As part of a randomized control trial to improve the delivery of preventive services, the authors studied the effect on clinic nurses in the roles of team leaders or facilitators of multidisciplinary, continuous quality improvement (CQI) teams. Our goal was to learn how these nurses felt about their experience with this project, specifically their satisfaction with process improvement, acquired knowledge and skills, and the impact on their nursing role. Overall, the nurses involved in this study reported significant gains in all three areas. This study suggests that CQI can be a valuable vehicle for improving and expanding the nursing role for clinic nurses.
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QUALITY improvement (QI), also referred to as Continuous QI (CQI), Total Quality Management (TQM), and other terms, has undergone an explosive growth in health care over the last 10 years.1,2 This growth has been accompanied by the publication of a steadily increasing number of articles. However, review of these articles would lead one to believe that nearly all of this QI activity has occurred in hospitals and large medical organizations and, until recently, most has involved administrative processes rather than clinical ones.3-6 Very few articles have addressed smaller ambulatory care settings and almost none have described the QI role of clinic nurses or the impact of these activities on nurses. Is involvement on QI teams helpful to nurses and do the changes in care processes produced by these teams improve the ability of nurses to provide better patient care? What is the potential for QI to affect the often-restricted role of nurses in ambulatory care?
Our involvement in a large scientific trial of QI as a way to create more systematic delivery of preventive services in private medical clinics has provided us with an opportunity to begin answering these questions. This involvement brought us into frequent contact with all types of clinic personnel, but particularly with the nurses who often served in leadership roles on the clinics’ QI teams. As we provided training or consulting with these nurses, we noted that many of them seemed to enjoy the opportunity and reported anecdotes about how it had expanded their abilities.
We conducted a systematic series of interviews and a survey with the clinic nurses who were involved in the trial as leaders or facilitators of the QI teams established in these clinics for preventive services. This study’s goal was to learn how these nurses felt about their experience in three areas:
1. satisfaction with the process and its results for them
2. acquisition of specific knowledge and skills
3. impact on the nursing role
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The trial was called IMPROVE (IMproving PRevention through Organization, Vision, and Empowerment) and it was funded by the Agency for Health Care Policy and Research as a randomized controlled trial.7,8 Sponsored by two normally competing managed care plans (Blue Plus and HealthPartners), it was designed to test the hypothesis that such plans could improve the delivery of specific adult preventive services in contracted clinics by using CQI methods to develop prevention systems.
Forty-four individual primary care medical clinics in the Twin Cities region of Minnesota were recruited for the trial from 33 of the 71 medical groups eligible to participate by reason of a contract with one or both plans and location within 50 miles. No financial incentives were provided to the clinics to participate other than reimbursement for the research evaluation efforts (eg, pulling charts for audits, providing patient appointment lists for sampling, etc.). The clinics ranged in size from 2 to 15 primary care clinicians (except for one residency-training clinic with 28), with an average of 8. At the time of recruitment, only an average of 19 percent of their patients were members of the two sponsoring plans. Thus, they were fairly typical of this region’s clinics except perhaps in having a particularly strong interest in working on improvement of their preventive services and in learning how to use CQI.
At the start of the trial in September 1994 each of the 22 clinics randomized to the intervention arm was asked to form a multidisciplinary QI team with a management sponsor and a leader and facilitator for the team. We suggested that they name a physician as leader and a nurse as facilitator but in this, as in all aspects of the trial, all decisions were up to the clinic. The IMPROVE team provided just-in-time group training to the leaders and facilitators in six sessions over seven months for a total of 26 hours. The training was focused on the specific knowledge and skills needed to use a seven-step CQI process to improve preventive services. During and after the training, IMPROVE project nurses provided periodic telephone and on-site consultation. After an 11-month training period, additional periodic opportunities were provided to network with other clinic leaders and facilitators and to obtain additional group consultations about areas of particular concern.
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In June of 1996 (22 months after starting the intervention), two of the authors obtained written surveys and conducted individual interviews with each of the nurses who had served as leader or facilitator for one of the clinic teams. One nurse practitioner and two nurses who became facilitators after the completion of the training were excluded in order to provide a more homogeneous group and experience. This left 13 nurses to participate in the study, 9 of whom had served as facilitators and 4 as leaders for their teams. All agreed and signed consents, although one nurse could not find time for the interview and only completed the questionnaire. Other nurses participated as members of some teams, but we felt that the views of those with more project training and experience were especially valuable.
The questionnaire was designed to assess the respondent’s attitudes and beliefs in each of the areas of focus for this study as well as to obtain relevant demographic information. It contained 55 close-ended questions that were developed from learning objectives for the training and a literature review of previous research on the nursing role in ambulatory care settings.9-12 Questions about skills and activities asked for a six-point Likert-scale response from “none” to “very much” choices and those asking about satisfaction and nursing roles asked for a five-point scale response from “strongly agree” to “strongly disagree.” After pretesting and revision, the questionnaire was mailed to the nurses to complete before the interview. The questionnaire is included in the Appendix.
The interviews were structured to obtain qualitative data to expand on the questions in the survey. Eleven interviews were conducted in person at the clinical site and one was conducted over the telephone. Each was tape-recorded and transcribed later.
Survey responses were simply summarized and reported directly for the small numbers involved. Questions that were stated negatively in order to improve response validity have been reworded for ease of comparing the answers. The interviews were analyzed for themes and for examples to illustrate questionnaire responses.
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Most of the nurses studied had already been involved in some degree of management in their clinics prior to the study. Only four were clinic nurses while two each were clinic manager, patient care manager, and nursing coordinator. The other three nurses were vice president of information services, medical services director, and health educator. Eight held positions that involved supervision of others, and an overlapping eight worked in direct patient care at least part time.
As might be expected from such a group, 12 had been nurses more than 10 years and 10 had worked at their present clinics for at least 5 years. Educationally, seven nurses were registered nurses (RNs) (2 with bachelors of science in nursing, two with diplomas, and three with associate degrees) and six were licensed practical nurses (LPNs). All were female.
Only four nurses reported that they had received previous formal training in CQI, although another four reported informal on-the-job training as part of a process improvement team. However, only the latter four and one additional other reported previous participation in QI. Three of these had been team leaders, one had been a facilitator, and one was a member of a team.
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Satisfaction with the IMPROVE process improvement experience
Table 1 suggests that, even after working on this process for 22 months, most nurses reported high levels of satisfaction associated with this experience of process improvement. That is particularly true for questions about obtaining personal value and improving patient care. Positive recognition from their clinics and greater job security are much less strongly supported.
From the interviews, several comments reinforced the written survey results concerning the opportunity to learn and grow:
I was looking for the experience of a CQI project. I had done some reading on Dr. Deming on my own. I knew he was very successful and I didn’t know how. This was just very fascinating to me.
Learning something new was probably one of the greatest things that attracted me to this. My mind is just constantly going all the time and I really like getting involved in new things.
The nurses also reported high scores in task significance. Questions included, “The time spent on this process improvement has been worth it,” “I feel like what I am doing with my team is worthwhile,” and “I believe that our process improvement activities have resulted in our patients receiving better care.” Comments around task significance centered largely on the perceived benefit to their clinic’s patients. One nurse responded to the question, “What are the three most positive benefits of your involvement in process improvement?” by answering:
Number one is that we actually focused on those eight preventive services and that when you take a look at them they are actually going to improve somebody’s life. And that’s going to continue here even after we’re formally finished.
Another repeated theme focused on participation-the opportunity provided to interact in a positive way, not only within each clinic site, but with other clinics involved in the project:
You’re not in this alone, you’re working with a lot of good people, and not just health professionals. We have good people like _____ who is not a health professional. She works in the business part, but I can’t imagine doing this without her because they have the skills of getting the word out when you’re busy with patients. So we need each other.
It has been fun to be involved with other people. This has given me an awareness of not only my own clinic site, but awareness of the broader picture of health care within the Twin Cities.
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Acquisition of specific knowledge and skills
Overall, these nurses reported increasing a wide variety of knowledge and skills relevant to process improvement and working with people as a result of this experience. Table 2 summarizes these reported changes between self-perceived skills before and after the 22-month project. The largest improvements involved learning how to make use of data, managing change, and managing meetings. Even the eight respondents with previous training in QI reported gains, even though they had rated their previous overall QI knowledge and skills as average (3 nurses) to above average (5 nurses).
From the interviews, several themes emerged as to what the nurses perceived as skills gained from participating in process improvement. The most frequently mentioned skill was the ability to apply a model for problem solving (the seven-step model):
I think really learning how to problem solve was very beneficial because we had tried to solve some situational process problems in our clinic before and it gets to a certain point where everyone complains about something and they decide to do something about it and we would set up some basic rules or policies and three or four months later no one was doing it anymore because it didn’t work. There never was a lot of follow through, so I think this really gave us a good role model on how to go about problem solving in the clinic.
Another frequently cited skill was the ability to effectively conduct meetings:
One of the major things I learned was how to run a meeting. It is so effective and we use it so much in other meetings now. People come out of those meetings and say, “This is a great way to do a meeting… we get out of here on time and we get something done.
Other themes cited were around skills gained in interpersonal relationships, specifically the ability to directly deal with coworkers or others on solving problems:
I now am being more direct and am looking at things more from a process point of view rather than a personal point of view.
Another nurse reported:
Overall, now if someone is not following the standard, I approach them now by going over what the protocol is or what the process is, rather than honing in on the fact that the person may not be a good nurse.
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Impact on the nursing role
As illustrated in Table 3, these nurses reported that they believe QI is important for nurses and that nurses have a crucial contribution to make to QI. With a few exceptions, they believe that QI will improve the ability of nurses to control their work and many of them feel that their work on process improvement has helped them to be better nurses. However, when asked about each of nine specific areas of nursing activities (room preparation, technical activities, nursing process, telephone communications, patient advocacy, patient education, care coordination, expert practice, and quality improvement), only in QI did more than 3 of the 13 nurses report that they had experienced a significant change in the frequency with which they performed that type of activity after working on this project.
During the interviews, the nurses were asked whether they saw a role for process improvement in the nursing profession. The majority of the responses revolved around the value they perceived in being able to approach problems in a systematic way:
I don’t think nurses’ training ever gave us the skills to deliberately study something and improve it. Yet we get out and we become head nurses.
It has helped the role of the nursing supervisors in dealing with their staff. It has helped them work through problems and problem solve rather than just coming to me for an answer.
Many of the nurses reported that their environment was changing and that their role had changed. Because of this changing environment, they reported needing new skills and a new way of thinking:
Everything is changing. We need to improve for our patients.
I think the scope of nursing has changed and that the nurses need to look at the whole system, you know what goes on with the patient besides just with the hands-on things. I think it (process improvement) is a blend of how you clinically take care of somebody, but I think it kind of helps you to critically look at other things. You’re dealing with so many systems with the patient and how they move through these systems.
We were never trained to deal with the system, we were only trained to deal with each patient.
In the clinic setting, we need to be aware of what we are doing and why we are doing it. There is a lot of time and wasted effort.
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Although the sample is small, this study helps to document the generally positive feelings of ambulatory practice nurses involved in leading or facilitating their local clinic QI effort to improve the process of providing preventive services. Both their questionnaire responses and their interview comments and anecdotes suggest that they feel they benefited from their involvement with this project, despite the fact that it required a great deal of time and energy from them. Overall, they report that they were very satisfied with the experience and that it provided them with increased knowledge and skills as well as enhancements for their nursing role.
In light of the reported knowledge, skill, and role enhancements, it is not surprising that these nurses would feel satisfied with their experience. Even though most of these nurses were already working at higher-level positions, nursing in ambulatory practice has traditionally been viewed as less prestigious and challenging than hospital nursing, both by nurses and by the public generally. Hackbarth’s study showed that ambulatory nurses reported more frequent performance of lower-level work dimensions and less frequent performance of dimensions requiring disciplinary knowledge and critical thinking, despite the growing complexity of care in ambulatory settings.12 Capell and Leggat’s comment that “the traditional view of the nurse as one only involved in the accomplishment of tasks prescribed by others is no longer fitting in today’s health care environment,” does not mean that traditional role is disappearing.13(p39) Thus, anything that promises improvement in the nursing role is likely to find appeal.
Counte has shown that in the hospital setting, personal participation in a TQM program was associated with higher job satisfaction.14 McLaughlin and Kaluzny feel that the new set of decision-making skills required by TQM includes not only technical skills like data management and statistical analysis, but also the ability to work well in multidisciplinary teams.15 Despite previous QI training and/or experience, all of the nurses in this project reported gains in skills, and most of these skills were gained in the areas noted above, along with change management.
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Another aspect of the current health care environment that lends both importance and urgency to acquiring new skills is the extreme degree of turmoil in health care, especially in the Twin Cities. As Magnan has documented for these clinics involved in the IMPROVE trial, enormous change is going on.16 Within a one-year time period during the process improvement efforts described here, 64 percent of the clinics were purchased, merged, or underwent a major shift in affiliations; 77 percent of the clinics changed at least one major internal system; and 45 percent of the clinics changed their medical director and/or their clinic manager. This turmoil may explain why so few respondents reported that the experience provided them with more job security in their current clinic (question 12 in Table 1), even though it gave them more job opportunities for the future (question 9).
Clearly QI is very important to health care improvement and reform. Phoon et al.17 believe that the success of health care delivery depends on the successful integration and coexistence of QI and managed care. Moreover, they believe that nurses play a key role in this integration, although they tend to emphasize primarily nurse managers and practitioners. Spoon et al., on the other hand, use their experience with 45 CQI process improvement teams in a community hospital to highlight the potential for this experience to empower typical hospital nurses.18 They also point out the many ways nurses are essential to most of the steps in the improvement process. Corbett and Pennypacker go on to describe a process improvement effort that took place entirely within a hospital nursing department,19 although that is not particularly consistent with the interdisciplinary needs for most QI efforts.
It is worth highlighting that the training in this project was very action oriented. It focused not on theory, but on the application of process improvement and team skills. For example, the trainees learned to flow chart their own clinic’s prevention process and to collect and analyze their own data in order to learn the root causes for the problems with that process. Role plays of meeting management skills and audits of dummy charts prepared them for applying those skills with their own clinic teams.
A basic assumption governing the intervention with these trainees and their teams was that they could act their way into a new way of thinking by applying specific skills in a structured way. These new ways of thinking derive from a real understanding of work as process and include recognizing that problems are generally due to systems deficiencies rather than to individual workers. In other words, we were teaching systems thinking-what Peter Senge describes in The Fifth Discipline as the “discipline for seeing wholes.”20(p68)
We believe that we saw this type of fundamental change in thinking in these nurses and others involved in this improvement process. Over time, the language of the group began to change and to include terms and statements that reflected systems thinking. For example, one rather taciturn physician remarked after the third training session that “I never realized how many people were involved in getting the patient ready to be seen by me”
Aside from the knowledge and skills acquired from the training and the task, it was clear that most of these participants highly valued the opportunity to talk with others in similar environments. They liked to share frustrations as well as to learn from the efforts of peers in other situations. Most clinic personnel are surprisingly isolated, with few opportunities to attend broadening learning experiences, much less to learn first-hand how their way of doing things compares with that of others.
We believe that this study and our experience with providing training and consulting for 60 clinics show that there is a great deal about the concepts and techniques of QI that appeals to nurses and other health care professionals. It appeals to both their scientific orientation and their desire to help improve things, in particular their customers-each patient. The acquisition and the application of these concepts and techniques appear to be both satisfying and broadens their views of how they can contribute to health care.
Finally, it is worth noting that besides enhancing the skills and satisfaction of nurses, the QI projects in which they work are often likely to lead to role enhancements for nurses, especially those in ambulatory care settings. QI teams interested in improving prevention or other clinical areas of focus, like those we had the privilege to work with, will find that they cannot do this without expanding the role of nurses. McCarthy et al.,21 among others, have demonstrated the power of empowering clinic nurses to offer and arrange for mammography as patients are seen. The Oxford Project in England has carried this even further by creating a new profession for facilitators to help primary care practices improve their prevention activities by training practice nurses to fill an expanded role in performing health checks and facilitating practice system changes.22 Most of these external facilitators are also nurses and it is recommended that all of them have that background.23 Astrop’s description of the facilitator’s activities within a practice sound very similar to those of the nurses involved in this project and paper.
Both this project and the literature suggest that QI concepts and techniques can be important vehicles for improvements in both patient care and in the skills, roles, and job satisfaction of nurses. This can be stimulated and assisted by managed care plans and others external to individual practice settings, but ultimately its success will depend on individual nurses, like those in this study, using their creativity and energy to make it happen.
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1. Berwick, D.M. “Continuous Improvement as an Ideal in Health Care. New England Journal of Medicine 320, no. 1 (1989): 53-56. UvaLinker Bibliographic Links [Context Link]
2. Laffel, G., and Blumenthal, D. “The Case for Using Industrial Quality Management Science in Health Care Organizations.” Journal of the American Medical Association 262, no. 20 (1989): 2869-2873. [Context Link]
3. Barsness, Z.I., Shortell, S.M., and Gillies, R.R. “National Survey of Hospital Quality Improvement Activities.” Hospitals and Health Networks 67, no. 23 (1993): 52-55. UvaLinker [Context Link]
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5. Shortell, S.M., Levin, D.Z., O’Brien, J.L., and Hughes, E.F. “Assessing the Evidence on CQI: Is the Glass Half Empty or Half Full?” Hospital and Health Services Administration 40, no. 1 (1995): 4-24. [Context Link]
6. Carman, J.M., Shortell, S.M., Foster, R.W., Hughes, E.F., et al. “Keys for Successful Implementation of Total Quality Management in Hospitals.” Health Care Management Review 21, no. 1 (1996): 48-60. Ovid Full Text UvaLinker Request Permissions Bibliographic Links [Context Link]
7. Solberg, L.I., Isham G., Kottke, T.E., et al. “Competing HMOs Collaborate to Improve Preventive Services.” The Joint Commission Journal on Quality Improvement 21, no. 11(1995): 600-610. [Context Link]
8. Solberg, L.I., Kottke, T.E., Brekke, M.L., et al. “Using CQI to Increase Preventive Services in Clinical Practice-Going Beyond Guidelines.” Preventive Medicine 25, no. 3 (1996): 259-267. [Context Link]
9. Solberg, L.I., and Johnson, J.M. “The Office Nurse: A Neglected but Valuable Ally.” Family Practice Research Journal 2, no. 2 (1982): 132-141. UvaLinker [Context Link]
10. Flarcy, D.L. “Redesigning Management Roles, The Executive Challenge.” Journal of Nursing Administration 21, no. 2 (1991): 40-45. UvaLinker Request Permissions Bibliographic Links [Context Link]
11. Haas, S.A., Hackbarth, D.P., Kavanagh, J.A., and Vlasses, F. “Dimensions of the Staff Nurse Role in Ambulatory Care: Part II-Comparison of Role Dimensions in Four Ambulatory Settings.” Nursing Economics 13, no. 3 (1995): 152-165. [Context Link]
12. Hackbarth, D.P., Haas, S.A., Kavanagh, J.A., and Vlasses, F. “Dimensions of the Staff Nurse Role in Ambulatory Care: Part I-Methodology and Analysis of Data on Current Staff Nurse Practice.” Nursing Economics 13, no. 2 (1995): 89-97. [Context Link]
13. Capell, E., and Leggat, S. “The Implementation of Theory-Based Nursing Practice: Laying the Groundwork for Total Quality Management Within A Nursing Department.” Canadian Journal of Nursing Administration 7, no. 1 (1994): 31-41. UvaLinker Bibliographic Links [Context Link]
14. Counte, M.A., Glandon, G.L., Oleske, D.M., and Hill, J.P. “Total Quality Management in a Health Care Organization: How are Employees Affected?” Hospital and Health Services Administration 37, No. 4 (1992): 503-518. UvaLinker [Context Link]
15. McLaughlin, C.P., and Kaluzny, A.D. “Total Quality Management in Health: Making it Work.” Health Care Management Review 15, no. 3 (1990): 7-14. [Context Link]
16. Magnan, S., Solberg, L.I., Giles, K., et al. “Primary Care, Process Improvement, and Turmoil.” Journal of Ambulatory Care Management 20, no. 4 (1997): 32-38. Ovid Full Text UvaLinker Request Permissions Bibliographic Links [Context Link]
17. Phoon, J., Corder, K., and Barte, M. “Managed Care and Total Quality Management: A Necessary Integration.” Journal of Nursing Care Quality 10, no. 2 (1998): 25-32. Ovid Full Text UvaLinker Request Permissions Bibliographic Links [Context Link]
18. Spoon, B.D., Reimels, E., Johnson, C.C., and Sale, W. “The CQI Paradigm: A Pathway to Nurse Empowerment in a Community Hospital.” Health Care Supervisor 14, no. 2 (1995): 11-18. Ovid Full Text UvaLinker Request Permissions Bibliographic Links [Context Link]
19. Corbett, C., and Pennypacker, B. “Using a Quality Improvement Team to Reduce Patient Falls.” Journal of Healthcare Quality 14, no. 5 (1992): 38-54. [Context Link]
20. Senge, P.M. The Fifth Discipline: The Art and Practice of the Learning Organization, New York: Doubleday, 1990. [Context Link]
21. McCarthy, B.D., Yood, M.U., Bolton, M.B., et al. “Redesigning Primary Care Processes to Improve the Offering of Mammography. The Use of Clinic Protocols by Nonphysicians.” Journal of General Internal Medicine 12, no. 6 (1997): 357-363. [Context Link]
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23. Astrop, P. “Facilitator-The Birth of a New Profession.” Health Visitor 61, no. 10 (1988): 311-312. [Context Link]
The authors would like to thank the 46 clinics that participated in the IMPROVE project. These included the two demonstration clinic sites; Kasson Mayo Family Practice Clinic and HealthPartners St. Paul Clinic.
Apple Valley Medical Center
Aspen Medical Group, W. St. Paul
Aspen Medical Group, W. Suburban
Chanhassen Medical Center
Chisago Medical Center
Creekside Family Practice
Douglas Drive Family Physicians
Fridley Medical Center
Hastings Family Practice
Hopkins Family Practice
Interstate Medical Center
Mork Clinic, Anoka
North St. Paul Medical Center
Ramsey Clinic, Amery
Ramsey Clinic, Baldwin
River Valley Clinic, Farmington
River Valley Clinic, Northfield
Southdale Family Practice
United Family Medical Center
Aspen Medical Group, Bloomington
East Main Physicians
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