Theory in quality improvement and patient safety education: A scoping review

We included English-language peer-reviewed articles that (a) described a QIPS curriculum or explicit education about QIPS and (b) used theory to inform how it was developed or studied. We included education programs that involved students or practitioners from any healthcare professional group and occurred in any education or healthcare organizational setting. An article met the ‘QIPS curriculum’ criteria if it was a description and/or study (using quantitative, qualitative or mixed methods) of any kind of organized learning of QIPS. A curriculum was defined as QIPS if the authors used these terms or concepts associated with the field (e.g., health systems science, human factors) and topics included processes and tools associated with the field (e.g., Model for Improvement, medical errors, incident reporting). An article met the ‘use of theory’ criteria if it cited a theory used and provided some detail about the theory and the connection between the theory and the education curriculum development or study. We used the definition of theory as a “set of interrelated constructs (concepts), definitions, and propositions that present a systematic view of phenomena by specifying relations among variables with the purpose of explaining and predicting phenomena” [21, p. 9]. We excluded articles that mentioned theory superficially (e.g., in a few words with no further elaboration) or that used learning models or frameworks which we did not classify as theory (e.g., Kirkpatrick model). We also excluded articles if patient safety was just used as a rationale for the education program, QI methods were used to improve the education program, or the article reported on building skills related to QIPS (e.g., professionalism and interpersonal skills) but not about learning QIPS itself.

A number of published systematic reviews have already identified QIPS education articles targeting learners across the learning curriculum from various health professions. Therefore, we used the keywords ‘curriculum’, ‘patient safety’, ‘quality improvement’ and ‘review’ in PubMed, ERIC and EMBASE (Database search strategy in ESM Appendix, Part One) to identify 20 systematic reviews of QIPS education (List of systematic reviews in ESM Appendix, Part Two). We performed a search in April 2018, which was updated in July 2020. We included all articles from these reviews as well as articles published after these reviews that cited one or more of these reviews, using Web of Science to capture these latter articles. We looked through reviews identified in the results to identify further relevant studies. Additionally, we hand searched the references of the included articles and journals which had published two or more of the included articles.

We used a two-stage review process to select included articles. The first focused on identifying articles about QIPS curricula. Three authors (JG, AS, BW) reviewed an initial set of 10 abstracts to ensure agreement regarding inclusion and exclusion criteria relating to QIPS curricula. Two authors (any combination of JG, BW, AS) independently reviewed the remaining abstracts. An 82–84% agreement between the reviewers occurred at this first stage. Articles identified as being about a QIPS curriculum by at least one reviewer, and articles where a determination could not be made, were promoted to the second review stage. The same three authors reviewed 10 promoted articles in full-text to ensure agreement regarding inclusion and exclusion criteria relating to use of theory. Two authors (JG plus either AS or BW) independently reviewed the remaining full-text articles to identify those that were about a QIPS curriculum and included use of theory. An 89–93% agreement between the reviewers occurred at this second stage. We resolved disagreements by seeking input from the third reviewer, and where necessary, from a fourth author (AK).

We developed and revised a data abstraction form after piloting on three randomly selected articles. We tested it on three more randomly selected articles and revised again. Two study authors (JG plus either AS or BW) independently abstracted the following data from included articles: authors, journal, publication year, country of origin, education setting, curriculum (curriculum objectives, teaching methods, duration, topics, participant details), research (study objectives, study design, Kirkpatrick evaluation level, other outcomes), and theory (theory used, purpose of use of theory, theory references). The two study authors reconciled data extraction details.

We did not examine the articles for methodological rigour as the purpose of this review was to map out the ways in which theory is being used in QIPS education rather than to make judgements as to the quality of such studies. Furthermore, assessing the rigour with which studies used theory is inherently problematic because the diverse disciplines represented in the QIPS education literature draw on different (and sometimes contradictory) definitions of research rigour and quality.

For data synthesis and interpretation, we began by summarizing descriptive details of each article. We then created narrative syntheses of how theory was used in each article and organized theories into various categories, including the types of theory, how theory was used (to develop or study QIPS education program) and the types of perspectives the theories offered. Articles identified as ‘superficial mention of theory’, and not included in our final group of papers, were classified by the type of theory listed.

The theories used fall into two broad, though overlapping, categories: learning theories (n = 20) and social science theories (n = 11). Table S3 (See ESM) summarizes definitions of theories reported and details of their use.

Learning theories are specifically concerned with how learning occurs, including what “drives and impedes learning” [25] and the strategies and environments that affect learning [10]. Learning theories used in the 15 articles were from the following categories: cognitive (n = 11), which included spaced education, team competition and testing effect, theory of intrinsic motivation, reflective learning, Kolb’s experiential learning, theory of attitude-relevant knowledge, self-regulated learning, and cognitive transfer [26‐36]; sociocultural (n = 3), which included Eraut’s theory of formal and informal learning, Senninger’s theory of learning, and community of practice [22, 33, 37]; transformative (n = 7), which included Mezirow’s theory of transformative learning and Sandars’ critical reflection [35, 38‐43]; and organizational (n = 1), which included psychological safety [44].

Social science theories refer to a wide range of disciplines (e.g., anthropology, economics, psychology) concerned with human behaviours and their social and cultural aspects. The ten articles that drew upon social science theories were from the fields of psychology (n = 7), which included theories of planned behaviour, behavioural psychology, self-determination, self-efficacy, as well as activity theory that has origins in psychology [31, 38, 45‐49]; sociology (n = 2), which involved Bourdieu’s concepts of field, habitus and capital and the sociological theory of professions [50, 51]; and philosophy (n = 2), with both articles using realist evaluation [38, 52].

Articles demonstrated the use of theories in two main ways, namely, the design (n = 12) or the study (n = 17) of QIPS education. While many articles could fit into both categories, such as an article that described the use of theory in the development of a curriculum and then evaluated the effectiveness of the educational approach, we classified each article by its dominant focus. One exception is De Feijter et al. [31], who utilized one theory to design their patient safety learning and a second one to study it.

In designing QIPS education, the twelve articles described the use of theory to inform decisions regarding education format [26‐28, 32] (e.g., online learning) and teaching strategies [30, 31, 33, 36, 39] (e.g., reflection), as well as strategies that attend to facilitators and barriers of QI project-based learning [47], faculty engagement [50] and the learning environment [44]. For example, one program developed an online, quiz-based QIPS education program, based on the psychological phenomena of knowledge presentation, repetition, spacing and testing impacting on learners’ retention and retrieval of information [28]. Another study used transformative learning theory, along with a conceptual framework of empathy and moral development, in their development of a program that involved a patient group sharing stories about inadequate care and its causes, followed by facilitated discussion between the patients and the junior doctors to allow for the doctors to reflect on the narrative and explore their own attitudes and beliefs about patient safety [39].

In 17 articles, theory was mainly used to study QIPS education programs. Seven articles used theory to help predict or understand learners’ reactions to QIPS education and impact of the education on learner’s knowledge, attitudes and behaviours [31, 34, 35, 38, 45, 46, 48]. For example, Jansma et al. [45] used theory of planned behaviour to underpin their study of a two-day patient safety course for residents. Based on the theory that intention is the immediate antecedent of behavioural change, they requested participants to formulate an action to improve patient safety following the course, and then conducted follow-up interviews three months later to examine actions and understand gaps between intentions and behaviours. In six articles, theory provided an analytical approach for interpreting QIPS learning processes [22, 29, 37, 43, 49, 51]. For example, de Feijter et al. used activity theory as an analytic framework to highlight potential difficulties of learning about patient safety in the complex system of workplace learning [49]. In three studies, theory was the object of examination; these included examinations of the processes and impacts of reflection [41, 42] and how QI project work can lead to transformative learning [40]. Two studies used realist evaluation as their methodological approach to study questions of ‘what works, in which circumstances and for whom’ in QIPS education programs [38, 52].

Articles that used theory to inform the design of QIPS education turned most frequently to learning theories, with cognitive theories being the single largest group of theories represented. However, articles reported on a range of learning theories stemming from different orientations (e.g., cognitive, transformative, organizational) [26‐28, 30‐33, 36, 39, 44], with two additional studies drawing upon psychological [47] and sociological theories [50] that demonstrate the potential for expanding beyond learning theories to inform QIPS education design. There were also examples of articles that focused on a particular teaching approach, but which drew upon different theories. For example, the use of reflection was connected to several different theories, such as Schon’s cognitively oriented reflection learning theory or Mezirow’s transformative learning theory. Taken together, these findings suggest that there is no single dominant theoretical lens through which to view QIPS educational design.

Articles that used theory as a lens to interpret QIPS education drew upon different types of theories including sociocultural learning theories, activity theory with origins in psychology, the cognitively oriented learning theory of intrinsic motivation and sociology of professions theory [22, 29, 37, 49, 51]. These articles examined different types of learning and social processes (e.g., formal and informal acquisition of knowledge, zones for learning, professional socialization) occurring across different types of educational activities and settings (e.g., workplace based learning, QI projects, undergraduate or continuing professional development curriculum), and highlighted the complexity of delivering QIPS education and the interplay of the various factors that influence learning processes and outcomes. Articles that used theory to help predict or understand the impact of QIPS education largely drew upon theories from psychology [30, 45, 46, 48], with less attention given to social and organizational factors that affect changes in behaviour. A few studies also provide examples of how to build evidence to support theoretically informed learning approaches in QIPS. For example, Wittich et al. [42] explored transformative learning processes by studying the associations between resident doctors’ reflections on QI opportunities and the quality of their QI project proposals. Finally, the two studies [38, 52] that used a realist evaluation illustrate how theory can influence methodological approaches in QIPS education research.

Many studies (n = 102) made superficial mention of theory, which seems to indicate interest in using theory to guide education planning or study. However, the articles were limited by having only a cursory description of the theory, with a few words and no further elaboration (ESM, Table S2). Many of these articles (n = 57) referred to experiential and/or active learning, or experiential learning in combination with another theory (e.g., adult learning, reflective practice) (n = 21).