Front-line nurse managers are ideally positioned and expected to lead such efforts, but gaps in their QI education and participation prevent them from realizing their full potential for doing so, according to a new study.

Maja Djukic, PhD, RN, assistant professor at the College of Nursing
Maja Djukic, PhD, RN, assistant professor at the College of Nursing



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Low levels of QI training don’t match high expectations for early-career nurse managers.


Achieving the triple aim in U.S. health care—­­­­­better population outcomes, better patient experience of care, and lower per capita costs—won’t happen without engaging nurses, the nation’s largest group of health care providers, in quality improvement (QI) efforts. Front-line nurse managers (FLNMs) are ideally positioned and expected to lead such efforts, but gaps in their QI education and participation prevent them from realizing their full potential for doing so, according to a study published in the Journal of Nursing Administration.


The study—part of the RN Work Project, funded by the Robert Wood Johnson Foundation (RWJF)—focused on early-career FLNMs (those with head nurse or assistant head nurse roles, who have been in practice as a registered nurse [RN] for less than four years). It found that fewer than one in three (30%) reported being very prepared with QI skills by their nursing education programs or employers. While more than half reported having good organizational support for QI, just 35 percent reported participating in a specific clinical QI effort aimed at improving patient care on their units more than once a month, and only around 30 percent reported being rewarded for their contributions to QI.


The research team included Maja Djukic, PhD, RN, assistant professor at the College of Nursing, New York University; Christine Kovner, PhD, RN, FAAN, Mathy Mezey Professor of Geriatric Nursing at the College of Nursing, New York University; and Carol Brewer, PhD, RN, FAAN, UB Distinguished Professor at the School of Nursing, University at Buffalo. Kovner and Brewer direct the RN Work Project.


“We can’t close the gaps in quality improvement without a better understanding of what the educational gaps are in the nurse manager population, because nurse managers are formally charged with leading the delivery of patient care,” said Djukic. “There hasn’t been a clear picture of what’s missing for front-line nurse managers in the United States, and this study is an important step forward in identifying gaps and strategizing about effective responses.”


“Correcting imbalances between what front-line nurse managers are prepared to do and what they’re expected to do, in terms of quality improvement, could be a transformative moment in our national health care journey,” said Kovner. “We are not yet where we want and need to be in improvement goals. Nurses at all practice levels, led by front-line nurse managers, are poised to make important progress on multiple issues, particularly hospital-acquired conditions, readmissions and patient satisfaction.”

The cross-sectional survey study includes analysis of a subset of longitudinal survey data from a national study of early career nurses. A subsample of respondents who reported working in hospitals was surveyed in 2008 and 2009 on quality and safety, and the 42 respondents who identified as head nurses or assistant head nurses make up the FLNM sample.


The Quality Improvement Survey was developed in collaboration with content experts including an adviser from the Quality and Safety Education for Nurses (QSEN) initiative, also funded by RWJF. The research team for the FLNM study noted that managers in the sample attended pre-licensure education programs before QSEN started, which could contribute to the generally low levels of quality and safety preparedness reflected in the study.


Researchers identified two areas that need significant improvement: repeating the improvement cycles, which involve measuring current performance, assessing gaps in practice, applying QI tools and methods to address those gaps, and measuring changes until desired improvements are achieved; and monitoring sustainability of improvements. They also recommended teaching FLNMs about root cause analysis, using national patient safety resources, and using information technology and strategies (such as personal digital assistants and checklists) that help reduce the mental demands of work, such as relying on memory.


“The study helps convey an important message for health care executives,” Brewer said. “Quality improvement efforts don’t rely solely on nurses and other providers; they also rely on managers. And even in hospitals where front-line nurse managers feel encouraged to lead on quality improvement, and where they feel supported with quality improvement resources, they still need meaningful incentives and rewards to help build the momentum needed to make quality improvement breakthroughs nationally.”


The study’s authors recommend several resources executives can use to boost FLNMs’ preparedness for QI, including those offered by QSEN, Clinical Microsystems, the Institute for Healthcare Improvement, Transforming Care at the Bedside, the Center for Care Innovation and Transformation, the Integrated Nurse Leadership Program, and the Clinical Scene Investigator Academy.


The RN Work Project is a 10-year study of newly licensed registered nurses that began in 2006. It is the only multi-state, longitudinal study of new nurses’ turnover rates, intentions, and attitudes—including intent, satisfaction, organizational commitment, and preferences about work. The study draws on data from nurses in 34 states and the District of Columbia, covering 51 metropolitan areas and nine rural areas.


About New York University College of Nursing
NYU College of Nursing is a global leader in nursing education, research, and practice. It offers a Bachelor of Science with major in Nursing, a Master of Science and Post-Master’s Certificate Programs, a Doctor of Nursing Practice degree and a Doctor of Philosophy in Research Theory and Development. For more information, visit

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit  



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