Using Project-Based Learning to Teach Advanced Practice Nurses About Quality Improvement

The universal challenge for clinicians worldwide is to provide safe and quality patient care that is based on the best available evidence. Despite current studies indicating that patients who receive evidence-based care have better outcomes, it is well documented that current care performed at the bedside is not based on the best current available evidence because of the delay from “bench to bedside.”1 Clinical inquiry aims to improve patient safety and quality of care through methodical exploration of a clinically significant phenomenon. So why are advanced practice nurses (APNs) not routinely formulating clinical inquiries in their daily clinical practice?Advanced practice nurses play a critical role in clinical inquiry, as we are able to identify local gaps in practice, processes, or systems that have the potential to negatively affect patient outcomes. Through curiosity about best available evidence, APNs can effectively guide clinical decision-making. Advanced practice nurses also have a perspective from patients about best care given their position at the bedside, bringing the literature and the patient perspective into alignment. Accordingly, a wide range of literature documents improvements in patient care and safety using quality improvement (QI) initiatives that have been developed and implemented by APNs. Therefore, with access to the right tools and education on how to best engage in and perform QI, APNs are poised to improve the quality of care and safety of patients. Despite adequate education, most APNs remain inexperienced in executing clinical inquiry independently in the clinical practice setting. Literature is still lacking on how to most effectively teach APNs in the clinical practice setting about clinical inquiry, specifically QI. Project-based learning (PjBL) is one teaching methodology, based in experiential adult learning theory and grounded in the notion that we as APNs learn better by doing; seeing and participating as a case unfolds in the form of PjBL provides important insights and demonstrates how to succeed in conducting a QI.The purpose of this column is to provide evidence for teaching QI to APNs in the clinical practice setting through the use of PjBL as a teaching methodology for facilitating more effective QI education.Quality improvement uses a systematic approach to distinguishing current practice from best practice and evidence-based practice (EBP). Quality improvement is about identifying gaps in performance in practice, process, or systems within an organization and implementing strategies to improve outcomes related to cost and productivity of work and care, quality of care, patient satisfaction, provider satisfaction, and ultimately patient outcomes. Advanced practice nurses are vital to QI given their presence at the bedside within the clinical practice setting. Regardless of widespread acknowledgement of the importance of QI in the clinical practice setting, it is likely not being used as effectively as possible. The Essentials: Core Competencies for Professional Nursing Education cite necessary competencies related to QI in the nursing scope of practice within broader domains at each education level.2 Among entry-level and advanced-level nursing education, nurses are prepared to participate in and develop initiatives that are aimed at quality and safety. If nurses have the knowledge and skills to participate in and develop QI, why is it not being done or done better?Despite their educational preparation, most APNs are unclear on how to successfully take a QI project from an idea to implementation. Education beyond the academic setting is needed even among doctor of nursing practice (DNP)-prepared nurses.3 To carefully construct a QI project, APNs must accurately identify a gap in their practice, engage with members of the interdisciplinary team and key stakeholders, evaluate the literature to determine best practice, develop a well-constructed plan, implement their plan, evaluate outcomes, and disseminate their findings internally to the organization and externally. Little guidance can be found in the literature on how to teach APNs about QI, particularly in the context of their clinical practice. Studies have shown that a lack of available continuing education and on-the-ground training about QI processes and a lack of mentorship within the practice setting remain barriers to nurses commencing projects.4-6Other barriers to QI exist at the provider and health-system levels; therefore, it is imperative that barriers to engagement in QI be addressed and overcome. Within the literature, barriers to engagement at the provider and health-system levels have included time constraints, heavy workload, lack of educational opportunities and mentorship, and the unique hospital or clinic-based culture.6-8 In addition, there is a notable lack of knowledge and skills among those who are practicing.9 Continuing education and training have been identified as facilitators of QI,4,8,10 and yet, these resources can be difficult to find. Education about QI has been associated with increased knowledge, skills, competency, and QI implementation and is urged by leading professional nursing organizations including the American Nurses Association and its subsidiaries.11Over the past decade, the number of APNs pursuing DNP degrees has grown exponentially. In a recent publication by the American Association of Colleges of Nursing, DNP graduates endorsed applying requisite skills in QI improvement to improve practice, processes, and systems in the clinical practice setting.12 All APNs, regardless of degree, can benefit from continuing to build skills and confidence for executing QI studies. The clinical practice arena provides an opportune setting to support APNs in pursuing advanced skills for improvement science through continuing education—education that provides APNs in the practice setting with the tools necessary to succeed. There is a need to promote the development, engagement, and mentorship of APNs interested in engaging in QI.6Quality improvement education with APNs new to QI at the bedside needs to be fostered, using teaching methodologies that encourage participation in existing projects in collaboration with mentorship with experienced colleagues.3,13 Several methods for teaching QI have been explored in the literature.14 Most methodologies for teaching QI have been explored in the academic setting with little evidence for teaching methodologies that can be applied in the clinical practice setting. Methodologies range from simple to complex, isolated to blended. Those that use active learning have been found to be more effective than traditional teaching methods such as didactic lectures.15Project-based learning is one teaching approach that has the potential to be used in the clinical practice setting to allow APNs to develop the knowledge and skills to execute QI more effectively, thus improving the development, design, and rigor of QI initiatives (Figure). Project-based learning encourages APNs who are novices in QI to collaborate with colleagues who have expertise in the clinical problem of interest. Through a standardized process, APNs obtain guidance and feedback on how to best facilitate nurse-led, evidence-based best practice initiatives. Rooted in constructivism, PjBL is a learner-focused teaching methodology that uses active learning and immersion to convey new knowledge (Figure). Project-based learning challenges the learner to apply theoretical knowledge and skills to real-world experiences in collaboration with faculty and others with expertise in the clinical problem.18 Through experiential learning, students engage in “learning by doing,” using an approach that is hands-on, clinically relevant, and culturally meaningful in the hospital setting.Advanced practice nurses curious about how to successfully develop, implement, and evaluate a QI project using PjBL can adopt a mentor-APN and learner-APN relationship through a professional nursing organization or several practice-based national networks (eg, the American Association of Critical-Care Nurses or the American Association of Nurse Practitioners). Project-based learning in the context of a QI project follows the EBP model with the intention of targeting specific learning goals through formal teaching principles and methods. The 7 steps for implementing PjBL can be sequentially followed, as depicted in the Figure. Through the steps, the mentor-APN provides support and guidance to accomplish successful transfer of knowledge, understanding, and skills while promoting learner-APN independence.19 Operationalization of learning goals for PjBL in QI projects can be found in the Table.Defining the problem is the foundation upon which to develop the QI project. The problem should be an important practice, process, or system issue that is identified, through discussion with other APNs and organizational leadership at different levels, as relevant within the context of the organization. After identification of the problem to be addressed, a broad clinical question should be developed that the learner-APN intends to answer. The initial clinical question will help drive subsequent steps.Sustained inquiry entails a deeper dive into the problem through the discovery and interpretation of relevant literature and iterative revision of the initial clinical question based on the literature.19 The learner-APN should appraise and synthesize the body of evidence related to the identified clinical problem. Accordingly, the learner-APN will formulate substantial conclusions of the most effective approaches to address the clinical problem that is based on the best evidence available. The learner-APN may propose alternative or complementary clinical questions.Quality improvement should be based on conclusive evidence. A key characteristic of authenticity is ensuring applicability within the real-world context.19 Real-world context can be related to quality and safety standards as deemed by regulatory or quality agencies, significance within the organization, relevance to current clinical practice, and vested interest in the clinical problem by the learner-APN.Integration of learner-APN input in the QI project is the basis for voice and choice.19 Development and implementation of the QI project should be based on the ideas of the learner-APN with guidance from the mentor-APN. Voice and choice fosters better learner-APN engagement and accountability within the QI project.Reflection involves learner-APN and mentor-APN self-evaluation of their role and performance within the QI project and evaluation of the outcomes associated with the QI project.19 Self-evaluation may involve specific knowledge and skill attained, quality of work, and barriers encountered with interventions implemented. Analysis of outcome data to determine the effectiveness of the practice, process, or system improvement should also be reflected upon.Methodical assessment of the learning process and the QI project is necessary to evaluate initial goals. Critique allows learner-APN views to be shared and acknowledged.19 Subsequently, the learner-APN is able to apply learned views to the revision of the QI project, resulting in an iterative process of improvement to both the learning process and the QI project.Dissemination of the QI project findings should take place within the organization and externally to achieve learner-APN knowledge translation and practice change. Internally, dissemination of the findings to organizational stakeholders, from unit leadership to hospital leadership, should take place. Externally, dissemination of outcomes can take place through presentation at professional meetings or publication within peer-reviewed journals to contribute to the current literature.Project-based learning is an innovative, evidence-based strategy by which learners are exposed to opportunities and challenges in the health care environment that may not be appreciated using other teaching methodologies. Project-based learning has been associated with improved learning outcomes, critical thinking and problem-solving skills, and competence by solving actual problems in an educational environment using dialogue between faculty and nursing students.20-25 Although little evidence exists regarding its use in the clinical practice setting in the nursing profession, PjBL specifically for QI has been shown to be an effective teaching strategy and increases knowledge and confidence in the academic setting.16,26 Current literature has demonstrated positive effects for PjBL on knowledge, critical thinking, problem-solving, and teamwork, among others.Project-based learning has been used infrequently by APNs in the clinical practice setting. Most QI learning tools offered in the clinical practice setting are executed through isolated didactic lecture rather than “learn by doing.” In contrast to the project-based, layered learning that takes place with PjBL, other QI tools for use in the clinical setting offer “micro-learning” in small, app-based segments.21 One example, BiteSizedQI, a mobile application developed for use by both clinicians and patients, offers small “sound bites” to provide the language and skills necessary for QI in clinical settings.27 Based on principles of Lean Six Sigma, the app shows a series of videos that build low-literacy, user-friendly questions and answers to reinforce content and evaluate learning. Similarly, the Institute for Healthcare Improvement web-based tools offer web-based skills development and online certification using learning modules and post-test quizzes.28 Unlike PjBL, these web-based programs deliver content and validate knowledge achievement without the added benefit of clinical context. Providing the clinical context adds meaningful learning and insight for APNs practicing in the clinical setting. Integration of PjBL into the clinical practice setting for APNs learning about QI should be a considered procedure to ensure accurate and standardized execution of QI can be achieved.Substantial evidence exists for the use of PjBL in the academic setting for teaching QI to nursing students; this experience may be applied in the clinical practice setting when teaching QI to APNs. Project-based learning is an effective teaching methodology for practicing APNs, in that it promotes the transfer of knowledge into clinical practice in a contextually and culturally meaningful way, addressing both the cognitive and psychomotor domains. Successful implementation of PjBL in the clinical practice setting engages the novice and expert APN together in QI and may be particularly advantageous for APNs pursuing clinical inquiry.