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Developing and sustaining nurses' service improvement capability: a phenomenological study

11 June 2020
Volume 29 · Issue 11



Service improvement to enhance care quality is a key nursing responsibility and developing sustainable skills and knowledge to become confident, capable service improvement practitioners is important for nurses in order to continually improve practice. How this happens is an under-researched area.


A hermeneutic, longitudinal study in Northern England aimed to better understand the service improvement lived experiences of participants as they progressed from undergraduate adult nursing students to registrants.


Twenty year 3 student adult nurses were purposively selected to participate in individual semi-structured interviews just prior to graduation and up to 12 months post-registration. Hermeneutic circle data analysis were used.


Themes identified were service improvement learning in nursing; socialisation in nursing practice; power and powerlessness in the clinical setting; and overcoming service improvement challenges. At the end of the study, participants developed seven positive adaptive behaviours to support their service improvement practice and the ‘model of self-efficacy in service improvement enablement’ was developed.


This study provides a model to enable student and registered nurses to develop and sustain service improvement capability.

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.

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