1. Altmiller, Gerry EdD, APRN, ACNS-BC, ANEF, FAAN

Article Content

Quality and Safety Education for Nurses (QSEN) competencies of patient-centered care, teamwork and collaboration, quality improvement (QI), evidence-based practice, safety, and the integrated use of informatics1 encompass the knowledge, skills, and attitudes that nurses must possess to effectively care for patients in today's complex health care system. Of those, the competency of QI has continued to be the least represented in nursing education programs,2-5 and there is little literature on how to integrate it into student learning. What is clear in the literature is that teaching nursing students quality and safety concepts of identifying gaps, developing a plan of action, implementing the plan, and evaluating the outcome to increase competence as change agents should be incorporated into and throughout all nursing curricula.6,7


The Institute for Healthcare Improvement (IHI) identifies 2 interdependent roles for everyone working in health care: one is doing the work and the other is improving the work.8 To that end, nurses are expected to participate in QI initiatives and should learn core concepts of the process during their education. Knowledge and skills that can be developed during prelicensure education include learning the steps for conducting a QI project, identifying appropriate measures, and creating data displays to report outcomes; data displays allow nurses to see small gains and recognize where adjustments might yield greater results.


Although beginning nursing students may have little knowledge of the health care system and change theory, it is possible for them to learn early on in their education how to conduct a QI project. Basic concepts of improvement science can be applied as students identify gaps where change is needed, learn the sequential steps in conducting QI, understand the importance of a meaningful measure, and experience the joy that a successful improvement project can bring. Because the QSEN competencies overlap, integrating QI into student learning allows educators to also emphasize principles of evidence-based practice as students conduct literature searches for the best course of action for their improvement projects and explore concepts of informatics during the data collection, data analysis, and data report phases of QI.


An organized and systematic approach to initiate change that all nursing students should be introduced to is the implementation of Plan-Do-Study-Act (PDSA) cycles.9 This methodology is driven by 3 questions: (1) What are we trying to accomplish? (2) How will we know a change is an improvement? And (3) what change can we make that will result in improvement? The Plan stage begins with a gap analysis to identify what can be changed that will lead to improvement; it creates a blueprint for the change. The Do stage is where the plan is carried out, data are collected, and observations made. During the Study stage, the data obtained from observations are analyzed to determine the effectiveness of the plan's implementation. Finally, the Act stage is where adjustments are made based on the collected data in preparation for the next PDSA cycle. With this model, iterations of the PDSA cycle continue until the change goal is achieved.


Teaching Strategy Overview

The Quality Improvement Project for Prelicensure Nursing Students10 teaching strategy from the QSEN website is designed to teach the process for implementing and evaluating a QI project. It can be implemented in any class but lends itself to an introduction to nursing course or a management and leadership course. To begin, students are taught about QI in class using the 15-slide presentation that is available on the QSEN website at The presentation provides an overview of what QI is and how it connects to the role of health care providers. It also describes a student assignment to use PDSA cycles to change something about oneself and contains all the information the student needs to be successful, including the IHI tool kit11 for reporting data and videos that provide instruction for making bar graphs and run charts using MS Excel (Microsoft Office 2016).


The assignment, provided in Table 1, begins after the presentation and lasts for a total of 4 consecutive weeks. Students choose something about themselves that they would like to improve. Ideas could include sleeping more, studying more hours, drinking more water daily, eating healthier-whatever students identify in their regiment as a gap where improvement is possible. The student implements an improvement plan for 3 PDSA cycles, 1 cycle per week over the next 3 weeks, recording data daily to measure the effectiveness of the change. With the completion of each weeklong PDSA cycle, the student acts on the collected data to fine-tune the plan and implementation process.

Table 1 - Click to enlarge in new windowTable 1 Quality Improvement Project for Students

Strategy Evaluation

During the fourth week, the student submits a 2-part assignment, which accounts for a percentage of the student's course grade. The first part is a 1-page essay following the criteria described in the grading rubric that includes describing the QI project, including an aim statement, using a meaningful measure, and identifying changes made with each PDSA cycle (Table 2). The second page of the assignment is a full-size graph or run chart to illustrate the improvement measurement over the 3 weeks. Grading is not based on the success of the project but rather on the student's adherence to the steps of the QI process. Through this assignment, students learn how QI is done and how project results are displayed.

Table 2 - Click to enlarge in new windowTable 2 Assignment Grading Rubric

This teaching strategy has been implemented with sophomore students in an introduction to nursing course and yielded an excellent understanding of the basic concepts of the QI process and how to illustrate data (see Supplemental Digital Content, Figure, Placing this assignment at the beginning of the nursing education program allows students to be introduced to the sequential steps of carrying out a QI project so that they can participate in QI at their clinical settings throughout their nursing education. Goal-directed assignments such as this support students in their development as change agents, augmenting achievement of quality and safety competencies.




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