A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders

Abstract

Aim: This study aimed to understand the facilitators and barriers of quality improvement (QI) from the perspective of nurses and leaders at the frontline.Background: Nurse engagement in QI has been associated with quality care and improved patient outcomes, yet nurse reported participation is low.Methods: A descriptive qualitative design and purposive sampling was used to examine barriers and facilitators of nurse engagement.Results: Facilitators (1) A leader's influence on a QI culture. Subthemes: creating buy-in, support of a just culture and working in partnership with nurses. Barriers(1) Barriers in organizational culture for nurses to lead QI. Subthemes: organizational hierarchy, absence of a just culture, nurses' role not valued, lack of accountability for QI in nursing role and resistance to change. (2) Barriers in organisational structure for nurses to lead QI. Subthemes: manager disengagement, time pressures, lack of access to timely data, lack of QI knowledge, siloed departments and lack of QI experts. Conclusion:Barriers to QI engagement prevent nurses from fully engaging in QI. Creating a just culture and building the infrastructure to support nurse engagement is critical for success.Implications for Nursing Management: Specific facilitators and barriers were identified that nurse leaders can assess in their practice setting and use relevant strategies to support engagement in QI.

Quality improvement engagement

“…These data align with a qualitative study by Alexander and colleagues that found both culture and leadership were powerful "influencers" of frontline engagement in QI. 21 Nurses in the study expressed having a limited voice in practice decisions and feared being viewed as a troublemaker if they spoke up about QI issues. 21,22 Developing a just culture where nurses feel safe to report errors and all staff members are held to the same standards is critical for achieving positive patient outcomes.…”

“…21 Nurses in the study expressed having a limited voice in practice decisions and feared being viewed as a troublemaker if they spoke up about QI issues. 21,22 Developing a just culture where nurses feel safe to report errors and all staff members are held to the same standards is critical for achieving positive patient outcomes. Research is needed to study the relationship between a just culture and its impact on patient outcomes at the front line.…”

“…This would also explain the finding from this study that nurse leaders were significantly more likely to report access to data as a barrier, which is aligned with previous studies noting difficulty collecting and analyzing data in real time as a barrier. 11,15,16,18,21 Nurse leaders were also more likely to identify lack of physician involvement as a barrier than their frontline nurse counterparts. Current research supports an interprofessional approach to QI, with each member of the team providing unique perspectives and expertise.…”

“…18,19 Identical to the data on barriers, clinical nurses and APRNs were more likely to identify a supportive leader and a supportive culture as facilitators of QI, signaling to nurse leaders how critical the leadership role is to employee engagement in QI. 21 Nurse leaders must advocate for clinical nurses, giving them opportunities to share insights into QI and participate in the subsequent work to improve care.…”

Identifying nursing sensitive indicators from electronic health records in acute cardiac care―Towards intelligent automated assessment of care quality

“…However, issues regarding the selection of appropriate indicators to use, report and embed in clinical practice hinder their introduction in continuous quality assessment and improvement initiatives (Burston et al, 2013 ). A recent study indicated that barriers to quality improvement for nurse managers included a lack of timely data presented in a usable and easy‐to‐access manner (Alexander et al, 2022 ). Additionally, information needs vary between different actors and settings in health care, such as professionals, units and work shifts, creating a need for tailored and dynamic information systems, which respond to different users' individual needs (Peltonen et al, 2019 ).…”