Few Early-Career Registered Nurses Participating in Hospital Quality Improvement Activities

New RWJF-funded study looks at hospitals in 15 states.

    • February 11, 2013

Health care leaders and experts agree that engaging registered nurses (RNs) in quality improvement (QI) efforts is essential to improving our health care system, patient care, and the nation’s health. Despite that, a newly-published study funded by the Robert Wood Johnson Foundation (RWJF) RN Work Project and the National Council of State Boards of Nursing Center for Regulatory Excellence reveals that few nurses are involved in hospital QI initiatives and nurse participation levels do not appear to be growing.

The study, published in the Journal of Nursing Care Quality, compared participation levels in hospital QI activities for RNs who were first licensed during 2004 and 2005, and RNs first licensed between 2007 and 2008. The research team found little difference between the two cohorts for a variety of activities, including performance measurement, working to improve processes or systems of care, monitoring sustainability of improved practices, and working to improve performance. The only exception was “use of appropriate strategies to improve hand washing compliance to reduce nosocomial infection rates;” nosocomial infections are hospital-acquired.

The research team included Maja Djukic, PhD, RN, assistant professor at the College of Nursing, New York University; Christine Kovner, PhD, RN, FAAN, professor at the College of Nursing, New York University;  Carol Brewer, PhD, RN, FAAN, professor at the School of Nursing, University at Buffalo; and Ilya Bernstein, BS, RN, Langone Medical Center, New York University. Kovner and Brewer direct the RN Work Project.

“We expected to find a greater variation in QI participation between the two groups,” said Djukic. “These findings underscore the need for hospitals to collaborate with nursing schools to develop effective strategies to ensure that RNs expect and are prepared to engage in QI activities. Nurses are an important resource in efforts to improve care and patient outcomes and, right now, that resource is too often being underutilized.”

The number of hospitals that participate in formal programs aimed at increasing nurses’ engagement in quality and safety initiatives has risen. Among those initiatives are Transforming Care at the Bedside, National Database of Nursing Quality Indicators Program, and the hospital Magnet Recognition Program. The Quality and Safety Education for Nurses (QSEN) initiative, funded by RWJF, is being implemented at an increasing number of nursing schools to boost students’ readiness for QI. Researchers expected this to increase nurse participation in QI activities for the later cohort.

The researchers noted that there may be several reasons they did not see significant changes in reported participation between the two cohorts of nurses. They include:

  • The two-year difference between the surveys may not have allowed enough time for QI initiatives to make a difference in participation levels among early-career RNs;
  • The growth in implementation or penetration of QI initiatives over the two-year span might not have been large enough to manifest in differences in early-career RN participation; and
  • Early-career RNs might not be the group most likely to be engaged in QI.

As to the final reason, the researchers maintained there is no reason not to engage early-career RNs in QI, and cited several promising programs for engaging staff RNs. Those include the Integrated Nurse Leadership Program in California, and the Bi-State Nursing Workforce Innovation Center’s Clinical Scene Investigator Academy in Kansas and Missouri.

They also recommended better data systems for monitoring quality outcomes specific to nursing care so that RNs receive timely feedback on their performance. Other recommendations for hospital leadership include:

  • Subscribing to programs that allow RNs to complete self-directed online modules to learn about QI, such as the Institute for Healthcare Improvement Open School for Health Professions and QSEN;
  • Having more experienced colleagues guide early-career RNs in translating newly-acquired QI knowledge into action;
  • Ensuring staffing levels are high enough and that RNs have sufficient release time to participate in QI activities; and
  • Ensuring RNs have access to an information technology infrastructure that provides meaningful, timely, and actionable QI data.

The study was based on surveys of 539 RNs who work in hospitals in 15 states: Alabama, Kentucky, Maryland, Michigan, North Carolina, New Jersey, Nevada, New York, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas and West Virginia.

The RN Work Project is a 10-year study of newly licensed registered nurses (NLRNs) that began in 2006. It is the only multi-state, longitudinal study of new nurses’ turnover rates, intentions and attitudes—including satisfaction, organizational commitment and preferences about work. The study draws on data from nurses in 34 states and the District of Columbia, covering 51 metropolitan areas and nine rural areas.