Taking the Initiative

Of all the lessons that Scarling Perez, MS ’24, learned at Columbia University School of Nursing, some of the most surprising came when she was assigned to assess practicing nurses’ knowledge and compliance in the realm of nursing care and patient safety. Those revelations arrived during her final semester in the Masters Direct Entry (MDE) program, in a course known as the Quality Improvement Practicum.

Launched two years ago by Assistant Professor Candice Ann Smith, DNP, the practicum introduces students to the theory and practice of strategic hospital-based quality improvement (QI) initiatives. During the on-site portion of the 10-week course, students support a range of efforts to enhance nursing-sensitive quality outcomes and patient safety initiatives at NewYork-Presbyterian Hospital (NYP).

Perez participated in a drive to improve prevention of the often-intractable hospital-based infection Clostridioides difficile (C. diff). Prior to conducting their observations, she and her fellow students were educated about the hospital’s process requirements to prevent C. diff, data collection methods, NYP’s QI tool (a survey containing standardized questions based on best practices), criteria for scoring their observations, and how to provide feedback to clinical nurses and nurse leaders. Then every Tuesday for 10 weeks, Perez spent the morning on NYP/Allen Hospital’s ICU, using a hospital-approved third-party app to collect de-identified data from patients, staff members, and visitors. During each session, she provided the unit’s leaders and frontline staff with real-time feedback on her findings. “Our main task,” Perez recalls, “besides checking patient rooms for instructional signage and chlorhexidine soap, was to ask anyone we saw on the unit what they knew about preventing C. diff.” She and her classmates would use prompts from the app to ask questions, score the responses, and provide educational opportunities when appropriate.

NYP is a national leader in patient quality and safety, holding a five-star rating from the federal Centers for Medicare and Medicaid Services—and one reason for that is the health system’s commitment to engaging frontline clinical nurses, support staff, and nurse leaders in the development and implementation of QI initiatives. The hospital’s compliance rates for infection prevention measures consistently exceed 95%, for example, and its C. diff rates outperform national benchmarks. Yet even so, NYP continually evaluates its performance so strengths can be enhanced and process gaps addressed. The QI Practicum is one among many aspects of that continual monitoring. Perez came away from the course with a better appreciation for the role of nurses in providing quality care and for the impact of nursing care on overall performance and outcomes.

As part of the QI Practicum, nursing students also have a chance to hone their communication skills by reporting to nurse leaders on opportunities for improvement. One example Perez encountered was in the use of personal protective equipment (PPE). A key intervention to prevent the spread of infection is following explicit steps for removal of contaminated PPE. As part of the practicum, Perez learned the proper sequence of steps: “You’re supposed to remove your gloves first,” she explains, “throw them away, then grab your gown from the inside to rip it off. Then you fold it inside out and toss it in the garbage.” But although the steps may sound straightforward, the fast-paced, complex clinical environment can all too often pose distractions that impact adherence to best practices.

This, she adds, highlighted another key lesson of her QI experience: the fact that ongoing reinforcement of best practices is essential to ensuring compliance in a fast-paced care environment. During her clinical rotations, she’d seen how difficult it could be for nurses to stay on schedule while juggling multiple patients who needed medication or monitoring at precise intervals. Once, a nurse she was shadowing had to spend at least 20 minutes calming a patient’s family members when they panicked after an IV alarm began beeping by the patient’s bed—since part of an RN’s role, in addition to delivering care, is to take the time to address patient and family concerns.

Given the competing demands on nurses’ attention, Perez understood why some might lose focus on C. diff control procedures. Her experience in the QI Practicum made her wonder: “When I become a practicing nurse, how can I make sure to stay on top of the details? And how can hospitals help all nurses stay focused on the little things that play a big role in keeping patients safe?”

Getting students to ponder such puzzles was one of Smith’s central purposes in designing the course. The other was to encourage them to seek solutions. “The goal,” she says, “is to produce not only better nurses but better nurse leaders—and, ultimately, to improve the quality of patient care wherever their careers take them.”

A Groundbreaking Project

Although other nursing schools offer QI-focused courses for graduate nurses, Columbia Nursing’s practicum is the only one geared to students at the prelicensure stage. The idea was born in 2021, when Smith took over teaching the school’s long-running Leadership and Management course. “I wanted to emphasize students’ awareness of quality and safety beyond just the bedside,” she says, “extending it to how leadership and management track data and meet compliance.”

To further that aim, Smith designed a course unit centered on QI. Her concept was inspired partly by the American Academy of Nursing’s just-released “AACN Essentials,” a set of 10 core competencies for nursing curricula. By participating in a real-life quality improvement initiative, she reasoned, students could also enhance their skills in the other domains that the AACN had identified, including systems-based practice, informatics and health care technologies, patient-centered care, nursing scholarship, and professional and leadership development.

Smith developed the project in partnership with NYP’s patient quality and safety team. Students were assigned to support a single initiative: improving C. diff prevention. Some rounded in the hospital, using tracers like those that NYP’s own quality auditors employed; others worked behind the scenes, doing research and literature reviews. Then both groups joined forces to create posters—similar to those produced for nursing conferences and symposia—reporting their findings and proposing innovative ways to boost staff education and patient care.

“The response was fantastic,” Smith recalls. “The hospital was impressed with the students’ competence and the reliability of their data, and they were thrilled to have extra boots on the ground to do surveillance.” When she suggested launching a standalone practicum on QI for all senior Columbia Nursing students, NYP administrators embraced the notion wholeheartedly. “This project wouldn’t have been possible without the ongoing collaboration of the NewYork-Presbyterian
team,” she adds. “This course highlights their dedication to patient safety, and to developing nurses who are committed to enhancing it.”

The practicum debuted in the summer of 2022 and has followed the same basic format ever since. It begins with a classroom component, led by Assistant Professor Ashley Graham-Perel, EdD. After a few days, the lessons move to the school’s simulation center, where the students—typically about 200—practice in replicas of patients’ rooms, using task trainers, mannequins, and actual hospital equipment. Led by Smith and an assortment of clinical instructors and NYP nurses, they learn how to handle tracers, audit the care environment, and elicit participation from survey subjects.

From weeks three to eight, the students are deployed to over 50 units at all six NYP hospitals, where they assist in QI initiatives to prevent C. diff infections, central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and—starting with this summer’s session—inpatient falls. They then spend two weeks analyzing their data and preparing their research posters. Finally, they present their findings at the school-wide nursing symposium held every August, which affiliate partners and nursing colleagues are invited to attend.

“The practicum instills values and behaviors that help ensure students will always put patient safety first,” Smith says, “no matter what the clinical environment throws at them.” On a more bread-and-butter level, it inculcates skills that can lead to career opportunities. “I’ve heard many students say they didn’t realize quality and regulatory matters were possible career paths for nurses,” says NYP Manager-Business Administration for Quality and Patient Safety Keila Soto, who facilitates the hospital’s involvement with the course. “The practicum teaches them not only to monitor compliance and collect relevant data, but it prepares them to have critical conversations with peers and leadership around patient safety.”

“The benefits run both ways,” adds NYP Director of Nursing Quality Bertha Ku, DNP. “The students bring us a fresh perspective. They notice issues that we sometimes miss, and the ideas in their poster presentations are useful and innovative. I always tell the students, ‘If you’re interested in working here, please join us. You would be the right person to implement your idea because you understand what’s happening on the unit.’ Several students have taken her up on the invitation.

The practicum also brings even more concrete benefits to NYP. “The students are an amazing resource for us,” says Patient Care Director Rochelle Ibe, MS ’21, who has sometimes served as a clinical instructor for the practicum. “We’ve seen a 31% decrease in falls since last year, and a week-to-week improvement in falls education compliance while they were doing their audit. At least in part, those numbers represent tangible outcomes of their participation.”

The course could have a broader impact, as well, Ibe observes—especially if other nursing schools adopt a similar model. “Immersing students in quality improvement helps them appreciate its importance to the profession. And that could inspire them to make contributions that improve health care at a larger scale.”

Bringing New Insights to Students—and to the Profession

For Katherine Zhao, MS ’24, the QI Practicum opened a new perspective on her chosen profession. Raised by two physicians in Southern California, Zhao recognized her calling when her father suffered a medical crisis and a crew of diligent nurses in a surgical intensive care unit saved his life. An interest in global health brought her to Columbia Nursing, and she completed her clinical integration at the school’s affiliated center in Amman, Jordan. During the practicum, however, she gained insights that only an immersion in QI could have afforded her.

Zhao was assigned to support a fall-prevention initiative at NYP/Allen Hospital, at the northern tip of Manhattan. “I hadn’t had the experience of collecting data on a hospital unit before, so it was very rewarding,” she says. It was also eye-opening. She and her classmates reviewed electronic medical records to see if documentation on high–fall-risk patients met clinical standards and had been properly updated. They inspected patients’ rooms to see if the environment was safe, checking for hazards such as loose wires, water on the floor, or missing bed rails. They checked that the fall-prevention sheets in those rooms were up-to-date and matched the data in the occupants’ electronic medical records.

In addition, they spoke with the patients themselves, asking a battery of questions: Did the nurse go over your fall-risk profile with you? Do you remember receiving any fall-prevention education? Can you recite some of the preventive steps you can take? They surveyed patients’ family members, too, asking similar questions. And they interviewed the unit’s nurses.

Like Scarling Perez, Zhao found them to be knowledgeable and helpful. “They knew whether patients had had a fall or not,” she recalls. “They knew the risk factors. They knew the prevention protocols.” But although nurses are knowledgeable regarding each individual patient’s fall risk, and they routinely provide patients with educational materials, the patients may not always remember the safety information that they received.

Zhao understood that nurses needed to prioritize their expenditures of time and energy. “You’re doing triage throughout the day,” she says. “You’re never going to get everything 100% perfect. But when I become a working nurse, I want to hold myself to the highest possible standard.”

To help other nurses do just that, Zhao looked for a way to reconnect them with their early training. In the literature review portion of the practicum, she and her partners found studies showing that prevention education significantly reduced the numbers of falls in hospitals. Zhao also remembered a video on pediatric trauma that she’d seen during her OB rotation, which had been shown to improve outcomes. So, in their research poster, she and her team recommended creating a fallprevention video that nurses could show to patients, reminding both parties of the fundamentals.

“At the poster presentation, an NYP representative told us that they’re working on something similar,” Zhao says. “I’m happy to know that our idea was actually valid and that we were able to contribute to the hospital’s larger fall prevention efforts. But more than that, I’m grateful that the QI Practicum prepared us to approach nursing from a systematic viewpoint—not just for my own sake, but for the profession as a whole.”

Perez shares that sentiment. Like Zhao, she was drawn to the profession by her family background; watching her father struggle with diabetes, she’d seen the difference that good nursing made in both his physical and his emotional well-being and in his sense of empowerment as a patient. Perhaps for that reason, the lessons she learned in the QI practicum felt profoundly personal.

“What I loved about the practicum,” Perez says, “was that it drilled down on the most important aspect of nursing: keeping patients safe. It showed me that even the most experienced nurses at the best hospitals can sometimes get things wrong. And it demonstrated that we can always find ways to do things better.”

Photographs by Zack Garlitos

This article originally appeared in the Spring 2025 issue of Columbia Nursing Magazine.