Do new nurses have QI skills, understanding?

One study says no

She watched the young nurse getting chastised for making an error and could see the fear in her face as her manager's voice rose in anger. The young nurse was put on indefinite leave. That's what happens when you make mistakes, she thought to herself.

According to two authors of a recent study, this is not what new nurses should think or see as an example of making an error, or reporting one. In a new study — "New nurses' views of quality improvement education" — published in the Jan. 10 issue of The Joint Commission Journal on Quality and Patient Safety, 38.6% of novice nurses responded that they were "poorly" or "very poorly" prepared from their education to implement quality improvement measures.1 The study was funded by the Robert Wood Johnson Foundation.

Nurses were surveyed in December 2008, having graduated between Aug. 1, 2004, and July 31, 2005. They were asked about specific quality improvement vocabulary and techniques, whether they were engaged with them or familiar with them. Questions included: How prepared or unprepared were you by your basic nursing program in the following quality improvement areas:

  • patient-centered care;
  • teamwork and collaboration;
  • evidence-based practice;
  • safety;
  • restraint and seclusion;
  • infection control;
  • pain management;
  • using appropriate information technology or strategies to reduce reliance on memory;
  • hazards to patients and/or families;
  • using organized error-reporting systems for near-miss and error reporting;
  • participating in analyzing errors and designing system improvements.

Christine T. Kovner, PhD, RN, FAAN, professor of nursing at the NYU College of Nursing and author of the study, says, the report shows that 46% of the nurses studied had never participated in a root-cause analysis. "That's almost half of these nurses who've been working for three years have never been part of such a process," she says.

The respondents also showed unfamiliarity with using appropriate technology. "We have a very sophisticated patient information system that we've had for 30 years with mandatory physician order entry. But students are not allowed to use the system. Because the students are only there for 15 weeks, they can't get an IV and go through orientation, and I think that's not uncommon, and I think hospitals should again rethink that," says Kovner.

She's also seen new nurses harshly criticized by managers when an error is made. "That's of course not the role modeling that we want our students to get... We teach at NYU about no-fault error reporting. And then they go out and they hear about and see people who made errors who were put on leave or fired or lashed out at," Kovner says, which neither empowers new nurses to speak up if they see errors or to report an error if they make one.

"So the question I guess I have is if they didn't do this and they say they're not doing it at work, are they not doing it at work because they didn't learn it in school or are they not doing it at work because hospitals aren't doing it or hospitals systematically don't include new nurses in these processes?" Kovner says.

"And I think another implication, it's not something we even talked about in the article, but another implication is what is the culture of the hospital that nurtures the critical thinking it takes to analyze systems and find problems and fix problems? How do they inculcate that kind of thinking in their new graduates, their new nurses? Because it's got to start early and go all the way up the organization," adds co-author Carol S. Brewer, PhD, RN, professor of nursing at the school of nursing, University at Buffalo and the director of nursing for the State Area Health Education System Statewide Office.

She adds that empowering novice nurses to speak up and being brought into and contribute to QI processes "takes some very deliberate work on the part of the employer."

It's the chasm between educational experience and real-world experience. Kovner says much of the faculty in nursing programs are in their fifties. "So that means they went to school 30 years ago for their undergraduate program and maybe 25 for their master's. But people weren't talking about quality improvement then... I suspect that many of the faculty don't know quality improvement," she says.

She suggests patient safety and quality improvement officers come in to the classroom and talk to students. "And that's where we think there's an important opportunity for the educational programs and the hospitals to get together about what they're teaching in both places and how the hospitals, particularly, when the students have their clinical experience there, can participate in and help the students have clinical experiences related to quality improvement. And to me that seems like the perfect opportunity for the quality improvement officer or the patient safety officer," she says.

"My guess is that the patient safety officer has nothing to do with the education department in the hospital, which is responsible for working out the clinical practice experience for the students and the orientation for new nurses. That those are just separate worlds," that should be better aligned, she says.


  1. Kovner, C.T., Brewer, C.S., Yinqrenqeung, S., Fairchild, S. New Nurses' Views of Quality Improvement Education. Jt Comm J Qual Patient Saf. Vol. 36, No. 1., pp. 29-5AP.