Why It Matters
"Improvement skills are like muscles. We all have them, but we don’t always use them to their fullest potential."
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Why Nurses Are Meant to Be Improvers

By Jennifer Lenoci-Edwards | Friday, May 6, 2016

Why Nurses Were Meant to Be Improvers

Imagine you’re an ED nurse, and a hypotensive patient has just arrived via ambulance.

First, you think about potential causes of the low blood pressure. The paramedics give you a clue: they found her on mile 23 of the Boston Marathon route with a running bib on. Suspecting she’s dehydrated, you give her fluids and continuously monitor her condition to see if you should continue or change your treatment course. If the fluids don’t work, your team might explore different causes by trying other treatments until you see improvement.

As an ED nurse myself, I’ve been through this algorithm countless times with countless conditions. If you’re a clinician, you probably have, too. But what you may not know is that applying the science of improvement isn’t so different.

Lately, it’s dawned on me that nurses know more about improvement than they often realize. Although we sometimes use different terminology, quality improvement embraces many concepts we learned in nursing school and use every day on the job.

In the table below, you can see this clinical example alongside a team-based example of a quality improvement project. In the quality example, the problem you want to improve is not the illness of an individual patient, but the goals are still the same:

  • Engage the team
  • Look for the root causes of the problem
  • Create a prediction and a test to address the problem at hand
  • Follow up with further action until you see improvement

Here are some parallels between bedside nursing care and common components of an improvement project:


Hypotension in one patient

Post-op surgical site infections

Possible Root Causes

Bleeding, medication, and dehydration

Handwashing and antibiotic timing

The team

Nurses, doctors, and other allied health professionals

Pre-surgical and surgical teams

Prediction and Test

Patient is dehydrated. Administer fluids.

Antibiotics are not being timed appropriately before surgery. Give antibiotics to prevent infection.

Real-Time Quantitative Measurement

Blood pressure and heart rate

Antibiotic timing

Qualitative Measurement

Patient complaints, such as dizziness, headache, and nausea

Team concerns about process, such as time and effort required

Constant Assessment and Follow-Up

Did the BP stabilize?

Did it get worse?

Reassess and test next protocol.

Did increased reliability of antibiotic timing decrease surgical site infections?

The same thinking applies in all care settings. For example, in a primary care setting, you might be working to reduce vaccination errors. As you consider the root causes of the problem, you learn that the vaccine fridge is a mess. You engage the team to determine how to best organize it to minimize errors and monitor whether the error rate is improving with quantitative and qualitative real-time data. You repeat the process until you’re happy with the results.

Just like with PDSA cycles, you are assessing and re-assessing real-time data to determine improvement, stabilization, or decline. Based on this information, you continue your course of action or consider other possible causes for the patient or system problem and test something else.

Strengthening Nurses’ Improvement Muscles

I love being a nurse. It’s the best career choice I ever made. I’m grateful for all of the special moments patients have allowed me to share. But I’m also frustrated that the clinical teamwork and testing that helps us save individual patients hasn’t been ingrained into our daily workflow for solving problems on a larger scale.

Improvement skills are like muscles. We all have them, but we don’t always use them to their fullest potential. Sometimes, we lack the knowledge, training, and disciplined practice to fully flex them and make them stronger. Flexing this muscle more regularly everywhere we work could help us improve our joy in work, our patient outcomes, and our daily lives.

So, I challenge nurses all over the world to think about the next quality problem you encounter as you’d approach an ailing patient. What’s causing the problem? What changes might lead to an improvement? What can you test, right now, to see if it makes a difference? What data or feedback can you use to learn whether you should stay the course or make a change?

Let’s train our improvement muscles, and get stronger, so we can work together to make sustainable change.

Jennifer Lenoci-Edwards is the Director of IHI's Patient Safety Focus Area.


You may also be interested in:

Transforming Care at the Bedside How-to Guide: Engaging Front-Line Staff in Innovation and Quality Improvement

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