Author: Kathleen Z. Wisser, PhD, RN, CNE, CPHQ
Title: Dean of Nursing
Institution: Notre Dame of Maryland University
Coauthors: Louise Fura, DNP
Quality Improvement, Safety
Pre-Licensure ADN/Diploma, Pre-Licensure BSN
• Apply quality improvement (QI) tools for process and system improvement.
• Articulate awareness of strategies to mitigate harm through the systems approach.
The educational strategy, a one four-hour learning activity, engages pre-licensure nursing students in the application of a QI tool and systems thinking approaches to patient safety. The non-graded patient safety and QI educational strategy encompasses a two-pronged approach.
The first prong consists of an introduction to patient harm using a video (The Josie King Story, 2001). In small groups, students brainstorm patient safety risks to Josie’s safety by answering the following question. In what ways could or should the nurse have recognized risks to Josie’s safety? The first prong culminates with a “Patient Safety and QI. Educational Strategy” slide presentation, which includes two theory bursts. This slide presentation was adapted from Phase III of the QSEN National Initiative, Patient Safety and Quality Improvement Learning Module (2009).
The second prong introduces students to systems thinking and root cause analysis by using a fishbone diagram. This QI tool visually displays underlying causes for a specific problem or effect. The second prong encompasses a series of seven steps.
In the first step, small groups of six to eight students, review a case study to examine the impact of a medication error from a systems perspective. Next, the faculty facilitator describes the purpose of a fishbone diagram and how to complete the diagram. There are a variety of videos available on the internet demonstrating how to complete a fishbone diagram. The faculty facilitator assigns each group one branch of a fishbone diagram—staff, work environment, admission process, and computer system. In the third step, ask each group to identify underlying causes for the medication error that resulted in deterioration of the patient’s medical condition as described in the case study. To ensure students stay on track in completing their assigned individual branch, the faculty facilitator guides individual groups to continually ask the question “why?” with the goal of thoroughly and accurately identify all underlying causal factors. In the fourth step, each student group generates one – two system improvement recommendations and any immediate corrective actions that address causal factors within the assigned individual branch.
The fifth step occurs upon completion of the fishbone diagram. One student group exchanges a fishbone diagram with another student group that completed a different branch. The ‘new’ group evaluates the completeness of another group’s assigned branch by answering five questions as described on the student learning assessment rubric, “Patient Safety and Quality Improvement Educational Strategy for Pre-Licensure Students Rubric to Evaluate Student Learning.” The two groups are given an opportunity to ask each other questions and offer feedback. Questions on the rubric guide this conversation.
The sixth step involves a report-out where all student groups present their assigned branches. During the report-out phase, a student recorder inserts underlying causal factors on a blank fishbone template visible to all participants. The purpose of this step illustrates the root cause analysis in its entirety. During the report-out step, all students examine recommendations and corrective actions identified by each student group and articulate strategies to mitigate harm from a systems approach. The faculty facilitator guides students in identifying the most appropriate and achievable recommendations. Finally as the last step, student groups are given the opportunity to re-convene. Groups revise their assigned branch using feedback from faculty and students. The first and second fishbone diagrams are submitted to the faculty facilitator.
The faculty facilitator assesses student learning and if students satisfactorily met the two learning objectives by comparing student groups’ first attempt and the revised second attempt. The faculty facilitator offers written feedback to each student group about the thoroughness of their assigned branch and quality of recommendations for systems improvement using the same set of five questions on the rubric, “Patient Safety and Quality Improvement Educational Strategy for Pre-Licensure Students Rubric to Evaluate Student Learning.” To further evaluate student learning, at the conclusion of the educational strategy, students answer and submit answers to three questions:
1. Identify one nursing action that may prevent a medication error.
2. Identify the primary purpose in completing a fishbone diagram.
3. Offer one way to improve this learning experience.
Indirect measurement of student learning occurs throughout the educational strategy based on student anecdotal comments.
This educational strategy emphasizes integration of QI tools, brainstorming and fishbone diagram, and systems thinking principles in pre-licensure curriculum. Activities in this strategy have the potential to improve future practitioners’ application of systems thinking in the clinical environment. Additionally, the strategy may broaden thinking about errors with a change in focus from an individual to a systems perspective.