The American Association of Colleges of Nursing (2008) recognized the importance of professional nurse involvement in quality improvement (QI) by requiring baccalaureate programs to prepare students for participation in these activities. Bachelor of science in nursing (BSN) programs now integrate education about QI across their programs, though ways in which this is accomplished vary considerably. Ideally, students develop QI skills in a clinical environment where participation in several Plan-Do-Study-Act (PDSA) cycles is possible. However, not all BSN programs have access to settings where students may be embedded in real-time clinical QI projects.
To prepare students, some schools use didactic sessions, group work, self-directed studies, and experiential activities (Armstrong et al., 2017). Typically, activities involve the study of isolated components of QI and the PDSA workflow (Gabarino & Monforte, 2019). The Institute for Healthcare Improvement's (IHI, 2020) introductory assignment has also been used to acquaint students with QI and the change process (Altmiller, 2020). By nature, most of these activities are relatively short, providing learners with only a glimpse of the expansive QI process.
ACTIVITY PURPOSE AND GOAL
The purpose of this innovative activity was to create an experience in which students could learn and apply key concepts of QI and the PDSA process, including problem and target outcome identification, root cause analysis, development and implementation of interventions during repeated PDSA cycles, and dissemination of data and results to stakeholders. The goal of this semester-long activity was to help students develop the knowledge, skills, and positive attitudes essential to QI and the PDSA process. Because of the limited number of clinical sites offering embedded QI activities, a nonclinical alternative was prepared.
RESOURCES AND ACTIVITES
Resources to support the activity were obtained through concurrent enrollment of all students in the IHI's (2020) Basic Quality and Safety Certificate Course. This course consists of a series of modules that introduce learners to QI and to the data-driven process necessary to achieve and maintain change. The IHI's (2020) Quality Improvement Essentials Toolkit was also used. The toolkit offers a range of documents to support QI and associated change processes. Both resources are available, without charge, to health professionals and students.
The activity was conducted as part of the Nursing Research and Evidence-Based Practice course. At the beginning of the semester, the instructor presented a list of topics relevant to either the university community or the school of nursing. Examples included stethoscope hygiene practices, weekly fast food consumption, and weekly screen time. Students were divided into seven workgroups based on topic preference. At intervals during the initial PDSA cycle, all students completed the related QI module from the Basic Quality and Safety Certification Course.
During the Plan phase of the first cycle, workgroups learned about the assigned topic and scope of the problem, identified stakeholders, and determined the aim of the project. Workgroups spoke to students in the school of nursing population as well as others on campus, making observations and learning about specific behaviors or practices. Groups collected quantitative data and generated Pareto diagrams to display discrete factors contributing to the problem. Information was pieced together gradually to reveal the flow of behaviors and stimuli that influenced the assigned topic.
After establishing some understanding of the problem and the people and agreeing upon the aim of the QI project, workgroups completed a simple root cause analysis using a fishbone diagram to visualize how different phenomena influence the outcome. Workgroups also recognized that keeping up with an entire population would be unrealistic, so small cohorts of 20 nursing students were identified and followed throughout the semester. Workgroups designed the first intervention, as well as how to implement it and assess the outcome.
During the Do phase of the PDSA cycle, workgroups implemented interventions and measured outcomes every three weeks. Examples of interventions included educational flyers, group text reminders, and in-person meetings with the student cohorts. Workgroups began the Study phase by collecting data for entry into run charts. Run charts were reviewed for evidence of change before considering how to revisit the problem and prepare for another PDSA cycle. In the Act phase, workgroups reviewed factors such as cohort size, effectiveness of communication, and data collection processes. Workgroups also assessed intragroup communication effectiveness.
Over the semester, each workgroup completed three PDSA cycles. Near the end of the semester, workgroups designed a professional poster to describe the PDSA journey and share findings with the class. Posters displayed information about the assessments and processes involved in the PDSA cycles, including the aim, initial Pareto chart, interventions, run charts, and data analyses. Presentation style was similar to professional conferences, allowing small groups of students to circulate between posters to view and discuss findings with the presenters. Because of the disruption of face-to-face learning caused by the COVID-19 pandemic, posters were displayed on screens within breakout rooms in the learning management system. Real-time interaction between presenters and audience members was primarily oral, though the chat function was also used. After the presentations, the instructor conducted a debriefing session to learn about students' experiences and perceptions of the value of this semester-long learning activity. Students wrote comments anonymously on the whiteboard within the learning management system.
STUDENT RESPONSE TO LEARNING ACTIVITY
Students recognized that QI is a professional nursing role, describing the process as empowering, writing "I wondered why we were doing this - its [sic] extremely important in our field." Another wrote, QI "shows how you can make a difference." Several students described QI as an opportunity for patient advocacy. Students were committed to QI because they could envision their role in it. Many commented about how the experience shaped perceptions about how change occurs in the workplace, describing greater awareness of factors affecting change, such as attitudes and the need for ongoing education.
Students realized that change is likely more difficult at larger institutions and that collaboration is important to achieve desired outcomes. One student commented: "[QI] was a lot more difficult than I was thinking it would be. Quality improvement, you think, well, someone could have an idea and propose it to a manager and then automatically they implement it, but it's a lot more than just that." Students also shared impressions about the entire experience, including how working with ordinary problems made the experience less intimidating than if they had been addressing clinical problems. Students expressed how they could "see the bigger picture" and that they enjoyed the learning experience. Some reported this activity changed their impression of QI and piqued interest in participation in future QI activities.
CONCLUSION
Preparation of BSN students for participation in QI activities can be accomplished in many ways, both within and outside actual clinical settings. When high-impact, experiential learning activities are implemented, students develop knowledge, skills, and positive attitudes necessary for participation in QI and PDSA cycles. Nurse educators are challenged to integrate innovations such as this activity to advance nursing education and ensure a more prepared workforce.
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