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HealthOctober 05, 2020

New QI tool helps drive change in healthcare settings

By: Sarah Handzel, BSN, RN
In the United States alone, over 250,000 deaths are attributed to medical errors every year.1 Studies suggest that medical errors are now the third leading cause of death in the U.S., surpassed only by heart disease and cancer.2,3

As a result, hospitals and other healthcare facilities are focused on quality improvement efforts to identify and change injurious behaviors by healthcare staff.

Quality improvement (QI) can be defined as a systematic, formal approach to the analysis of practice performance and efforts to improve performance.4 The QI process can help improve patient safety and outcomes while also increasing staff efficiency. There are already several tools nurse leaders can use to measure QI attitudes and culture on specific nursing units, but so far, there isn’t any way to determine how engaged frontline nurses are, or what the barriers and facilitators to participation in QI initiatives are.

A new study in the Journal of Nursing Care Quality5 developed, refined, and psychometrically tested a new QI measurement tool, the Nurse Quality Improvement in Practice (N-QuIP). By using the N-QuIP, nurse leaders may be able to better engage frontline nurses and develop strategies for change.

How the N-QuIP works

Initially, the N-QuIP tool consisted of 60 items across the following categories: demographics and engagement, QI competence, and facilitators and barriers. For the purpose of the study, QI competencies were defined as knowledge, skills, and attitudes aligned with QI.

Within each category, study participants were asked to identify their level of agreement with specific statements using different scales. For example, when asked about attitudes toward QI, nurses were asked to rate their agreement with a question on a five-point Likert scale (1 strongly disagree to 5 strongly agree). Other questions asked nurses to rate their level of proficiency in certain skills, from novice to expert. In some cases, respondents were able to input free-text responses if certain information, such as a specific barrier to QI, wasn’t included in the tool.

N-QuIP survey results

After initial testing, the N-QuIP was distributed to nurses working at the study site. A total of 681 nurses submitted usable responses, meaning all questions in the N-QuIP tool were answered. QI competency was measured in terms of skills and attitudes. For the skills scale, researchers identified four subscales which help drive QI efforts: QI tools, data and QI planning, team collaboration, and evidence translation. Three important factors were identified for the attitudes scale—QI importance, QI self-efficacy, and QI organizational culture.

The tool also helped researchers identify current levels of engagement in QI among staff nurses on the frontlines of healthcare. The lowest level of participation was measured simply as participation in a QI project, and over half of the nurses surveyed reported this. The study authors determined that, based on this and previous work, nurses are not fully engaged in QI efforts. Additionally, when they are involved, it’s unclear what actual role nurses play in these efforts.

In terms of barriers and facilitators to QI participation, many nurses identified heavy workload and time constraints as barriers to engagement. Conversely, factors which helped increase engagement included QI training and time for QI activities.

Implications for nurse leaders

As healthcare organizations look to improve quality of care, tools like the N-QuIP can be used to gauge nurse involvement with QI efforts, as well as identify factors making it more or less likely nurses will participate. Leaders can use the results to also identify current attitudes about QI engagement, which may help provide direction toward system-level change to better support bedside nurses.

Increasing engagement in QI initiatives can help to drive changes that lead to improved healthcare quality, better patient outcomes, and a safer U.S. healthcare system. Understanding nurses’ engagement levels, QI competence, and the facilitators and barriers to engagement is the first step toward developing methods of change.

Sarah Handzel, BSN, RN
Freelance Health and Medical Content Writer, Wolters Kluwer Health
Sarah has over nine years’ experience in various clinical areas, including surgery, endocrinology, family practice, and pharmaceuticals. She began writing professionally in 2016 as a way to use her medical knowledge beyond the bedside to help educate and inform healthcare consumers and providers.
  1. Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S. - 05/03/2016, 3 May 2016,
  2. Makary, Martin A, and Michael Daniel. “Medical Error-the Third Leading Cause of Death in the US.” The BMJ, British Medical Journal Publishing Group, 3 May 2016,
  3. “FastStats - Leading Causes of Death.” Centers for Disease Control and Prevention, 6 Feb. 2020,
  4. “Quality Improvement Basics.” AAFP Home, 2020,
  5. “Development of the Nursing Quality Improvement in Practice Tool: Advancing Frontline Nursing Practice.” NursingCenter, 2020,
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