The National League for Nursing (NLN) has established nurse educator competencies as guides for nurse educators (NLN, n.d.). Three of these competencies relate directly to the formation of academic-practice partnerships in a prelicensure baccalaureate nursing program: facilitate learning, facilitate learner development and socialization, and participate in curriculum design. The NLN model focuses on ensuring that students are provided with student-centered, innovative curricula that prepare them to meet the multifaceted roles of the nurse. Nurse faculty also use Institute of Medicine reports to guide the development of courses focused on quality and safety education for nurses (Maxwell & Wright, 2016).
As nurse educators, we can facilitate student engagement in quality improvement (QI) by developing student-centered interactive activities and innovative programs and curricula to promote leadership skills. These activities, designed and implemented in cooperation with practice partners, help students understand and appreciate next-level thinking and expose them to the application and implementation of solutions and leadership concepts. Students require preparation for the roles they will assume upon licensure, which include being leaders and change agents on their nursing units; in the health care organizations in which they work; and in professional organizations on the local, state, and national levels.
A review of the literature shows that QI concepts are not new to nursing. Maxwell and Wright (2016) conducted a quantitative study to measure nursing students' knowledge, skills, and attitudes regarding QI and safety. An intervention group received online modules and a weekly flipped classroom seminar approach to understanding QI; a control group received online modules without the weekly seminar. Six quality and safety education for nurses competencies were measured before and after the program. Students in the intervention group showed improved understanding of the QI process over the control group.
Tschannen et al. (2015) implemented student-led root cause analysis projects for practice partners in an undergraduate course. Feedback from practice partners showed that facility leaders found value in the work and solutions of the student teams, enhancing the transition from nursing student to new graduate nurse. The Fuld Fellows Program at Johns Hopkins University facilitates systems thinking and assists prelicensure nursing students to integrate quality and safety concepts into their practice (Gleason et al. (2019). In this yearlong fellowship program, students work to complete QI projects.
STRUCTURE OF THE QI PRACTICUM
In our nursing program, senior prelicensure nursing students engage in a semester-long course entitled Synthesis for Nursing Practice in which they apply the QI process to manage a real-world clinical problem. In prior courses, these students completed a variety of Institute for Healthcare Improvement (IHI) Open School modules, worked collaboratively on a root cause analysis for a hypothetical clinical issue, learned to critically appraise evidence-based research, and learned how organizational structure and process impact change initiatives and patient outcomes.
The senior-level synthesis course has didactic and practicum components. The practicum component requires students to apply their skills in teamwork, communication, and collaboration with their knowledge of leadership, change management, and quality and safety concepts to a real-world nursing problem in collaboration with practice partners. Students work in small groups to design a QI project related to population health, service excellence, or leadership in nursing. To gain an in-depth understanding of the topic, students spend 90 hours at practicum sites gathering information from the site liaison, staff members, and patients; meet with their student groups and/or with faculty; research and synthesize literature; and create a poster presentation to be presented at an informal college showcase as well as a formal podium presentation. Practice partner leaders invited to attend the final podium presentations include the site liaison, the facility chief nursing officer (CNO), site clinical educators, Magnet site directors, and staff nurses.
PRACTICE PARTNERSHIPS
The practice partners include public health settings, including a mobile health clinic, and a variety of nursing units within acute care hospitals. Practice stakeholders include hospital CNOs, community partner leaders, and clinical site liaisons. Academic stakeholders include the dean of academic affairs, course faculty, and senior baccalaureate students. It is essential to recognize students as partners because they are an intricate part of the process.
Prior to each semester, the dean of academic affairs collaborates with CNOs and community partner leaders to identify timely, real-world nursing problems. Topics vary, depending on the focus of the partner. When a topic is selected for use, the practice partner assigns a site liaison who engages with students throughout the semester. The site liaison works directly with students and faculty, once or twice in person and then via email, to provide information and clarity about the problem as experienced in the practice setting. Course faculty meet with students weekly to guide their understanding and application of the QI process as it relates to the clinical topic. Two groups of four or five students are assigned to each topic selected per semester. Although the two groups work with the same faculty member and site liaison, they explore the literature and meet independently with patients, families, and staff to collect current data. Consequently, the practice partners are provided with two potential solutions for each issue, providing richness and relevance to the students' education.
The IHI Model for Improvement (IHI, 2020) guides the students' work, and students complete IHI Open School modules specific to implementing improvements in the health care setting. While applying the model, students must analyze evidence from the literature and data collected at the clinical site to perform a root cause analysis. Upon determining a root cause, students brainstorm possible solutions and return to the literature to prepare an evidence-based solution. Students must apply their knowledge of organizational structure and process to provide consideration for the solution's logistics, stakeholders, costs, timeline, and a method for evaluation. The process helps students synthesize how a change project can impact the outcomes and resources of an organization.
BECOMING A CHANGE AGENT
Garnering feedback from students and the academic-practice partner leaders about the value of the learning process is essential for continued development and revision of the course. Students submit a paper in which they reflect on the practicum experience and how they can serve as change agents in their future role as nurses. In these reflections, students often state that they did not realize they could contribute by examining clinical issues and strategizing QI solutions while still in their baccalaureate program. As one student shared, "I have learned the process does not require a scientific background or a PhD, it just involves a little curiosity and persistence." Commenting that the course molded their new-found role as a change agent, one student wrote: "Considering myself as a so-called 'change agent' makes this issue [resiliency in newly licensed nurses][horizontal ellipsis]more real. Knowing that I could have a hand in changing the process[horizontal ellipsis]would be an incredibly proud moment to have." The students' comments show that they appreciate the professional development opportunity and feel empowered to enact change in their role as nurses.
Academic leaders attend the podium presentation rehearsal and provide feedback to students prior to the formal presentation to practice partners. Practice partners in attendance for the final podium presentation debrief with students and course faculty and share their perceptions. Practice partners have spoken of the value that students' evidence-based solutions bring to their practice setting. They have described solutions as well thought out and realistic and aligned with the organizational mission and vision. Faculty have noted that students gain a deeper understanding of how applying QI concepts to a real-world problem can bring about change in the practice setting.
CONCLUSION
Students in our Synthesis for Nursing Practice course have an opportunity to collaborate with stakeholders, collect and analyze real data, and critically appraise the current literature on a real-world issue. This helps them view themselves as change agents and clinical problems as opportunities to develop evidence-based solutions. The NLN Excellence in Nursing Education Model provides a guide for faculty to ensure that students are provided with student-centered innovative curricula. The IHI Model for Improvement provides nursing students with a framework to continue this work and prepares them to meet the various roles of the registered nurse.
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