentor and [[chi]2(2, 5804) = 23.53, P < .001] for data access, respectively. APRNs and clinical nurses were more likely to identify leadership support (33.7%; 31.6%) and supportive QI organizational culture (26.7%; 22.3%) as facilitators of QI engagement than nurse leaders (22.8% and 17.9%, respectively) [[chi]2(2, 5804) = 25.79, P < .001 for supportive leader and [[chi]2(2, 5804) = 10.44, P = .005] for supportive QI culture, respectively.
Nurse leaders (42.6%) and clinical nurses (41.2%) both reported the need for QI education and training, significantly more often than APRNs (32.2%) [[chi]2(2, 5804) = 7.36, P = .025]. The facilitator of nurse ownership of QI was significantly different among the three roles, with nurse leaders reporting the highest ownership (n = 330, 42.2%), followed by clinical nurses (n = 1,454, 30.2%) and APRNs (n = 45, 22.3%) [[chi]2(2, 5804) = 53.42, P < .001].
Additional barriers and facilitators
A total of 335 (5.61%) respondents wrote information in the free-text portion on barriers and facilitators not listed in the survey. This section reports results in aggregate because roles couldn't be determined. Of the 335 respondents, 196 (58.51%) reported additional barriers. Almost one-third of these respondents noted that their current clinical schedule and role were barriers to engagement (n = 61, 31.0%). This included working night shift, having a contingent or per diem role, and being recently hired on the unit. Some nurses (n = 42, 21.4%) reported feeling like they had different priorities than leadership and that their participation wasn't welcome or the opportunity to engage in QI was only made available after an initiative was underway.
Additional facilitators were reported by 139 (2.4%) respondents. Of these, 23 (16.5%) reported the facilitator of having what they need to engage in QI. Others (n = 18, 12.9%) indicated that a department-level approach and support would facilitate engagement. Respondents wanted leadership in their respective health systems to ask for their feedback, identify projects that are important to frontline staff, value their input, and desire their direct participation (n = 9, 6.5%). Some respondents (n = 6, 4.3%) noted communication and feedback about the results of previous QI initiatives as an important facilitator.
Discussion
This is the first study to identify barriers and facilitators in a national sample of clinical nurses, APRNs, and nurse leaders and compare barriers and facilitators across these roles. Findings from this study are consistent with previous studies that cited no time, resources, and workload as major contributors to limited engagement by nurses in QI.11-18 Overall, dedicated time, adequate resources, and access to a QI mentor were the most frequently reported facilitators in this study, which supports previous research.19 Nurses in frontline roles acknowledge the impact of limited time and heavy workloads on engagement.
Differences in perspectives on barriers were reported by nurse role. Although all nurse roles reported lack of resources as a contributing factor, nurse leaders were more likely to report this than frontline staff. This may be due to their job expectations for quality care on the unit. This would also explain the finding from this study that nurse leaders were significantly more likely to report access to data as a barrier, which is aligned with previous studies noting difficulty collecting and analyzing data in real time as a barrier.11,15,16,18,21 Nurse leaders were also more likely to identify lack of physician involvement as a barrier than their frontline nurse counterparts. Current research supports an interprofessional approach to QI, with each member of the team providing unique perspectives and expertise.20 However, there's a lack of known role-specific strategies for nurse leaders to engage other healthcare team members in QI collaboration.
When considering additional barriers to engagement, lack of an organizational culture that supports QI and lack of leadership support were noted more often by clinical nurses and APRNs than nurse leaders. Clinical nurses and APRNs want and need support from their leaders to engage in QI, which in some instances may require support for stepping aside from direct care or being open to feedback related to opportunities to improve care processes. These data align with a qualitative study by Alexander and colleagues that found both culture and leadership were powerful "influencers" of frontline engagement in QI.21 Nurses in the study expressed having a limited voice in practice decisions and feared being viewed as a troublemaker if they spoke up about QI issues.21,22 Developing a just culture where nurses feel safe to report errors and all staff members are held to the same standards is critical for achieving positive patient outcomes. Research is needed to study the relationship between a just culture and its impact on patient outcomes at the front line.
Differences in perceptions of facilitators were also identified by nurse role. Nurse leaders and APRNs desired dedicated time for QI significantly more often than clinical nurses, which may be a direct reflection of their position and job expectations, particularly for nurse leaders. APRNs and nurse leaders also reported the desire for a QI mentor. This may be explained by previous work noting limited skills in QI among nurses.23 A QI mentor could provide support in the planning, implementation, and evaluation of practice changes. Furthermore, the importance of QI mentors mirrors a national study on evidence-based practice (EBP) competencies that showed mentorship had the strongest association with EBP competency.19 It's unclear to what degree mentors are currently being used to facilitate QI initiatives. Given that 47% of respondents identified mentorship as a facilitator, it may be an area to target through well-defined implementation studies.
Findings from this study also noted QI education and training as a facilitator of engagement. The importance of QI education and training across all roles highlights why ongoing education programs and skill development are essential.6,19 Melnyk and colleagues found that education and training were key predictors of EBP competence.19 Opportunities to engage in QI projects must be embedded in nurses' daily work because without ongoing, repeated practice, QI skills are difficult to adopt in practice.18,19
Identical to the data on barriers, clinical nurses and APRNs were more likely to identify a supportive leader and a supportive culture as facilitators of QI, signaling to nurse leaders how critical the leadership role is to employee engagement in QI.21 Nurse leaders must advocate for clinical nurses, giving them opportunities to share insights into QI and participate in the subsequent work to improve care.
Notably, nurse ownership of QI was significantly different among all three roles. Nurse leaders had the highest level of ownership, followed by clinical nurses and APRNs. This finding is of concern because clinical nurses have the potential to drive quality and improve patient outcomes while delivering safe care. One explanation may be that quality measures and patient outcomes are closely linked to reimbursement, and leaders may have a higher level of responsibility and accountability for ownership than clinical nurses and APRNs.
Limitations
There are several limitations to this study. Although it included nurses from across the country, generalization may be limited due to the use of a convenience sample. Nurses volunteered to participate and therefore may have been biased in their responses. Furthermore, a response rate wasn't computed because we couldn't determine the number of nurses who opened the email and subsequent survey link.
Implications for nursing practice
Results from this study provide nurse leaders with data to inform the development of tailored interventions and implementation strategies to increase frontline nurse engagement in QI. Where applicable, nurse leaders should make every effort to remove or mitigate identified barriers while expounding upon efforts identified as facilitating QI engagement. Ensuring access to data, supporting time dedicated for QI, and aligning resources with initiatives aimed at improving care processes and outcomes may be the first areas of focus. Furthermore, nurse leaders should consider engaging mentors, such as DNP-prepared nurses who have expertise in research translation and QI processes and tools, to encourage and assist frontline nurses in the QI process and help ensure that initiatives are effectively developed, implemented, and evaluated.
Facilitating engagement
As healthcare organizations search for ways to improve outcomes, a better understanding is needed regarding how to leverage frontline nurse engagement in QI. Findings from this work have identified key factors contributing to QI engagement among frontline nurses. Nurse leaders within healthcare organizations can foster frontline nurse engagement in QI by partnering with nurses to use the results of this study for both mitigating identified barriers and maximizing identified facilitators. Through the concerted efforts of nurse leaders, organizations can implement tailored interventions aimed at improving overall frontline staff engagement.
INSTRUCTIONS Quality improvement engagement: Barriers and facilitators
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