Embedding a nursing service improvement culture has been a focus of successive UK policy initiatives (Craig, 2018), such as the NHS Safety Thermometers scheme (NHS Improvement, 2017), the 2012 nurse-led quality framework Energise for Excellence, High Impact Actions for Nursing and Midwifery (NHS website, 2010) and the NHS Productive Series (NHS website, 2020). However, information about how nurses develop and sustain service improvement skills beyond their initial education is lacking.
Service improvement can be defined as ‘the combined efforts of everyone to make changes, leading to better patient outcomes (health), better system performance (care) and better professional development (learning) regardless of the theoretical concept or tool utilised’ (Batalden and Davidoff, 2007:2).
In 2007, a national initiative to embed this learning in undergraduate programmes created many opportunities for pre-registration nursing students to develop these skills (Johnson et al, 2010). Students involved in the initiative evaluated it very positively and subsequent studies suggest it enhanced their understanding of the practicalities of implementing service improvement activity (Machin and Jones 2014). Johnson et al's (2010) study suggested that resistance from staff, lack of time and student status were barriers to the success of students' service improvement efforts. Despite challenges, service improvement learning and the opportunity to improve the patient care experience is valued by pre-registration students (Smith and Lister, 2011), with classroom-based sessions seen as beneficial for learning (Baillie et al, 2014; Smith et al, 2014). Educational programmes encompassing service improvement have helped prepare student nurses to make changes in practice when qualified (Machin and Jones, 2014; James et al, 2016). However, little is known about the sustainability of this learning.
Aim
This study aimed to understand service improvement experiences of undergraduate adult nursing students in their final year of university and up to 12 months into their graduate practice. The following research questions were posed:
Method
A longitudinal hermeneutic phenomenological design was used to explore participants' perceptions of their pre- and post-qualification experiences of service improvement in nursing. Phenomenology was appropriate as a research methodology because it seeks to understand particular phenomenon as it is lived by participants.
Sampling from five to 25 participants is often suggested for qualitative research methodologies, which include phenomenology. A longitudinal hermeneutic study carried out by Standing (2009) explored the experiences of transition from student to registered nurse. Following the post-qualifying period, there was 50% attrition. This helped inform the decision to include 20 participants in the present study, a sufficient number to enable rich data collection and allow for potential attrition during phase 2 (there were 15 participants for phase 2, an attrition of 5).
Participants had completed a service improvement module as part of their second-year education programme, where they engaged with service improvement, explored theoretical improvement methodologies and appraised via a written assessment of their experiences.
All participants' placements were in the NHS trust that was likely to be the location of their first staff nurse job. This was important to enable post-graduate follow-up. The 20 students gave consent to be individually interviewed twice, once as a student and again in their first year of being qualified.
An interview schedule was developed to facilitate semi-structured interviews in both phases of the study. Robson (2011) suggested that interview schedules should incorporate an introduction, a focused lead question and several key questions or prompts:
Each participant was asked the same opening question and the same final question.
Forty interviews lasting 30-45 minutes were undertaken by the lead researcher (LC) at the university, digitally recorded and transcribed verbatim. Digital and written data were stored in line with data protection policy. Data were analysed using a phenomenological, hermeneutic circle approach (van Manen, 1990), comprising three stages (Lindseth and Norberg, 2004), and the process was informed by re-reading the relevant literature:
Researcher understanding of participants' experiences was checked with them throughout data collection. Member checking occurred with participants concurrently as part of each interview during both phases.
A transparent audit trail of researcher decision-making ensured that the study and its results were trustworthy (Guba and Lincoln, 1994).
Ethical permission
Ethical permission was given by the university's ethical approval committee and the research development department at the participating NHS trust.
Findings
van Manen's (1990) six-step approach was used because it was congruent with the research methodology and is conducive to analysing hermeneutic phenomenological data. Although there are six steps, the process undertaken was not linear and the lead researcher (LC) frequently returned to the hermeneutic circle for naive reading, re-reading and interpretation of the transcripts throughout each stage of analysis (Table 1). Gadamer (1979) supports this approach, suggesting that movement between the six activities, forward and backward, allows researchers the time to consider, reconsider and reflect on the parts and the whole. It is through these activities that the researcher can fully engage in the hermeneutic circle and enabled them to identify convergent and divergent viewpoints.
| Activities of data analysis | Application of activity to study | Hermeneutic circle, research journal notes and reflexivity |
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| Turning to the phenomenon of interest |
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| Investigating experience as we live it |
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| Reflecting on essential themes that characterise the phenomena |
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| Describing the phenomena: the art of writing and rewriting |
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| Maintaining a strong and orientated relation to the phenomenon |
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| Balancing the research context by considering the parts and the whole |
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Four overarching themes emerged from the hermeneutic data analysis of the participants' (Figure 1):
Service improvement learning in nursing
Service improvement in nursing was an overarching theme incorporating subthemes, such as a personal understanding of service improvement, seeing a need for service improvement, micro and macro perspectives of service improvement and linking theory to practice. It was evident in the findings that all participants had socially constructed an understanding of service improvement and were able to give a definition of what this meant to them. The findings illustrated that participants had experienced service improvement both in university and in their clinical practice.
As students, they conveyed their understanding of service improvement, citing their rationale, and applied theoretical models and different approaches for the process:
‘[Service improvement] means trying to improve and change the service so patients have a better experience, an overall experience’
Another participant also identified a patient-focused rationale for service improvement:
‘[Service improvement is] changing any service or [a] service that you give to patients, so it could be an intervention or some other way care is given or organised’
This understanding stayed with the newly qualified participants; however, they talked about their nursing role in service improvement in a more personalised way, recognising the scope of the contribution they could make as individual newly qualified practitioners:
‘Looking back, you gain knowledge and skills as your career progresses. You don't want to go in with a huge service improvement, just start little and build up. I have used some of the theory about change and PDSA [plan, do, study, act]. I am always reflecting and learning’
Another talked about the importance of having service improvement confidence, despite being newly qualified and still on a learning journey:
‘I am still learning, but if you have a good idea about something, having the confidence to go with it, giving reasons and rationale as to how and why you want to do it, to improve the patients service’
Several participants described service improvement opportunities within the preceptorship period as consolidating their learning:
‘As part of preceptorship I did service improvement. We have the knowledge and skills framework, which we have to work towards. Without learning, you would never be getting to best practice. I think, if you don't look for how you can improve your service, you don't improve things for your patients’
Several of the new registrants recognised that, as lifelong learners, there may be a time when they would need to refresh their understanding of service improvement learning theory, for example:
‘If I was doing some service improvement, I would look back at the theories behind it. I would have a good read and re-educate myself’
Socialisation in nursing practice
It was apparent that socialisation and learning in nursing practice was an important feature for participants, both when they were students and as registered nurses. Socialisation is a process that starts during nurse education and continues throughout a nurse's career (Dinmohammadi et al, 2013; Strouse and Nickerson, 2016). Socialisation in nursing occurs through social interactions with colleagues in clinical practice and can have both positive and negative consequences concerning the development of nurses (Gray and Smith, 1999; Mackintosh, 2006).
Service improvement confidence was not always experienced by student participants who, arguably, had not yet been fully socialised into the nursing community of practice. One student participant felt they did not really belong to the clinical area team within which they were trying to make improvements:
‘As a student, I think it is difficult to fit in, you haven't been properly socialised into the team’
Another expressed the same feelings, describing having to ‘fit in’ as a prerequisite to making changes of any kind:
‘You don't feel you belong. It doesn't matter what you do. You have to just learn to fit in. You're not part of the social scene. I felt not supported [in service improvement activity]’
Several suggested that they tried to join conversations to develop relationships with work colleagues, but were ignored:
‘They did not like the idea of me coming in as an outsider and changing [service improvements]. You don't fit in. You would go to lunch and try and join the conversation, and they would blank you. It wasn't sociable’
At a time when retention of nursing students on their course is a national priority, this perceived lack of support on placement is of concern. However, this perception changed after the nurses became qualified and were employed in their first job. Fitting in and having supportive relationships was perceived as important:
‘As a student you weren't embedded in a culture or in a team quite yet. You were an outsider with outside views which is sometimes good, but when you are working here all the time it is easier to pick up the things that need a little bit of help’
This sense of becoming an ‘insider’ is an indication of the participants' socialisation into the nursing profession post-qualification. Another newly qualified participant also reflected on how different she had felt as a student:
‘When I look back to being a student, I don't think I was ever really part of the team. Compared to now’
Power and powerlessness in the clinical setting
As students, and later as registered nurses, the participants discussed an awareness of power in the context of making changes through service improvements. They were aware of power as a dynamic in the clinical environment and that this influenced how they approached and undertook service improvements in practice. Power and powerlessness emerged as an important feature in how they experienced service improvements in nursing.
Nursing occurs in a social environment, where power impacts nurses in context of their working situation (Gray and Thomas, 2005). Power pervades social norms and sustains power-imbalanced relationships (Potter, 1996; Gray and Thomas, 2005). In this context, this theme had three related subthemes: personal influence, fear of failure and professional responsibility. Student participants were aware of the power imbalance in the clinical environment and this influenced how they approached their service improvements projects. Some felt powerless because of their student nurse status:
‘There was nothing, nothing [service improvement] I could do as a lowly student nurse’
Another, who had also felt powerless, suggested that common assumptions were that service improvements were implemented ‘top-down’, driven by people more ‘senior’ with more organisational power:
‘I am still in my little white student nurse uniform, not higher up. I have no power. I think a lot of people expect service improvement to come from higher up’
This perception reflects a lack of confidence as a student for engaging in ‘bottom-up’ improvements and change. As registered nurses participants noted a tangible change in their power, status, responsibility and authority in making improvements once they had qualified:
‘It's completely different, looking back. [As a staff nurse] I am aware of it [service improvement] in everything I do. I am aware of small things every day that you can do to improve the service. You can see where the flaws are. We have the power now to say, “maybe we can change this’ ”
Another participant felt empowered in her newly qualified status, and able to suggest changes proactively:
‘Now, when qualified, you do have a say [in service improvement] and it's important that I do speak up … you do have the power to say how things are done’
Another recently qualified participant described the transition phase between student and becoming a registered nurse as being an optimum time to engage in service improvement:
‘Looking back, you are in the best place. You just come in from university with new eyes and want to improve’
This suggests that harnessing service improvement enthusiasm in the important preceptorship period and empowering graduates might be a way of maintaining the sustainability of service improvement learning and practice.
Challenges in changing practice
There were several subthemes associated with challenges to change: mentors and staff as practice-based support, ward manager as change agent, resistance to change and ritual and routine. Positive relationships in clinical practice were key enablers for overcoming challenges in implementing service improvement. For students, perhaps understandably, it was the positive, effective mentors they had encountered who helped them to feel good about their service improvement efforts:
‘It depends who you work with. You can have some mentors who are quite good at facilitating change and asking for ideas, and they have some respect for the student. You are not just another body’
‘My mentor was brilliant, she respected student nurses … She was a role model for me [in service improvement]’
Some of the newly qualified nurse participants reflected on their student experiences. They were able to make comparisons between their experiences then and now, in trying to overcome service improvement challenges. They also identified relationships within teams as factor influencing nurses' ability and opportunity to challenge and improve practice:
‘As a student, you don't have the confidence to implement anything. I guess it's how well you get on in the team, but moving from placement to placement all the time makes it really difficult. As a qualified member of the team you get on well with everyone. You fit in and you wouldn't be afraid to say to someone, “maybe we can do it this way” ’
Having colleagues on the ward with a research role seemed to be something that could enhance the receptivity of staff to new ideas and try them out:
‘I would go and see the other nurses and see what they thought, if there was enough “oomph” behind it. We have a lot of research nurses … They are a great support’
People-focused ward managers were key enablers in empowering qualified participants to make improvements:
‘Definitely our ward manager supports change and values your ideas, and always listens to what you have to say’
‘She [the sister] was really receptive. She was a great help to me’
Strong leadership skills were identified by another as pivotal to embedding a service improvement culture where challenges could be overcome:
‘They [the ward manager] is confident, they are a strong leader. They are supportive, open to staff opinions; not only listening to senior staff member, but to everybody’
Self-determination was identified as a way of overcoming the challenges of implementing service improvement. One student participant said:
‘I just got on with it [service improvement]. I got a bit more confident. Sometimes you can't please everyone, you just have to get on with things’
Several participants, once qualified, discussed how, despite challenges, they would persevere, believing that they had an important role to play in improving care for patients:
‘If you don't look at how you can improve your services, you don't improve things for your patients. There are not going to be any advances, you are not going to use any evidenced-based practice’
One participant suggested that continuous improvement and change were essential to ensure that patients received the best, contemporary, evidence-based nursing care:
‘If you are stuck in your ways and set in a certain pattern, you are not always going to meet everybody's needs, and it could be detrimental to patients’
Summary of findings and further theoretical development
In keeping with hermeneutic phenomenology, the four key themes and related subthemes have been presented supported by literature to inform the analysis of the findings (Draucker, 1999). Through further theoretical analysis of each key theme, there was evidence that a range of contextual, professional and behavioural factors were influencing the lived experience of the participants engaging in service improvement (Figure 2). These factors and the four themes identified were synthesised into three overarching processes experienced by participants: professional transformation, developing resilience and becoming empowered in making service improvements. This helped to develop further understanding of the participants' lived experiences.
Discussion
This study aimed to better understand the service improvement experiences of participants as student nurses and throughout their first year of post-registration practice. Across the themes identified common behaviours helped participants engage in service improvement, sustaining their knowledge and enthusiasm post-qualification. Participants were revealing behaviours they had developed in response to their learning and experiences of service improvement in nursing. These ‘positive adaptive behaviours’ are consistent with Bandura (2002), who found that effective problem solvers are motivated to improve their own practice. The adaptive behaviours identified included (Figure 3):
Valuing positive role models
Several participants (P9, P14, P17, P19, P20) talked about role model mentors and colleagues. They described how their sense of self-efficacy had grown from watching and learning from them as students to seeking to emulate them as qualified nurses. Positive role modelling in nursing usually occurs through a process of mentorship, and helping students to fit in and develop the skills necessary for professional practice (Gignac-Caille and Oermann, 2010; Huybrecht et al, 2011; Houghton, 2014; Ó Lúanaigh, 2015). This study identified that service improvement role models are also important for students and new registrants.
Developing reflective practice
Many participants (P2, P8, P7, P13, P20) reflected on their service improvement experiences. In keeping with other research (Hatlevik, 2012), they perceived that reflection helped bridge the service improvement theory–implementation gap, facilitating development of their identity and knowledge as service improvers. Through reflection, participants developed resilience, as has been reported in other studies (Jackson et al, 2007; Thomas and Revell, 2016). Reflection also helped them to identify strategies to overcome service improvement challenges, believing passionately in the positive impact service improvement has on patient care. Bandura (1977) found that learners model their behaviours through being self-reflective and self-reactive.
Becoming a lifelong learner
Two participants (P2, P15) discussed preceptorship and lifelong learning as being integral to the nursing role (Benner, 1984; Nursing and MIdwifery Council, 2018). Other studies have shown that professional development that starts in the pre-qualifying period continues throughout a nursing career through lifelong learning (Davis et al, 2014; Coventry et al, 2015). In this study, the preceptorship period was crucial for sustaining and further developing service improvement learning. A service improvement mindset was synonymous with a lifelong learning philosophy mindset. Where confidence dipped, participants would return to study the theory underpinning their practice.
Effective ward managers were viewed as those willing to listen and learn from students, as well as qualified staff, where new learning could improve patient care. Effective integration of lifelong service improvement learning into a clinical practice setting culture will also have positive benefits for future students.
Growing in self-confidence
Participants (P2, P4, P5, P6, P14, P19) who felt supported in practice developed more self-confidence as service improvers. Conversely, a lack of support from mentors and colleagues impacted negatively on participants' confidence as change agents. Other research has also indicated that student nurses develop self-confidence in practice through positive mentoring experiences, peer support and being successful in practice (Bahn, 2001; Chesser-Smyth and Long, 2013). Self-confidence is linked to self-efficacy and reflects an individual's perception of their own ability to perform a goal or task (Bandura, 1997; Potter and Perry, 2001. Once qualified, participants described growing service improvement self-confidence and self-efficacy through reflective practice and colleague support.
Playing the game to fit in
Several participants (P20, P7, P13, P8) described developing what might be called ‘belongingness’ in social psychological terms; through social contact, working on incremental acceptance and becoming an integral component of the group in the clinical practice area (Baumeister and Leary, 1995; Maslow, 2014). Studies suggest that nursing socialisation starts during training, through social interactions in practice placements, and continues throughout a nursing career (Gray and Smith, 1999; Mackintosh, 2006; Dinmohammadi et al, 2013; Strouse and Nickerson, 2016).
As students, participants perceived that their lack of confidence in making service improvements was linked to feelings of not fitting in or lack of belonging, and this was exacerbated by the short length of time spent in any one area. They described the adaptive behaviours they adopted to fit in, such as using previous work and personal stories to start conversations. Some participants perceived that these casual, non-threatening conversations could help them get their service improvement ideas accepted.
Adapting to role transition
Role transition was an important point in participants' service improvement experiences. As students, some of them felt powerless to make service improvements. Research suggests that social norms in nursing sustain power-imbalanced relationships: where this is negative, it can affect practice efficacy (Potter, 1996; Gray and Thomas, 2005). Some participants described a feeling akin to ‘transition shock’ (Duchscher, 2009) in the newly qualified period, finding it hard to cope with the competing demands of clinical practice and ongoing learning, including service improvement learning.
This is in keeping with other research suggesting that role transition is complex and challenging (Maben et al, 2006; Feng and Tsai, 2012; Hatlevik, 2012). In this context, some participants also found it hard to make service improvements during role transition unless it was part of their preceptorship programme expectations (Chang and Hancock, 2003; Schoessler and Waldo, 2006; Duchscher, 2008; Duchscher, 2009; Feng and Tsai, 2012; Hatlevik, 2012). Nevertheless, through professional transformation, some participants (P1, P2, P4, P16) recognised an increased accountability and responsibility for making service improvements now that they were qualified.
Seeking ward manager feedback and support
Most participants (P2, P4, P5, P12, P9, P16) described ward managers as important in fostering a culture of service improvement and change. The significance of the ward manager in creating ward learning cultures is well documented (Orton, 1981; Fretwell, 1982; Ogier, 1986; Welsh and Swann, 2002; McGowan, 2006; Carlin and Duffy, 2013). Whether student participants felt empowered to make service improvements depended mainly on ward manager leadership. This leadership was also identified as important by the new registrants. Active engagement from those in senior positions is critical to successful service improvement (Gollop et al, 2004). Nurses can experience high levels of empowerment when ward managers nurture perceptions of autonomy and confidence (Madden, 2007). This study confirms that ward manager leadership is integral to nurse-led service improvement models (Shafer and Aziz, 2013).
A proposed model of self-efficacy in service improvement enablement
The seven positive adaptive behaviours identified (Figure 3) underpinned a process of participant professional transformation towards self-efficacy (Bandura, 1997). With increasing resilience, they felt more empowered to make service improvements as they transitioned from student to registered nurse. The ‘model of self-efficacy in service improvement enablement’ brings together these positive adaptive behaviours as a way of understanding how participants' education and practice were interrelated to influence their service improvement learning and practice.
Although the model is presented as a linear process, the rate of service improvement engagement and development differed between participants, and was influenced by the context of their learning and practice. However, by the time they had made the transition from student to registered nurse they had all achieved a degree of empowerment, resilience and transformation, enabling them to move forward with service improvements in their own work context. This model offers an explanation for other research, which found that nurse-led service improvement requires knowledge and skills that must be continually practised and refined in order to be successful (Wilcock and Carr, 2001; Christiansen et al, 2010).
Nursing undergraduate and preceptorship programmes should focus on developing these positive adaptive behaviours towards sustainable service improvement knowledge and skills. Policymakers at local level need to ensure that students and new registrants are supported by ward managers in their implementation of service improvement projects in order to develop their service improvement self-efficacy. Further research with other professional groups and in different healthcare contexts is needed to refine and test the model.
Limitations
This study took place in one university and NHS foundation trust; it is therefore context specific. Participants were in adult nursing only, which reduces transferability of the findings.
Conclusion
This study explored service improvement experiences of adult nurses as students and as qualified practitioners. It showed that they used positive adaptive behaviours to navigate their service improvement learning and practice contexts. The process of becoming service improvement practitioners has been explained through the ‘model of self-efficacy in service improvement enablement’. This provides a framework for understanding how nurses undergo concurrent processes of professional transformation, empowerment and resilience building, through service improvement experiences.
Ward management leadership approaches, supportive colleagues and an opportunity to practise service improvement skills pre-qualifying and in the preceptorship period were identified as essential to develop and sustain service improvement capability. This was important for participants as students but also as qualified nurses, at which time they believed that service improvement practice could be sustained through reflection and lifelong learning.
For all participants the central motivation to push past challenges encountered was a commitment to improving care for the patients they were caring for. This study's findings can inform the practice of nurse educators, practitioners, policy makers and healthcare delivery organisations, thereby potentially making a contribution to global efforts to embed a service improvement culture for the ongoing benefit of all.