Clinical Inquiry and Problem Identification.

This is the second article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making. It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to http://links.lww.com/AJN/A133). This follow-up series will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey.

National evaluation of DNP students' use of the PICOT method for formulating clinical questions.

BACKGROUND: The intent of the PICOT (i.e., Population, Intervention, Comparison, Outcome, Time) method is to formulate focused clinical questions to facilitate the discovery of relevant evidence through systematic searching, with the components of the question serving as the foundation for the search. Doctor of Nursing Practice (DNP) graduates use evidence-based practices to institute changes in their organizations' systems and policies, thereby yielding positive effects on both patient and system outcomes. Given that the clinical question is the foundation of the evidence-based practice process, DNP graduates' competence in the PICOT method needs to be better understood. AIMS: This analysis aimed to describe how DNP students used the PICOT method to ask clinical questions in their DNP projects. METHODS: Project questions were retrieved from a subset (n = 129, 60.56%) of an existing national random sample of publicly available DNP projects spanning the years 2010 to 2021 from Commission on Collegiate Nursing Education-accredited schools (n = 213). Project questions using the PICOT method were further evaluated with a scoring system of 0 = no and 1 = yes for missing elements, formatting, directional outcome, and project purpose. Possible scores ranged from 0 to 8, with higher scores indicating more errors. Discussion among five researchers, until agreement was achieved, yielded consensus. RESULTS: Although the PICOT method was project author-identified in 66 (31.0%) projects, only four (6%) followed the PICOT method. All 66 (100%) were intervention questions. There were 2.74 (SD 1.55) mean errors, ranging from 0 to 6. No questions were missing P or O. Specific errors included missing I 3 (4.5%) or missing C 37 (56%), poor formatting 34 (51.5%), directional outcome 44 (66.7%), and project purpose 38 (57.6%). Thirty-three (50%) of the questions were missing T; however, T is not used for searching, so researchers recalculated the mean error without T (M = 2.24, SD = 1.28, range 0-5). LINKING EVIDENCE TO ACTION: Gaps in the accurate use of the PICOT method to construct clinical questions can lead to biased searches, inaccurate clinical problem identification, and, when used as the project purpose, jumping to non-evidence-based solutions. Academic faculty and clinical educators can mitigate these skewed outcomes and enhance their impact on quality outcomes by helping DNP-prepared nurses shore up this foundational skill.

Cultivating an Evidence-Based Decision-Making Mindset.

This is the first article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making. It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to http://links.lww.com/AJN/A133). This follow-up series will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey.

National evaluation of DNP projects based on 2015 AACN white paper and 2019 DNP project roadmap.

The AACN expectation to prepare DNP graduates with EBP and QI competencies using the project was clarified with the 2015 White Paper and these expectations have not changed with the new Essentials. Evidence suggests DNP projects continue to be a mix of research and QI. Using the DNP Project Roadmap, we reviewed 214 projects from 120 schools from publicly available sources for the presence of EBP and QI project elements. Of the 27 Roadmap elements evaluated, only two had a significant (p ≤ .05) positive change after the release of the White Paper 1) a question to frame the problem/issue (pre-48.4 %, n = 45, post-64.5 %, n = 78) and 2) an evidence search (pre-26.9 %, n = 25, post-39.7 %, n = 48). Nineteen of the 27 elements had positive change; however, were still not present in >50% of the project papers. These findings can be used to engage in a national conversation on DNP curricular expectations of projects that demonstrate student competency in EBP and QI.

Original Research: Exploring Frontline Nurses' Self-Perceived Levels of QI Engagement and QI Competence.

BACKGROUND AND PURPOSE: Nurse engagement in quality improvement (QI) is critical in the delivery of safe high-quality care, yet few studies have evaluated frontline nurses in this area. The purpose of this study was to identify and compare levels of self-reported QI engagement and QI competence among frontline nurses and nurse leaders. METHODS: This study used a cross-sectional descriptive design. A convenience sample of frontline nurses (bedside RNs and advanced practice nurses) and nurse leaders from acute and ambulatory care sites completed the Nursing Quality Improvement in Practice (NQuIP) tool, which measures engagement and competence (knowledge, skills, and attitudes) in QI. RESULTS: Data from 6,351 surveys completed by frontline nurses and nurse leaders representing 66 sites nationwide were analyzed. Only 52.5% of all respondents reported participating in QI. Knowledge scores were relatively high, while skills scores-especially those related to using QI tools-were low. Overall attitudes toward QI were positive. Nurse leaders scored significantly higher in engagement and competence than the frontline nurses they supervise. CONCLUSIONS: The study findings indicate that nurse engagement in QI is limited. Although nurses' knowledge levels appear to be high, their limited competency in QI-related skills may contribute to low QI engagement. Leaders must make efforts to increase nurse engagement in order to attain high-quality outcomes. Using the NQuIP tool will allow leaders to evaluate nurses' self-perceived QI competence and engagement, which will aid in identifying target areas and developing effective strategies for improvement.

Evolution of Visiting the Intensive Care Unit.

This article gives a historical perspective of visitation in the intensive care unit (ICU) since the establishment of critical care units. Initially, visitors were not allowed because it was thought to be harmful to the patient. Despite the evidence, ICUs with open visitation have consistently been in the minority and the COVID-19 pandemic halted progress in this area. Virtual visitation was introduced during the pandemic to maintain family presence, but limited evidence suggests that this is not equivalent to in-person visitation. Going forward ICUs and health systems must consider family presence policies that allow for visitation under any circumstance.

From Open to Closed: COVID-19 Restrictions on Previously Unrestricted Visitation Policies in Adult Intensive Care Units.

BACKGROUND: In March 2020, rising numbers of COVID-19 infections contributed to changes in intensive care unit visitation policies, with some facilities allowing no visitors. OBJECTIVE: To compare visitation policies of Magnet and Pathway to Excellence hospitals with prepandemic open visitation in adult intensive care units. METHODS: A mixed-methods study was conducted from January through March 2021. Quantitative data on visitation policies were extracted from websites of 96 Magnet and Pathway to Excellence hospitals that had allowed unrestricted visits in adult intensive care units before the pandemic. Qualitative data were collected via semistructured interviews with 9 nurse leaders from these hospitals. RESULTS: More than 1 year after the start of the pandemic, all of the hospitals had instituted restricted visitation policies. The policies varied, with little to no evidence-based justification. Restrictions included 83% of hospitals (n = 80) allowing just 1 visitor per day and 69% of hospitals (n = 50 of 72) allowing no visits at all for patients with COVID-19 in the intensive care unit. Five themes were found when nurse leaders' interviews were analyzed: visitors not welcome, doing harm, external decisions at system level, visiting within limits, and changes in critical care nursing work. CONCLUSION: Results of the study suggest that despite the vast amount of evidence supporting the benefits of visitation and the harms of restricted visitation and expert recommendations for returning safe visitation to hospitals, Magnet and Pathway to Excellence hospitals continue to enforce restricted visitation policies in intensive care units. Patients, families, and nursing and health care staff must partner to create pandemic-proof visitation policies.

Implementation of Just Culture Policy in Nursing Programs to Support Quality Safety Competency.

BACKGROUND: Despite the shift to a just culture (JC) in health care systems more than a decade ago, many nursing programs continue to lack a JC environment, which may result in students entering the workforce without adequate preparation. This study evaluated prelicensure nursing students' perceptions of JC at baseline and 4 months after policy implementation. METHOD: The JC Assessment Tool for Nursing Education (JCAT-NE) was used to measure nursing students' perceptions of JC. RESULTS: Nursing students had high JC at baseline. Senior nursing students had significantly lower scores for the JCAT-NE dimensions of feedback and communication (p < .001), openness of communication (p < .001), and trust (p < .015) compared with freshman, sophomore, and junior nursing students. A negative mean change was observed for senior nursing students in all JCAT-NE dimensions at 4 months. CONCLUSION: Nursing students with the lowest perception of JC were the closest to entering practice, which should raise concern among faculty and future employers. [J Nurs Educ. 2022;61(12):706-710.].

Quality improvement engagement: Barriers and facilitators.

A comparison of frontline nurses, advanced practice nurses, and nurse leaders.

An Integrative Review of the Barriers and Facilitators to Nurse Engagement in Quality Improvement in the Clinical Practice Setting.

BACKGROUND: Nurse engagement in quality improvement (QI) improves health care quality and outcomes but is typically low in clinical settings. PURPOSE: An integrative review was conducted to identify facilitators and barriers of nurse engagement in QI. METHODS: This integrative review was conducted using an electronic search of databases with search terms specific to nursing engagement in QI. The Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide was used to rate quality and level of evidence. RESULTS: Nine articles met the criteria for review. Top barriers were leadership, education and training, resource constraints, data, culture, and time. Top facilitators were leadership, education and training, culture, mentors, and champions. CONCLUSION: High-quality literature exploring barriers and facilitators of nurse engagement in QI is lacking. Research is needed to examine the degree to which these barriers and facilitators impact engagement and how they can be addressed to increase it.

Navigating the Path to a Sustainable "PACU Pause" and Standardized Perioperative Handoff: A Quality Improvement Project.

PURPOSE: The purpose of this project was to develop and implement a pause and standardized perioperative handoff to improve the quality of the handoff and the satisfaction of the perioperative team in the postanesthesia care unit (PACU) setting. DESIGN: The Iowa Model for Evidence-Based Practice guided this evidence-based practice-quality improvement project. METHODS: A team was formed of key nurses and other perioperative members to execute the project. The outcome of the evidence review, appraisal, and synthesis supported the change to a pause and standardized perioperative handoff. The project team educated perioperative staff on the practice change and new process. Baseline, 3-month and 1-year data were collected for adherence to the PACU PAUSE and handoff critical elements, and baseline and 3-months for satisfaction. FINDINGS: PACU PAUSE adherence was 42.30% prepractice change, 92.3% postchange and 96.10% at 1-year. Adherence to the 17 critical elements in the standardized handoff was 40.16% prepractice change, 77.36% postchange and 71.78% at 1-year. Nurse satisfaction with the PACU PAUSE and handoff increased 59% and 50% respectively from pre to postpractice change. Operating room nurse and anesthesia provider satisfaction with PACU PAUSE and handoffs was greater than 85% at baseline and increased 14% and 8% respectively. CONCLUSIONS: The PACU PAUSE allows for increased nurse concentration during the handoff and this can improve patient safety. Using a standardized handoff in situation, background, assessment, response format can decrease information loss and miscommunication, improve the quality of the handoff and the perioperative team members satisfaction with the handoff, and may mitigate patient safety events.

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

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 and competence: A comparison between frontline nurses and nurse leaders.

BACKGROUND: Nurses play a pivotal role in improving patient care. To maximize nurses' impact on quality, nurses must have quality improvement (QI) competence and engage fully in QI initiatives. PURPOSE: To describe QI competence (knowledge, skills, and attitudes) among frontline nurses and leaders; and compare variations in competence among nursing roles, experience, and specialty areas. METHODS: A total of 681 nurses at one heath system fully completed the Nursing Quality Improvement Practice tool electronically. FINDINGS: Half of the respondents reported QI engagement (53.6%). Mean knowledge scores were 5.08 (SD 1.16, 7 items). Skill proficiency was low (M = 2.82, SD = 1.03; range 1-6) although QI attitudes were favorable (M = 3.76, SD = 0.63; range 1-5). Significant differences in skills and attitudes were identified by role. QI competence among nurses employed in various specialty areas were similar. DISCUSSION: Strategies for increasing QI competence and engagement of nurses must be created and deployed in order to improve quality and safety.

Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study.

OBJECTIVE: Open visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership. RESEARCH DESIGN: Qualitative approach using grounded theory. PARTICIPANTS: Nurse leaders in adult intensive care units with open visitation. SETTING: Magnet® or Pathway to Excellence® designated hospitals in the United States. METHODS: Semi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development. FINDINGS: The analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces. CONCLUSION: Intensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.

Implementation of the Surviving Sepsis Campaign one-hour bundle in a short stay unit: A quality improvement project.

OBJECTIVE: To improve timely sepsis care by implementing the 2018 Surviving Sepsis Campaign one-hour interventions. DESIGN: Ten-month prospective quality improvement project. SETTING: A 38-bed short stay unit within an 800-bed hospital in New York City. PARTICIPANTS: Patients admitted to the short stay unit who screened positive for sepsis. INTERVENTION: A sepsis implementation tool was created from the 2018 Surviving Sepsis Campaign guidelines. Sepsis champions delivered education on sepsis recognition, treatment, and management, and the sepsis implementation tool to the healthcare staff. PROCESS AND OUTCOME MEASURES: Time to first lactate, blood cultures × 2, antibiotic administration, length of stay and mortality were tracked weekly for five months. RESULTS: From May 6, 2019 to October 1, 2019, 32 patients were diagnosed with sepsis. Initial lactate and blood cultures were completed on every patient within 1one-hour of sepsis diagnosis. Administration of antibiotics within one-hour reached 100% after week four and was sustained. CONCLUSION: Use of a registered nurse-initiated sepsis implementation tool in a short stay unit led to the completion of blood cultures, initial lactate, and antibiotic administration within one-hour. Key factors to support this practice improvement were increasing registered nurse, physician and physician assistant sepsis knowledge, registered nurse and physician/physician assistant early collaboration, increased staffing and intravenous access equipment.

Is Open Visitation Really "Open" in Adult Intensive Care Units in the United States?

BACKGROUND: Evidence indicates that open visitation in adult intensive care units is a best practice for patient- and family-centered care, and nurses substantially influence such visitation patterns. However, it is unclear whether intensive care units in Magnet and Pathway to Excellence (MPE) facilities nationwide implement this in practice. OBJECTIVE: To describe current national visitation practices in adult intensive care units and determine whether they have changed since the last national study, which used data from 2008 to 2009. METHODS: From February through April 2018, websites of MPE hospitals were reviewed in order to identify their adult intensive care unit visitation policy. If this information was unavailable online, the hospital was telephoned to obtain the policy. From May through August 2018, follow-up telephone calls were made to hospitals that reported open visitation, during which intensive care unit nurses at the hospitals were asked to verify that the policy did not restrict visiting hours or the number, type, or age of visitors. RESULTS: Among the 536 MPE hospitals contacted, 51% (n = 274) indicated that they allowed open visitation. Further examination, however, revealed that 64% (n = 175) restricted the number (68.2%), age (59.5%), or type (4.4%) of visitors, or visiting hours (19.8%). Only 18.5% of MPE hospitals (n = 99) allowed unrestricted visitation. CONCLUSION: This study suggests a lack of progress toward implementing open visitation in adult intensive care units nationwide. Research on MPE hospitals that have adopted truly open visitation policies is needed to identify successful methods for implementing and sustaining open visitation.

Development of the Nursing Quality Improvement in Practice Tool: Advancing Frontline Nursing Practice.

BACKGROUND: Frontline nurse engagement in quality improvement (QI) improves nurse-sensitive outcomes; yet research suggests frontline nurses are not engaging in QI. PURPOSE: The purpose of this study was to develop, refine, and psychometrically evaluate the Nursing Quality Improvement in Practice (N-QuIP) tool to measure nurses' competency, engagement, and barriers/facilitators to QI engagement. METHODS: Item development was guided by an expert panel and literature review. Factor analysis and reliability indices were assessed through 681 surveys completed by nurses at one medical center. RESULTS: Cronbach α coefficients were 0.97 (Skill Scale) and 0.90 (Attitude Scale). Kuder-Richardson Formula 20 (KR-20) for knowledge was 0.36. Exploratory factor analysis identified 4 (Skill) and 3 (Attitude) subscales respectively, aligning well with QI competencies. CONCLUSIONS: Preliminary data suggest that the N-QuIP is a valid and reliable tool for assessing nurse QI competence and engagement. Understanding current knowledge, skills, and attitudes and identified barriers/facilitators can help the development of strategies aimed at increasing QI engagement.