1. Walker, Heather MSN, RN, AGNP-C


Nurses need the tools to reenvision processes and alleviate pressures on nursing staff.


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Unless quality improvement (QI) is incorporated into practice, nurses will be overwhelmed by chronic nursing home staffing issues and the pressures of providing care to the increasing older adult population. The 2010 Institute of Medicine Future of Nursing report recommended that nursing education include competencies such as systems thinking, research, teamwork, and collaboration-thus preparing nurses for a leadership role on interdisciplinary teams that apply evidence-based knowledge to clinical practice.

Figure. Heather Walk... - Click to enlarge in new window Heather Walker

Consider the following example. Mr. D. has dementia and becomes agitated every evening. Staff repeatedly redirect Mr. D. but his agitation escalates. The staff nurse gives him a prn benzodiazepine to decrease his agitation. The following day-shift nurse notices that Mr. D. is drowsy and unsteady. Although usually independent, Mr. D. stays in a wheelchair and staff feed him his breakfast.


The occupational therapist (OT) tells the staff nurse about a tailored activity program that Gitlin and colleagues (2009) found to decrease agitation in community-dwelling adults with dementia. After doing online research at home, the nurse decides this program might help Mr. D. She sets up a meeting with administration to present the program's benefits.


Thanks to the nurse's leadership, administration initiates a team intervention. The social worker learns more about Mr. D.'s social history, the OT completes an evaluation and orders an activity plan, and the nursing supervisor places a treatment plan for Mr. D. at the nursing desk.


Mr. D., a former police officer, is provided detective movies to watch after dinner. Since he used to spend hours refinishing furniture, the activity department provides him wooden blocks to paint. Within a few days, Mr. D.'s agitation decreases. Staff is amazed at the time his change in behavior saves them. They begin to talk about other residents who could benefit from similar interventions.


QI can make nursing home care more efficient and cost-effective while allowing nurses to identify areas for improvement and be leaders for change. Nurses often view themselves through an isolative lens, with each responsible for only her or his assignments. Chronic staffing issues also affect quality of care, making it too easy to blame an individual nurse when an issue arises. QI doesn't negate personal responsibility, but it broadens the focus so that systemic problems are taken into account.


What will lead nursing homes to embrace QI?


* Reenvision the use of limited resources. OTs typically focus on rehab services, but activity evaluations, as in our case study, are also within their scope of practice. Volunteers can be trained to assist with activities.


* Keep staff updated. Administration can provide less formal training that's focused on developing QI skills, sharing success stories, and allocating nurses' time for QI initiatives.


* Foster teamwork. Resources exist to help nursing staff get involved in quality initiatives. The Quality Assurance and Performance Improvement program provides tools and assistance.


* Utilize advance practice RNs to "sell" the QI initiative, highlighting that it addresses quality indicators; increases teamwork, staff satisfaction, and nursing retention; and can save money.


* Reflect. Consider areas of care that could be done differently. Focus on one area at a time-small changes are more likely to succeed.


* Gather information. Online QI resources include the Quality and Safety Education for Nurses Institute and the Institute for Healthcare Improvement.


* Advocate. Additional research is needed to develop interventions that incorporate QI into nursing homes.



QI is a challenge unless organizational supports are in place. With a changing health care system and an increasing older adult population, QI is an essential tool to help nurses and the nursing homes they work in thrive.