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Perspectives, experiences, and opinions precepting advanced practice registered nurse students

      Dear Editor,
      We thank Drs. Waldrop and Reynolds for their interest in our paper and for raising an important point. We agree that clarity in terminology and nomenclature are foundational to the scientific process. We appreciate the opportunity to share in dialogue about the ways in which the concept of quality improvement (QI) may be approached in nursing education and practice.
      Multiple definitions of QI exist, and the interface between QI and research is not mutually exclusive, (
      • Foster J.
      Differentiating quality improvement and research activities.
      ;
      • Newhouse R.P.
      • Pettit J.C.
      • Poe S.
      • Rocco L.
      The slippery slope: Differentiating between quality improvement and research.
      ) likely lending to the inconsistent application of terminology noted by Drs. Waldrop and Reynolds. The Center for Medicare and Medicaid Services defines QI as a “framework used to systematically improve care which …… seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, health care systems, and organizations”(
      The Center for Medicare and Medicaid Services
      Quality Measurement and Quality Improvement.
      ). The Agency for Health Care Research and Quality [AHRQ] defines QI as “using data and feedback to (a) track and assess performance over time, and (b) make necessary changes in processes”(
      • Fries Taylor Erin
      • Peikes Deborah
      • Genevro Janice
      • Meyers David
      The Agency for Healthcare Research and Quality
      Creating capacity for improvement in primary care: The case for developing a quality improvement infrastructure.
      ). The Hastings Report defined QI as “systematic, data-guided activity that is designed to bring about the immediate improvement of care in a local setting”(
      • Baily M.A.
      • Bottrell M.
      • Lynn J.
      • Jennings B.
      • Hastings C.
      The ethics of using QI methods to improve health care quality and safety.
      ). The common theme among these three definitions is a data driven process improvement. The multiplicity of definitions speaks to the need for agreed upon terminology and represents a topic that would make an excellent concept analysis in the future.
      While the Hastings Report indicated that QI methodologies are rapidly evolving, (
      • Baily M.A.
      • Bottrell M.
      • Lynn J.
      • Jennings B.
      • Hastings C.
      The ethics of using QI methods to improve health care quality and safety.
      ) it is commonly accepted that the design of QI projects are characterized by application of a project planning model or framework (
      • Carter E.J.
      • Usseglio J.
      • Pahlevan-Ibrekic C.
      • Vose C.
      • Rivera R.R.
      • Larson E.L.
      Differentiating research and quality improvement activities: A scoping review and implications for clinical scholarship.
      ). The Plan, Do, Study (or Check), Act (PDSA) (AHRQ, 2020) is one of the most common, but alternatives exist including The Define, Measure, Analyze, Improve, and Control (DMAIC) (
      • Dahlgaard-Park S.
      Define, measure, analyze, improve, and control (dmaic) process.
      ). Our project relied upon the PDSA framework for project planning and implementation as our initial goal was to collect data for analysis of a problem to affect systematic change. After identification of a problem within our state with regards to an overwhelming number of requests for Advance Practice Registered Nurse student's clinical practicum placements, a collaborative committee was convened at the State Board of Nursing as the plan phase of the PDSA process. Our committee consisted of regulatory, academic, and clinical stakeholders across the state with a shared goal of improving and reducing the variability in Advance Practice Registered Nurse student's clinical practicum processes within the state. Our article, Perspectives, experiences, and opinions precepting advanced practice registered nurse students, details the Do (collection of data via a survey), Study (analysis and interpretation of results), and Act (legislative administrative rule changes at the State Board of Nursing level) phases of the PDSA cycle. Our project was designed to achieve data driven change resulting in immediate improvements (
      • Foster J.
      Differentiating quality improvement and research activities.
      ) in a process specific to our local context (
      • Itri J.N.
      • Bakow E.
      • Probyn L.
      • Kadom N.
      • Duong P.T.
      • Gettle L.M.
      • Rosenkrantz A.B.
      The Science of Quality Improvement.
      ), thus meeting the definition of QI. Methodologically, surveys are frequently used to collect data in QI projects (
      • Davies E.A.
      • Meterko M.M.
      • Charns M.P.
      • Nealon Seibert M.E.
      • Cleary P.D.
      Factors affecting the use of patient survey data for quality improvement in the Veterans Health Administration.
      ) and are not mutually exclusive of research. Based on the inquires received by the Board of Nursing to our article, we recognize the potential for our article to inform future projects of a similar scope. However, the ability to inform future work is also not an exclusive characteristic of research. Generalizability of results was not the goal of our project, nor our article, and there are several limitations in our project which influenced the ability to generalize results, including potential risks of self-selection bias and inability to account for confounding variables due to lack of demographic data. The defining characteristic of our project, and what delineates this project as QI and not research, is the act phase of the project which is the rapid implementation of state level legislative administrative rule changes.
      State level Board of Nursing QI collaboration with a variety of stakeholders, from The National Council of State Boards of Nursing to individual clinician, on projects that not only flourish into legislative rules and regulations but also are disseminated as publications and scholarly presentations is not unusual. For example,
      • Castaldo R.R.
      • Zickafoose P.C.
      • Walker R.D.
      Delaware's Pathway to Achieving APRN Consensus.
      used a statewide electronic survey of Advance Practice Registered Nurses regarding the impact of collaborative agreements and the APRN Consensus Model resulting in the enactment of legislation and administrative rules by the Delaware Board of Nursing.
      • Hooper J.I.
      • Ayars V.D.
      How Texas Nursing Education Programs Increased NCLEX Pass Rates and Improved Programming.
      detail a QI project conducted by the Texas Board of Nursing which surveyed academic programs within the state to identify efficacious corrective measures for use among nursing programs with declining NCLEX pass rates, identifying a set of core measure for use by all programs interested in programmatic improvements. Our article also details the QI process beyond the individual facility level, expanding it to the state level, and is an opportunity to highlight how QI can enhance the profession beyond the classroom and bedside.
      Our article was prepared for submission according to the author guidelines as published on the journal website at the time of submission, which indicated there were no strict formatting requirements outside of systematic reviews (PRISMA) and randomized control trials (CONSORT). While we support consistent use of reporting guidelines to eliminate heterogeneity in dissemination, the SQUIRE 2.0 authors acknowledge that it is not always appropriate or necessary to include all 18 items of the SQUIRE 2.0 guidelines and there is flexibility in the order in which items may appear in a particular manuscript (
      • Ogrinc G.
      • Davies L.
      • Goodman D.
      • Batalden P.
      • Davidoff F.
      • Stevens D.
      SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process.
      ). Our manuscript was prepared with a title and abstract, introduction, methods, results, discussion, and conclusion sections consistent with the SQUIRE 2.0 structure recommendations.
      Thank you again for the interest in our article and insightful comments.
      Respectfully,
      Heather Dunn, PhD, ARNP, ACNP-BC
      Maria A. Lofgren, DNP, ARNP, NNP-BC, CPNP, FAANP
      Jimmy Reyes, DNP, PhD(c), AGNP, FRE
      Mary Dirks, DNP, ARNP, CPNP, FAANP, ELAN Fellow

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