Variables Associated With Nurse-Reported Quality Improvement Participation

Abstract

Lack of staff engagement in quality improvement (QI) is a persistent challenge in improving quality in health care. In this study, we examined variables associated with nurse-reported participation in QI using data from over 500 registered nurses employed in US hospitals. Of the 16 studied variables, based on the adjusted multivariate regression analysis, the following were positively associated (p < 0.05) with nurse-reported participation in QI: working in advanced practice nursing and manager roles versus staff nurse role, working a full-time work schedule versus a part-time work schedule, and reporting higher levels of procedural justice, quantitative workload, and work motivation. Lack of staff engagement in quality improvement (QI) is a persistent challenge in improving quality in health care. In this study, we examined variables associated with nurse-reported participation in QI using data from over 500 registered nurses employed in US hospitals. Of the 16 studied variables, based on the adjusted multivariate regression analysis, the following were positively associated (p < 0.05) with nurse-reported participation in QI: working in advanced practice nursing and manager roles versus staff nurse role, working a full-time work schedule versus a part-time work schedule, and reporting higher levels of procedural justice, quantitative workload, and work motivation. Key Points•Engaging nurses in quality improvement (QI) is challenging, yet increasingly important as hospitals face escalating demands to achieve reimbursement and reputation targets.•To improve nurses’ participation in QI, nurse leaders must foster strong procedural justice in the workplace.•Including nurses’ in organizational decision-making and informing proposed changes based on data instead of opinions are key markers of strong procedural justice. •Engaging nurses in quality improvement (QI) is challenging, yet increasingly important as hospitals face escalating demands to achieve reimbursement and reputation targets.•To improve nurses’ participation in QI, nurse leaders must foster strong procedural justice in the workplace.•Including nurses’ in organizational decision-making and informing proposed changes based on data instead of opinions are key markers of strong procedural justice. Evaluation of the Health Foundation’s quality improvement (QI) programs and related literature identified lack of staff engagement in QI as one of the top 10 challenges in improving quality in health care.1Dixon-Woods M. McNicol S. Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature.BMJ Qual Saf. 2012; 21: 876-884Crossref PubMed Scopus (280) Google Scholar Engaging nurses in QI, particularly around nurse-sensitive quality indicators such as central line and urinary catheter infections, is an imperative2Yakusheva O. Lindrooth R.C. Weiner J. Spetz J. Pauly M.V. How Nursing Affects Medicare’s Outcome-Based Hospital Payments. Policy Brief. November 2015. Penn LDI Leonard Davis Institute of Health Economics. Interdisciplinary Nursing Quality Research Initiative.https://ldi.upenn.edu/sites/default/files/pdf/INQRI%20BRIEF%20IV.pdfDate accessed: February 20, 2020Google Scholar that has not been met on a wide scale.3Djukic M. Kovner C.T. Brewer C.S. Fatehi F.K. Bernstein I. Early-career registered nurses’ participation in hospital quality improvement activities.J Nurs Care Qual. 2013; 28: 198-207Crossref PubMed Scopus (10) Google Scholar Hospitals that implement focused programs for staff engagement in QI such as the Transforming Care at the Bedside (TCAB) have shown positive results for staff and the fiscal bottom line.4Unruh L. Agrawal M. Hassmiller S. The business case for Transforming Care at the Bedside among the “TCAB 10” and lessons learned.Nurs Adm Q. 2011; 35: 97-109Crossref PubMed Scopus (12) Google Scholar,5Pearson M.L. Needleman J. Beckman R. Han B. Facilitating nurses’ engagement in hospital quality improvement: the New Jersey Hospital Association’s implementation of Transforming Care at the Bedside.J Healthc Qual. 2016; 38: e64-e75Crossref PubMed Scopus (11) Google Scholar However, <10% of US hospitals participate in such programs. Although some data exist on barriers and facilitators of nurses’ QI participation,6Draper D.A. Felland L.E. Liebhaber A. Melichar L. The role of nurses in hospital quality improvement.Res Brief. 2008; : 1-8Google Scholar, 7Eriksson N. Mullern T. Andersson T. Gadolin C. Tengblad S. Ujvari S. Involvement drivers: a study of nurses and physicians in improvement work.Qual Manag Health Care. 2016; 25: 85-91Crossref PubMed Scopus (8) Google Scholar, 8Pannick S. Sevdalis N. Athanasiou T. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities.BMJ Qual Saf. 2016; 25: 716-725Crossref PubMed Scopus (57) Google Scholar large scale research on factors associated with nurses’ participation in QI is absent. The purpose of this study was to explore a broad range of variables associated with QI participation in a large sample of nurses employed in hospitals. This correlational survey study was approved by a human subjects protection board. We analyzed cross-sectional survey data from a study with a nationally representative sample of US nurses.9Djukic M. Kovner C.T. Brewer C.S. Fatehi F.K. Cline D.D. Work environment factors other than staffing associated with nurses’ ratings of patient care quality.Health Care Manage Rev. 2013; 38: 105-114Crossref PubMed Scopus (41) Google Scholar Our sample included 511 nurses who participated in the study in 2016. Using multiple linear regression, we estimated the effect of 16 variables on QI participation, measured as nurse-reported frequency of participation across 9 QI activities (Table 1). The dependent variable was a sum of the 9 QI activities reported in Table 1. We used the Systems Engineering Initiative for Patient Safety (SEIPS) model10Carayon P. Xie A. Kianfar S. Human factors and ergonomics as a patient safety practice.BMJ Qual Saf. 2016; 23: 196-205Crossref Scopus (74) Google Scholar to guide selection of our independent variables across three of the model’s work system domains (Table 2): person, tasks, and organization. We operationalized the model components as follows: person domain (nurse education, work motivation), tasks (autonomy, variety, quantitative workload, patient load, job role), and organization (full-time/part-time schedule, supervisor support, workgroup cohesion, nurse–physician relations, distributive justice, procedural justice, safety climate, Magnet® status, and union status). Descriptions of multi-item scales, including evidence of strong internal consistency reliability and construct validity in the studied sample, have been previously published.9Djukic M. Kovner C.T. Brewer C.S. Fatehi F.K. Cline D.D. Work environment factors other than staffing associated with nurses’ ratings of patient care quality.Health Care Manage Rev. 2013; 38: 105-114Crossref PubMed Scopus (41) Google ScholarTable 1Description of Variables for Nurses’ Participation in QI (N = 511)VariablesFrequency of Participation in QI Activities Over 12 Months, n (%)MeanSDNeverOnceMore Than Once, but Less Than Once a MonthOnce per MonthMore Than Once per MonthIdentified good care from scientific evidence136 (23.4)53 (9.1)156 (26.9)104 (17.9)129 (22.2)3.11.5Measured current performance159 (27.4)94 (16.2)132 (22.7)93 (16.0)98 (16.9)2.81.4Assessed gaps in current practice179 (30.8)74 (12.7)138 (23.8)100 (17.2)87 (15.0)2.71.4Systematically applied tools and methods to improve performance167 (28.7)78 (13.4)144 (24.8)87 (15.0)104 (17.9)2.81.4Repeated the above four steps until desired performance is achieved166 (28.6)56 (9.6)156 (26.9)93 (16.0)108 (18.6)2.91.5Measured resulting changes227 (39.1)65 (11.2)132 (22.7)87 (15.0)67 (11.5)2.51.4Monitored sustainability266 (45.8)52 (9.0)131 (22.5)63 (10.8)64 (11.0)2.31.4Participated in QI processes, e.g., root cause analysis278 (47.8)82 (14.1)113 (19.4)48 (8.3)57 (9.8)2.21.4Worked in a team to improve processes/system as a result of errors reported back to unit233 (40.1)76 (13.1)121 (20.8)80 (13.8)71 (12.2)2.51.4QI activities summed score (dependent variable, range 1 to 5)2.61.2 Open table in a new tab Table 2Work System Variables (Independent Variables)VariablesItem RangeItem ExampleMeanSDWork motivation1 = strongly disagree to 5 = strongly agree“The most important things that happen in life involve work.”1.90.73Variety1 = none at all to 5 = a great deal“How much variety is there in your job?”3.20.72Autonomy1 = none at all to 5 = a great deal“To what extent are you able to act independently of your immediate supervisor in performing your job?”3.60.83Patient loadDo not care for patients, 1 to 100“During the most recent shift you worked, how many patients did you care for?”6.47.4Quantitative workload1 = never to 6 = 5 or more days per week“Does your job require you to work very fast?”4.01.0Supervisory support1 = none at all to 5 = a great deal“Pays attention to what I am saying.”3.41.0Workgroup cohesion1 = none at all to 5 = a great deal“Are individuals in your workgroup friendly?”3.90.83Collegial RN/MD relations1 = strongly disagree to 4 = strongly agree“Physicians and nurses have good working relationships.”3.00.61Distributive justice1 = not at all to 5 = to a very great extent“To what extent are you fairly rewarded for the amount of effort that you put forth?”2.60.96Procedural justice1 = strongly disagree to 5 = strongly agree“People involved in implementing decisions have a say in making the decisions.”2.60.96Patient safety1 = strongly disagree to 5 = strongly agree“Patient safety is never sacrificed to get more work done.”3.40.88 Open table in a new tab The sample was predominantly female (90%) and non-Hispanic white (84.5%). Three-quarters were staff RNs, whereas managers (17.2%) and advanced practice nurses (APNs) (8.2%) comprised the rest. Most worked full time (69.9%) in non-Magnet (80.6%) and non-union (68.9% ) hospitals. The majority of respondents held either an associate (40.7%) or baccalaureate (48.3%) degree. As shown in Table 1, almost half of the nurses (47.8%) reported never participating in QI processes such as root cause analyses over 12 months. Forty percent reported never having worked as part of a team to improve processes or system as a result of errors reported back to their unit. The summed mean score for the frequency of nurses’ reported engagement across all 9 measured QI activities over 12 months was 2.6 (SD = 1.2) on a scale from 1 = never participated in a QI activity to 5 = participated more than once a month in a QI activity. As shown in Table 3, 1 person-domain variable, work motivation, and 2 task-domain variables, job role, and quantitative workload were associated with QI participation. Specifically, APNs and managers reported greater QI participation compared to staff nurses. Higher level of quantitative workload was associated with greater frequency of QI participation. Two organization-domain variables, work schedule and procedural justice, were associated with QI participation. Specifically, nurses working full time versus part time reported a higher frequency of QI participation. All the variables in the adjusted model explained about 19% of the variance in nurse-reported QI participation.Table 3Variables Associated With Nurse-Reported Participation in QI (N = 511)VariablesUnstandardized CoefficientsStandardized CoefficientstρβS.E.βConstant−0.7900.455−1.7370.083Person domain Highest degree baccalaureate (ref: diploma/associate)−0.0470.103−0.020−0.4550.649 Highest degree masters (ref: diploma/associate)−0.0220.205−0.006−0.1050.916 Work motivation0.2000.0670.1252.9870.003Tasks domain Quantitative workload0.1210.0510.1082.3540.019 Patient load−0.0010.006−0.006−0.1490.881 Role: manager (ref: staff RN)0.5470.1330.1764.124<0.001 Role: APN (ref: staff RN)0.5560.2280.1302.4390.015 Variety0.0690.0730.0430.9450.762 Autonomy0.1170.0640.0811.8210.803Organization domain Full-time (ref: part-time)0.2600.1080.1022.4110.016 Magnet status0.0630.1250.0210.5070.612 Part of a union−0.0240.105−0.009−0.2290.819 Supervisory support0.0260.0570.0240.4470.655 Workgroup cohesion0.0860.0600.0601.3210.187 Collegial RN/MD relations0.0890.0470.0471.0110.312 Distributive justice0.0070.0060.0060.1030.918 Procedural justice0.2340.1830.1833.1350.002 Patient safety0.0540.0410.0410.7810.435Adjusted R2 = 0.188, F (18, 492) = 7.541, p < 0.001.Dependent variable is average score of QI participation (1 to 5). Open table in a new tab Adjusted R2 = 0.188, F (18, 492) = 7.541, p < 0.001. Dependent variable is average score of QI participation (1 to 5). Our results suggest that nurses on a national level report low participation in QI activities. This finding leaves nurse leaders with lots of room for improvement. On the basis of our study, apart from hiring nurses with high intrinsic work motivation, nurse leaders have the best chance of improving nurses’ participation in QI activities by fostering strong procedural justice in the workplace. Nurse leaders can foster strong procedural justice by including nurses’ in organizational decision-making that affects their daily work and informing proposed changes based primarily on data instead of opinions. Next, developing strategies to better engage part-time employees is also needed to boost overall nurses’ engagement in QI. Some strategies for engaging part-time nurses might include frequent briefings on ongoing QI projects through newsletters, e-mails, or unit-based posters and assigning specific tasks or roles to part-time employees related to ongoing QI projects on the days that they are working. Further, although we couldn’t measure the mechanisms that allow managers and APNs to have better participation in QI compared to staff nurses, we know that managers and APNs tend to be salaried employees who have more flexibility in their work schedules to do QI. Exploring work schedules or pay structures that can incentivize staff nurses to participate in QI could also be a fruitful strategy for increasing QI participation. Other studies identified leadership support and good teamwork as facilitators to QI participation and high workload as a barrier.6Draper D.A. Felland L.E. Liebhaber A. Melichar L. The role of nurses in hospital quality improvement.Res Brief. 2008; : 1-8Google Scholar, 7Eriksson N. Mullern T. Andersson T. Gadolin C. Tengblad S. Ujvari S. Involvement drivers: a study of nurses and physicians in improvement work.Qual Manag Health Care. 2016; 25: 85-91Crossref PubMed Scopus (8) Google Scholar, 8Pannick S. Sevdalis N. Athanasiou T. Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities.BMJ Qual Saf. 2016; 25: 716-725Crossref PubMed Scopus (57) Google Scholar In our study, supervisor support and teamwork were correlated with QI participation in bivariate analysis, but not when controlling for other work system variables. It is possible that the specific type of supervisor support such as fostering procedural justice is important for QI engagement. Further, higher quantitative workload was associated with increased QI participation. This was an unexpected finding. Perhaps when nurses are experiencing higher than desired workload they may be more motivated to participate in improvement efforts, hoping to improve the system that is causing the higher workload. Lack of staff engagement in QI is a persistent challenge in improving quality in health care. Existing knowledge on barriers and facilitators of nurses’ participation in QI is informed by qualitative research. Our study adds a quantitative research perspective. In this study, we explored the relationship between nurse-reported QI participation and a broad range of variables using a nationally representative sample of US nurses and robust statistical analysis. Our findings showed that in a multivariate analysis, 5 of 16 variables studied were associated with nurse-reported participation in QI activities. Procedural justice emerged as the strongest predictor of QI participation. Engaging nurses in QI is challenging, yet critical, as hospitals face escalating demands to participate in many QI and reporting programs, to qualify for optimal reimbursement, and to achieve a good reputation through public reporting of nurse-sensitive quality indicators. Although our findings might seem intuitive for nurse leaders on the ground, our study provides data-supported insights for nurse leaders to justify their organizational strategies and budget appropriations for boosting nurses’ QI participation.