Theoretical and Scientific Foundations of Nursing

Nurse Educator

Practice and Quality Improvement Leaders Survey of Expectations of DNP Graduates' Quality Improvement Expertise

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Margaret Hammersla, PhD, ANP-BC; Anne Belcher, PhD, RN; Lucy Rose Ruccio, BSN, RN; Jeff Martin,MBA; and Debra Bingham, DrPH, RN, FAAN

ABSTRACT Background: Input from practice leaders will improve how doctor of nursing practice (DNP) education ismeeting the needs of the employer and improving patient outcomes. Purpose: This article describes the expectations practice leaders have of new DNP graduates' ability to contribute to quality im- provement (QI) efforts within health care organizations. Methods: A survey of practice leaders and QI experts investigated the importance and use of QI knowledge and skills. Practice leaders were also asked about the expectations of DNP graduates at the time of hire. Results: The results of this study support the need for nurses pursuing a DNP in advanced nursing practice to have education and training beyond their area of specialization, specifically in QI methods and tools. Conclusions: Faculty need to provide DNP students education that includes concepts in QI and leadership to meet the expecta- tions of future employers and the needs of a complex and changing health care system. Keywords: DNP program, doctor of nursing practice, employer, health care organization, quality improvement

Cite this article as: Hammersla M, Belcher A, Ruccio LR, Martin J, Bingham D. Practice and quality improvement leaders survey of expec- tations of DNP graduates' quality improvement expertise. Nurse Educ. 2021;46(6):361-365. doi: 10.1097/NNE.0000000000001009

T he focus of the doctor of nursing practice (DNP) degree is intended topreparenurses to translate re- search into practice and develop and lead imple-

mentation efforts that will improve the quality of health care, whereas a PhD degree is intended to prepare re- searchers who are able to identify new interventions and strategies to address health care needs.1 Indeed, the need for the DNP degreewas supported bywidespread recogni- tion that there is a need for practice leaders who have the knowledge, skills, and attitudes to more effectively and

r Affiliations: Assistant Professor (Dr Hammersla), College of Nursing, na State University, Bozeman; Associate Professor (Dr Belcher), School cation, Johns Hopkins; and DNP Graduate Research Assistant (Ms o), Business Improvement Analyst (Mr Martin), and Associate Professor ngham), School of Nursing, University of Maryland Baltimore, Institute rinatal Quality Improvement, Quincy, MA.

ng was provided by the Maryland Health Service Cost Review ission, Nurse Support Program Grant managed by the Maryland r Education Commission.

uthors declare no conflicts of interest.

spondence:Dr Hammersla, Montana State University PO Box 173560, an, MT 59717 ([email protected]).

emental digital content is available for this article. Direct URL citations r in the printed text and are provided in the HTML and PDF versions of ticle on the journal’s Web site (www.nurseeducatoronline.com).

ted for publication: January 27, 2021

hed ahead of print: March 12, 2021

10.1097/NNE.0000000000001009

Educator • Vol. 46 • No. 6, pp. 361–365 • Copyright © 2021 Wolters Kluwer Heal

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efficiently translate research into practice. The Institute of Medicine (IOM) highlighted research that described a 17-year gap between the publication of research findings and translation of that research into practice.2 In addition, the Hastings Center, a national health care ethics think tank, formed a quality improvement (QI) expert panel em- phasizing that QI needs be intentionally and strategically implemented. The IOM later released Health Professions Education: A Bridge to Quality, which stated: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasiz- ing evidence-based practice, QI approaches, and infor- matics.”3(p3)

These data and recommendations have helped support the rapid growth of DNP education in the United States. In 2006, as an example, theUniversity ofMaryland School of Nursing's (UMSON's) DNP program opened and was one of the first in the nation. There are nowDNPprograms in all 50 states as well as the District of Columbia.4

Ninety-eight newDNP programs are in the planning stage nationally.4The expansionofDNPprogramshasoccurred at the same timeas the rapid evolutionof the fieldsof imple- mentation and improvement science.

AsDNP education expands and evolves, there is a recog- nition that there are limited data on the impact ofDNP grad- uates on health care structures, processes, and outcomes.5

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The Quality and Safety Education in Nursing (QSEN) DNP task force was formed to begin to answer this and other questions.5 As a first step, Tovar et al5 conducted a survey of 117 faculty who teach in a US DNP program and 30 DNP students. Two findings with statistically sig- nificant agreement among DNP faculty and graduates were that nurses have an important role in a hospital's QI efforts, and employers expect DNP graduates to be prepared to facilitate health care transformation in their setting.5 A related finding, which did not reach statistical significance, was that faculty were more likely than DNP graduates to strongly agree that employers expected grad- uates to be prepared to participate in, but not lead, QI ini- tiatives. This finding highlights the need for more research to identify the level and type of QI preparation that em- ployers desire among DNP graduates.

The Commission on Collegiate Nursing Education ac- creditation standards include recommendations that edu- cation programs include the community of interest at several points in program development, implementation, and evaluation. Some schools have developed formal academic-practice partnerships to strengthen relationships and obtain needed feedback. The AmericanAssociation of Colleges of Nursing (AACN) has created a toolkit to pro- vide support for how to form these partnerships. This toolkit includes guiding principles for building successful partnershipsandrecommends that theybemutuallybenefi- cial and serveas“amechanism for advancingnursingprac- tice to improve the health of the public.”6 Most of the literature on academic-practice partnerships is focused on prelicensure education. These partnerships are a mecha- nism for schools to increase dialogue and gain insights that ensure ongoing coordination between health care system leadership and the faculty responsible for the DNP curriculum.

Inputfrompracticepartnerswill likelyimprovetheeval- uation of how current DNP education is meeting the needs of theemployerand improvingpatientoutcomes.Yet, there is limited research that describes how practice partners in- form DNP curricular decisions and strengthen the rigor of DNP programs. Dols et al,7 in an online survey of 90 DNP program directors, found that locating and accessing sites and agencies thatwould allow students to conduct projects were challenging. Issues included finding responsible prac- tice mentors and allowing students to implement projects during a predetermined time frame.7 A project was usually well accepted if itwouldmakea significant difference to the site and patients served. Program directors indicated that developing a partnershipwith the site enhanced the experi- ence for all.7 VanderKooi et al8 conducted a study using an enhancedactualizedDNPmodelgeneratedbyBursonetal9

to address project placements, rigor, and completion. They discovered that implementation of the model resulted in, amongothereffects,highsatisfactionforstudents,mentors, and faculty, and a stronger academic-practice partnership reflected in additional student placements.8

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Therealsoare limiteddataandconsensusonthespecific QI and implementation knowledge, attitudes, and skills of faculty to guide DNP students. The QSEN Institute pub- lished Graduate Level Competencies in 2012.10 However, these are geared for all graduate nurses and not specific to doctorate education or the DNP degree specifically. DNP Essential II requires thatgraduatesbeproficient inQI tocre- ate sustainable organizational change.11 Durham et al12

published a review of the literature on the QI knowledge of DNP faculty that aligns with practice partner goals and prepares students to lead health care transformation. The major categories of QI content were: (1) faculty's knowl- edge of measurement and monitoring improvement, sus- tainability, spread and scaling, and reporting; (2) faculty development; (3) and a team model to address growth in programs.12

There is consensus that QI and implementation/ translation science need to be included in DNP education and that school of nursing faculty, and students benefit from strong academic-practice partnerships. There are limited data available that provide insights into em- ployers' expectations of DNP graduates. There are also conflicting data as to the role DNP graduates should per- form related to QI in health care. Our review of the liter- ature indicated that more research is needed to describe the expectations of practice partners who support DNP programs and how these expectations are related to the specific QI knowledge and skills inwhich employers want DNP graduates to be proficient.

Purpose The purpose of this study was to describe the expectations of practice partners and health care leaders of new DNP graduates' ability to contribute to QI efforts in health care organizations. The goal of this work is to support local andnationalefforts to identifypracticeexpectations related toQIknowledgeandskillsamongDNPgraduates.Thisun- derstanding will inform curriculum development and will allowDNPgraduates toenteraworkforcepreparedtocon- tribute in an immediate and meaningful way, reducing onboardingcostsandpotentially improvingshort-termem- ployee satisfaction and retention.

Methods This inquiry was conducted in 3 phases. All phases of the research were reviewed by the University ofMaryland In- stitutional Review Board and deemed non–human sub- jects research.

Phase 1: Online Survey of Practice Leaders' Perceptions A survey of practice leaders working in health care organi- zations in the Baltimore/Washington area hospitals that employ 1 or more DNP graduates was conducted to deter- mineemployers'perceptionsof (a)DNPgraduates' training in QI, leadership, area of advanced nursing practice, and translation of this knowledge and these skills into their

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work environment and (b) employer expectations of DNP graduates with regard to their role in QI and the degree to which theymeet these expectations.

The phase 1 practice leaders' perceptions survey asked respondents to rank a variety of QI skills and strategies in level of importance to their organization. The survey builds on and includes several questions from a survey conducted earlier that explored the QI expertise of faculty teaching in theUMSONDNPprogram.13Thequestions fromthat fac- ulty survey were included in the phase 1 survey because of their common relevance in shaping professional develop- ment education in the areas of QI and implementation sci- ence. To establish content validity, the survey was reviewed by 3 faculty members with experience in DNP education.

Thephase1 surveywasadministered toa targeted con- venience sample using an online survey platform. The sur- vey was emailed to 97 health care practice leaders in the area who have hired DNP graduates since 2016. Returned surveys were deidentified, and the findings reported in aggregate.

Phase 2: Online Survey of QI Experts' Perceptions On completion of the first online survey, a second survey wassent to55localandnationalQIexperts torankthe level of importance and frequency of use of common QI skills and strategies. The same list of QI knowledge and skills from the phase 1 survey was used for the phase 2 survey. In addition, the participants were asked about how fre- quently they used those knowledge and skills in their own QIwork.

The goal of the phase 2 survey was to compare em- ployers' opinions of the importance of various QI topics with those of experts in the field. The survey was also ad- ministered using online survey software. Returned surveys were deidentified, and the findings reported in aggregate.

Phase 3: Focus Group to Explore Practice Leaders' Perceptions Oncompletion of both online surveys, 2 focus groupswere conductedwith employers ofDNP graduates to further ex- plore practice leaders' perception of QI expectations. The first focus groupwas face-to-facewith 3 health care agency leaders, and the second was held via Zoomwith 7 leaders. Both sessions were recorded for the purpose of creating deidentified transcripts of the discussion. The focus groups utilized a loosely structured format. After introductions, participants were asked about their use of key knowledge andskills inQI,experiencewithDNPgraduates,andassess- ment of DNP graduates' expertise with QI and leadership. Participantswerealsoaskedtoprovidefeedbackonthepro- gram outcomes based on current and future needs of the practice settings. Participants in the focus groups included primarily chief nursing officers, vice presidents, directors of quality and safety, and others at the vice president or di- rector level fromlargeacademicmedicalcentersorcommu- nity hospitals.

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Results Phase 1: Practice Leaders' Perceptions Seventeen individuals completed the survey and are in- cludedintheresults (18%responserate).Surveyresultsrep- resent responses fromlargeacademicmedicalcenters (n=4, 23%), community hospitals (n = 10 [59%]), continuing care retirement centers (n = 1 [6%]), academia (n = 1 [6%]), and integrated health delivery systems (n = 1 [6%]).

With regard to expectations of DNP graduates for en- gagement in QI process, the majority of employers (n = 9 [52%])ofDNPgraduates expect themto independentlyde- velop QI ideas and then work with senior managers in de- veloping and implementing plans for QI. Respondents indicated the level of importance to their organization of an in- ventory list of QI skills and strategies. The skills and strategies that were most frequently rated as very important included ethical considerations in QI (n = 14 [82.4%]), safety in health care (n = 14 [82.4%]), and implementation strategies and tac- tics (n = 13 [76.5%]). The QI skills and strategies that were most frequently rated as not important were driver diagrams (n = 2, 11.8%) and logic models (n = 2 ]11.8%]) (see Supple- mental Digital Content, http://links.lww.com/NE/A921, Table 1, for complete information on responses).

Phase 2: QI Experts' Perceptions Eighteen individuals completed the survey (40% response rate)with2individualsnotprovidingratingsforeveryques- tion. Respondents indicated the level of importance of the same inventoryofQI skills and strategies to conducting rig- orousQI projects. TheQI skills and strategies thatmost of- ten received a ranking of very important were safety in health care (n = 14 [82.6%]), data collection and analysis (n=12 [70.6%]), and implementation strategiesand tactics (n=12[70.6%]).Theskills/strategiesofQIprojectaimsand safety in health care were rated as either very important or important by 100% of respondents. The skills rated most frequently as not important were driver diagrams (n = 4 [23.5%]) and logicmodels (n=5 [29.4%]) (see Supplemen- tal Digital Content, http://links.lww.com/NE/A922, Table 2, for complete information on responses).

TheQI skills and strategies thatweremost often rated as always used included data collection and analysis (n = 14 [77.8%]), QI project management (n = 13 [76.5%]), and implementation strategies (n = 11 [64.7%]). Safety in health care and team building were also highly ranked concepts, with 100% of respondents rating them as al- ways used (n = 9 [53%]) or often used (n = 8 [47%]). Driver diagrams and logic models received the lowest use ratings with 29.4% (n = 5) and 35.3% (n = 6) rating them as rarely used (Supplemental Digital Content, http:// links.lww.com/NE/A923, Table 3, has complete informa- tion on responses).

Phase 3: Focus Groups Thefocusgroupsincluded10employersrepresenting5area hospitals. Issues identified regarding new DNP graduates included their lack of leadership experience, experiencewith

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system-level operations of a hospital, and understanding of how QI works in a health care setting. In addition, as stu- dents, they go to the setting with projects that are important to them, whereas it would be more advantageous to them and to the agency if they joined a project already in progress.

One leader described the use of a nurse scientist in her setting who decides whether the student has a project that is in linewith the agency's vision andmission so the student has a meaningful experience and the agency benefits from the project. Another leader, who is contacted directly by the DNP student, arranges for herself, her director of qual- ity, and the clinical educator to meet with the student and determine if the proposed project is in line with the needs of the agency and if it is sustainable. This leader also hired acoordinator toworkwith the faculty to identify thenature of the project, support that the student will need from the agency, and support given by the nursing program. That support might include equipment or personnel, which has tobefactoredintothebudget.Whenaparticularhealthcare setting cannot provide the needed resources, the nursing programmay have to support the project financially.

The leaders in both focus groups viewed a list of tools, skills, and concepts to identify which ones are used in their setting. Many of the leaders cited their first choice as the QI project charter and the second choice as data collection and analysis. Specific comments with regard to the charter are that it includes defining scope, which is a vital aspect of the project, and gives direction and a template for consistency.

The leaders also discussed a high-reliability organization, human error theory, and error proofing.With regard to lead- ership, even though the students are professional in presenting and involving the stakeholders in their project, they lack the knowledge and experience to lead groups onQIprojects. Stu- dents need to understand trended data, evidence-based prac- tice, and measurement. For example, one leader commented that students often want to develop their own tools rather than to use existing valid and reliable instruments.

Discussion The results of this study support the need for nurses pursu- ing a DNP in advanced nursing practice to have education and trainingbeyond their areaof specialization, specifically in QI methods and tools. Practice partners who are hiring DNP-prepared nurses are expecting them to be leaders in the organizations and contribute to the organization's mis- sion beyond providing direct patient care. Data from the sur- veys and focus groups indicate that practice leaders who hire DNP graduates expect them to, at a minimum, identify QI areas on which to focus to improve health care structures, processes, and outcomes. These data also suggest that prac- tice leaders want DNP graduates to be part of the QI project implementation team.These expectations are consistentwith the DNP Essentials (II) that states nurses graduating from a DNP program should have expertise in analyzing organiza- tions, identifying issues within a system, and facilitating organization-wide changes in the delivery of quality care.11

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However, the practice leaders reported that new DNP graduates often lacked the level of leadership experience and understanding of how to implement QI within a com- plex organization that was needed. From a curricular stand- point, this finding supports the need for students to have a targeted leadership practicum experience to supplement their clinical courses. In particular, these data suggest the need for schools with DNP programs to include more education about organizational systems and how to de- velop and lead QI projects. The use of QI methods and tools as the basis of the DNP project supports students in acquiring skills that will enhance their ability to de- velop and implement improvement initiatives. For exam- ple, DNP QI projects provide the student with the opportunity to apply theoretical learning about leader- ship, organizational theory, and their area of advanced prac- tice in a real-world setting. This also is supported by the AACN White Paper that recommended that the DNP project focus on a change that impacts health care out- comes and has a system or population focus.14

Ourdata fromall phases of the studyalso indicate there was strong agreement that the ability to developQI project aims is of high level of importance. The practice leaders in- dicated that DNP graduates should be able to clearly de- fine and communicate the scope and purpose of the DNP project aims and how they relate to the organization's mis- sion and vision.

Althoughtherewasanagreementon the relative impor- tance of the majority of topics, there was considerable dif- ference in the importance of driver diagrams and logic models, with the QI experts rating them as less important than did the practice partners. Driver diagrams are used to help the QI leader and team identify improvement priori- ties. Logicmodels help show the relationship among goals, resources, activities, and outputs. These 2 tools are particu- larlyuseful foranorganization's leaderstogaininsights into the structures, processes, and outcomes that need to be im- proved. However, the use of these tools may be beyond the scope ofQI professionals' normalwork,whichmayex- plain the lower ranking comparedwithQIexperts. It is also possible that as many current QI professionals did not re- ceive formal education in QI frameworks and tools, they are not as familiar with these tools and have their own way of working through these processes. More research is needed to fullyunderstandwhyQI experts rated these tools of lower importance than the practice partners.

Thesefindingssuggest thatDNPprojectscouldbebetter coordinated with the project site leaders and their team members as much as practical. Better coordination could help students focus on solving the problems identified by the practice leaders.

Limitations There were a few limitations to the study. First this was a small convenience sample with a low response rate of indi- viduals invited to participate. However, the leaders included in the surveys and focus groups represent the major health

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care organizations in the Baltimore/Washington, DC, area. These leaders hire DNP graduates from multiple schools in the area. The expectations of leaders in other large urban areas are likely similar. Finally, the majority of the partici- pants were from large hospitals with limited representation from smaller hospitals and no representations of DNP graduate expectations in primary care and other outpa- tient care settings. Our data also showed that QI experts agreed in most instances with the findings from the QI leader survey findings.

Conclusion Further research should focus on how to build more effective academic-practice partnerships related to DNP projects. One way to enhance these relationships is for faculty to adjust cur- riculumwhenpossible to bettermeet the needs of their practice partners.A survey is an effectiveway for faculty to learnwhich skills and knowledge their practice partners find to be of greatest importance. If faculty disagree with the priorities of their practice partners, they can also use these findings to iden- tify areas where there is need for ongoing dialogue. Stronger academic-practice partnerships will support the ability to achieve the common goals of ensuring patients and popula- tions have access to evidence-based structures and processes that have been shown to improve outcomes. Faculty and stu- dents need tobegin theprojectwith collaboration, partnership, and sustainability in mind.

Better understanding what expectations of graduates are whenhired by health care organizationswill allowDNPpro- grams to prepare students to contribute in meaningful ways to the health care system. Nurses are expected to be systems thinkers and need the knowledge, skills, and abilities for them to not only care for individual patients but also work within complex organizations to create systematic changes that will improve patient outcomes on a population level. Faculty need to provide DNP students with an educational experience that includes concepts in both QI and leader- ship to meet the expectations of future employers and the needs of a complex and changing health care system.

Acknowledgments The authors acknowledge the hard work and dedication of

the AdvISE Steering Committee.

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