Avoiding Common Pitfalls in Quality Improvement Research: A Guide for NICU Nurses

By Gayla Eppinger, DNP APRN NNP-BC C-NPT C-NNIC C-ONQS CNE

Quality improvement (QI) initiatives have become essential to advancing patient outcomes in the neonatal intensive care unit (NICU), where high acuity and complex care are the norms. NICU nurses are uniquely positioned to find inefficiencies, propose practical solutions, and drive meaningful change. However, despite the growing emphasis on QI in nursing practice, well-intentioned projects fall short due to avoidable missteps in the planning and execution phases.

The following guide can be utilized by NICU nurses to navigate through common pitfalls in QI research and offers evidence-based strategies to overcome them. By focusing on foundational principles and real-world examples, this guide supports nurses in conducting impactful, sustainable QI work that enhances neonatal outcomes and team collaboration.

Common Pitfalls in QI Research

Lack of Clear Problem Definition

A common pitfall in QI efforts is the failure to define the problem thoroughly. Without a precise understanding of the issue, teams may invest critical time and resources into solutions that do not address the root cause.

For instance, a unit may notice an uptick in central line-associated bloodstream infections (CLABSIs) and immediately implement new sterile techniques without investigating the underlying variables. Was the increase related to staffing changes, procedural drift, or equipment issues? Without a clear problem definition, interventions risk being misaligned or ineffective.

Strategy: Use structured problem-identification tools—such as root cause analysis (like the Five Whys) or fishbone diagrams—to uncover deeper system issues. Frame the problem in a way that is specific, data-informed, and agreed upon by stakeholders. A clearly defined problem becomes the foundation for targeted and measurable interventions.

Neglecting Stakeholder Involvement

Successful QI initiatives require input and collaboration across disciplines. A common misstep occurs when projects are developed in isolation, often without input from those who will implement or be affected by the change. This can lead to resistance, logistical challenges, or unintended consequences.

For example, consider a QI team aiming to improve feeding initiation times by adjusting nursing workflows. If respiratory therapists or neonatal physicians are not consulted, the new protocol might inadvertently clash with intubation or stabilization practices, resulting in delays rather than improvements.

Strategy: Identify all stakeholders early in the project, including nurses, physicians, respiratory therapists, pharmacists, and families, when appropriate. Conduct stakeholder analyses and engage representatives in project design and testing phases. Inclusive collaboration fosters ownership, smoother implementation, and more sustainable outcomes (Institute for Healthcare Improvement, n.d.).

Poorly Defined Metrics

Without clearly defined, relevant, and measurable outcomes, a QI initiative’s impact is difficult to assess. Broad or vague goals such as “improve thermoregulation” fail to provide direction or an evaluation method.

Strategy: Use SMART goals—Specific, Measurable, Achievable, Relevant, and Time-bound—to guide metric development. For instance, instead of aiming to “reduce hypothermia,” a SMART goal might be: “Increase the percentage of newborns with normothermic admission temperatures (36.5°C–37.5°C) from 65% to 90% over six months.” Tools and resources are available to learn how to develop clear metrics, help track progress, guide adjustments, and communicate results to the team and leadership (Agency for Healthcare Research and Quality, 2020).

Inadequate Data Collection Planning

Even well-designed projects can falter without a strong plan for data collection. Inconsistent, incomplete, or biased data limit the ability to draw valid conclusions and make informed decisions.

Strategy: Design a standardized data collection process before the intervention begins. Identify what data are needed, who will collect data, how often, and how data will be stored and analyzed. Use validated tools where possible and use the electronic health record (EHR) system to reduce manual workload and increase reliability. Pilot test the data collection process to identify issues before scaling up.

Failure to Pilot Interventions

Another frequent misstep is implementing large-scale changes without first evaluating them in a controlled way. Skipping the pilot phase can lead to disruptions in care, staff confusion, or overlooked safety concerns.

Strategy: Use Plan-Do-Study-Act (PDSA) cycles to test changes on a small scale. For instance, a new bedside handoff tool can be trialed with one team for over a week before expanding unit wide. Piloting helps refine interventions, identify barriers early, and build staff confidence.

Lack of Sustainability Planning

Often, improvement is easier to achieve than sustain. QI initiatives can experience initial success but not maintain gains over time due to a lack of follow-up, ownership, or integration into routine practice.

Strategy: Plan for sustainability from the outset. Embed new practices into policies, electronic systems, and training programs. Assign champions to monitor compliance, provide feedback, and adapt as needed. Ongoing measurement and leadership support are critical to prevent regression.

Not Sharing or Publishing Results

When results are not shared beyond the unit, valuable insights and lessons are lost. This limits the potential for broader impact and professional growth.

Strategy: Disseminate findings through presentations, newsletters, or professional journals. Even small projects can inspire similar efforts elsewhere and contribute to the collective advancement of neonatal care. Sharing also strengthens the culture of learning and improvement.

Better QI Creates Lasting Change

Quality improvement is a powerful tool NICU nurses use to enhance care and outcomes. By avoiding common pitfalls—such as unclear problem definitions, poor metric planning, and lack of sustainability—nurses can lead effective and lasting change. Through structured planning, collaborative engagement, and thoughtful execution, every QI effort becomes an opportunity for growth and better care for our most vulnerable patients. (Institute for Healthcare Improvement, n.d.).

References

Agency for Healthcare Research and Quality. (March 2020). Tools and resources for research, quality improvement, and practice. https://www.ahrq.gov/ncepcr/tools/index.html

Institute for Healthcare Improvement. (n.d.). Model for improvement: Forming the team. https://www.ihi.org/library/model-for-improvement/forming-team

Bibliography

Langley, G. J., Moen, R., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd ed.). Jossey-Bass.

Standards for Quality Improvement Reporting Excellence. (2015). SQuIRE 2.0. https://www.squire-statement.org/index.cfm?fuseaction=Page.ViewPage&pageId=525