Nurse educators who have taught over the past decade or more have witnessed changes in the characteristics and learning preferences of the student population. Close to 11.8 million college students are less than 25 years old (U.S. Department of Education, 2017). Most students entering nursing programs today are members of Generation Y or Millennials, and they are very different from nursing students of previous generations (Johanson, 2012). Millennials are techno-savvy, want to be entertained and have fun when learning, and get bored quickly with traditional teaching methods (Blevins, 2014; Koeller, 2012). As digital natives, they are accustomed to constant stimulation, instantaneous results, and want immediate feedback and praise on performance (Blevins, 2014; Koeller, 2012; Murray, 2013; Robb, 2013). To engage Millennial learners, nurse educators must consider creative teaching strategies that integrate experiential learning opportunities, critical inquiry, and novel assignments (Johanson, 2012).

Implementing a change in teaching pedagogy can create apprehension for many, even seasoned faculty. A common tool used for change and continuous improvement is the Plan-Do-Study-Act (PDSA) cycle, a systematic series of four steps that provides a framework for planning and testing a change, observing the results, and acting on what is learned (Institute of Healthcare Improvement [IHI], 2016). This article describes the use of iterative PDSA cycles to implement a change in teaching pedagogy.

THE NEED FOR CHANGE

Nurse faculty are called to transform nursing education by integrating the Quality Safety Education for Nursing (QSEN) core competencies into prelicensure nursing programs and guiding students to understand, apply, and value each competency (Cronenwett et al., 2007; Sherwood, 2012). The QSEN core competencies include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement (QI), safety, and informatics. Competencies related to QI and safety have been identified as a challenge for many nursing students. Typically, students have a thorough understanding of safety at the bedside, but new nurses must be able to focus on safety beyond the point of care delivery. They are expected to have the knowledge, skills, and attitudes to participate in QI activities, but many are not prepared to do so (Dotson & Lewis, 2013; Seibert, 2014).

The faculty teaching a nursing leadership and management course identified that students in a prelicensure BSN program had difficulty understanding and applying QI and safety concepts. The course was delivered in a traditional manner using strategies such as lecture with PowerPoint slides, case studies, and multiple-choice testing. The majority of the students enrolled in the course were Millennials. Considering the learning preferences of Millennials, faculty believed implementing activities that engaged students in the application of QI and safety principles and encouraged peer collaboration and teamwork would enhance their learning. The decision was made to use iterative PDSA cycles as described by the IHI (2016) to implement changes in the course.

THE PDSA CYCLE

The first step in the PDSA cycle is plan; goals are identified, outcomes are predicted, measures are established, and a plan for implementation and collecting data is created. The next step is do, which involves implementing the plan, monitoring for problems and unexpected observations, and analyzing data. With study, the outcomes of the change are monitored for success or areas that need improvement, data analysis is completed, and findings are summarized. In the final step, act, learning generated by the process is used to determine if modifications are needed. The PDSA cycle is then repeated for continuous improvement.

The process begins with three fundamental questions (IHI, 2016): 1) What are we trying to accomplish? In this case, faculty wanted to improve student learning related to QI and safety. 2) How will we know that a change is an improvement? Faculty would know students learned and understood content when students were able to apply QI and safety concepts to clinical issues or problems. 3) What change can we make that will result in improvement? Faculty developed learning activities that would integrate quality and safety concepts and use of QI tools into the course.

Plan

The goals were to engage students in the QSEN core competencies of teamwork and collaboration, QI, and safety. Students were introduced to QI, safety concepts, and various QI tools, such as the fishbone diagram, in class around the sixth week of the semester. (The fishbone diagram, used to identify causes of a problem, is also known as an Ishikawa diagram or cause-and-effect diagram.)

The QSEN Institute Lewis Blackman story (http://qsen.org/publications/videos/the-lewis-blackman-story/) was shown in class, followed by discussion relating QSEN competencies to the story. Lewis was a 15-year-old boy who died in the hospital after a routine surgery to repair pectus excavatum. A series of adverse events resulted in his death 30 hours after surgery.

Do

Students, in small groups of three to four, worked as QI teams to identify a possible quality or safety problem in their clinical experience. Next, the teams collaborated on developing a realistic plan for improvement using the PDSA cycle. Students compiled their work and created a poster that was presented to the entire school of nursing faculty and students at the end of the semester. Faculty and students attending the poster session engaged the QI teams in discussion about their projects.

Study

The quality safety poster provided a summative evaluation strategy for the course. Students met learning outcomes and QSEN competencies through participation during team meetings, collaboration on the fishbone diagram, participation during the poster session, and the final quality safety posters. Students also participated in peer evaluation and self-assessment of their knowledge, skills, and attitudes related to the teamwork and collaboration competency. Students were asked to provide feedback about the activity and final poster presentations by completing an anonymous end-of-semester survey after the poster presentations. Findings during this step were used to determine the action in the next step of the cycle.

Act

Based on the data collected and student feedback, changes have been made to the learning activities and the assignment. To analyze the data and disseminate findings, approval was obtained from the university institutional review board.

OUTCOMES

Between fall 2013 and spring 2015, 113 students participated in the learning activity, and 107 provided anonymous feedback; 85 students (79.4 percent) indicated they felt the activity was an effective learning experience, 13 (12.1 percent) did not believe it was effective, and 6 (5.6 percent) were undecided. When asked what was most beneficial in the course, 24 (22.4 percent) indicated the poster project, whereas 4 students (3.7 percent) indicated it was least beneficial. Sixteen students commented that the poster helped pull everything together.

The teaching strategy has been adapted using iterative PDSA cycles each semester with the following changes made to the activity:

1. After initial implementation of the change in Cycle 1, student feedback indicated a need for more information about creating posters and more time in class to work on the project.

2. The plan for Cycle 2 included information about creating effective posters; 10 minutes at the end of each class was allotted for faculty-guided group work on the project. Although this helped some students, several students frequently asked to leave class early. Data collected during this cycle indicated students felt there was not enough time during the semester to devote to the posters, suggesting the need to begin the project earlier in the term. Students continued to have difficulty using QI tools such as the fishbone diagram.

3. PDSA Cycle 3 was implemented in the summer. QI and safety content was moved to the fourth week of the semester. Faculty allotted the first 10 minutes of class for group work and included a class activity to help students use a fishbone diagram. After teams watched the Lewis Blackman story, they were asked to brainstorm all possible causes of Lewis's situation and complete a fishbone diagram. A large fishbone was drawn on the white board, and each team added possible causes until no additional causes could be identified. Although feedback after this change was positive, many students continued to have difficulties with the fishbone diagram for their specific projects.

4. For PDSA cycle 4, faculty added the requirement that all QI teams would complete a fishbone diagram related to the identified problem and submit it for review early in the semester. This allowed teams to receive feedback, make recommended changes, and include the revised fishbone on their final posters. Data collected at the end of this cycle indicated students were more comfortable with the diagram and no additional changes were needed. Faculty continue to monitor the activity.

CONCLUSION

The results of this scholarship of teaching and learning activity provide information in support of using iterative PDSA cycles to improve teaching pedagogy. The limitation of the activity is that the findings of each PDSA cycle are contextual and course specific and, therefore, are not generalizable. Nurse educators are constantly faced with exploring new strategies for teaching the newest generation of learners. Using a systematic method to explore and implement changes in teaching pedagogy can provide valuable insight for continuous improvement. Iterative PDSA cycles provide a framework for continual refinement of the change being implemented and ongoing improvement in nursing education.

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