Five questions for Gail Armstrong

Nurse sees life-saving differences made by quality, safety


A volunteer experience led Gail Armstrong to a career in health care. After earning a bachelor’s and master’s degree in literature, Armstrong began teaching in New Hampshire. But she decided what she really wanted to do was become a full-time volunteer in a Third World country. She ended up in Micronesia where she taught students from 14 surrounding island groups.

While there, she realized that in the hierarchy of learning, there is no compromise when it comes to health.

“I was contributing to the educational system, but I had students struggling with a variety of health issues,” she said. “It opened my eyes to the fact that health is more important than education because if you are not healthy, you can’t learn.”

During her two years in Micronesia, she thought more and more about health professions. “I knew I didn’t want to get another baccalaureate degree, so, long story short, in the early ’90s, CU’s College of Nursing started a nursing doctorate degree, known as an ND. I applied while in Micronesia and came back to Denver where I completed my degree in 1995.”

Armstrong began practicing in the Centura system, and while there, a friend recruited her to teach a medical/surgical course at the College of Nursing. Armstrong has been on the college’s faculty since 2000 and is now an associate professor where her focus is adult acute care nursing and quality and safety.

She retains her love of literature, and is a voracious reader, especially modern fiction. She also is a volunteer moderator for the Pen & Podium Book Club, which discusses works by authors who make appearances at the Pen & Podium series hosted by The Denver Post. She loves hiking and enjoys taking her dog along on journeys to the high country near Silverthorne.

1.  You were a member of the Presidents’ Teaching and Learning Collaborative (PTLC) and have said it was one of the most “influential and important experiences” of your career. What was it about the program that so impressed you? How did it impact your career?

I was still a pretty new faculty member, teaching three days a week and practicing as a nurse two days a week. PTLC gave me the opportunity to interact with teachers from many different disciplines within the CU system: In my cohort, there was a professor of music and a professor of physics. It was stimulating in terms of my own thinking about my pedagogy and sharing my teaching challenges and successes with colleagues. We came from different environments, but we were considering a lot of the same questions. It changed how I thought about my own teaching and it launched me into being more innovative in ways that probably wouldn’t have happened if I hadn’t have been part of the collaborative.

My PLTC project looked at whether high-fidelity simulation that we had just adopted in nursing improved students’ clinical reasoning skills. The experience made me think deeply about how we place different types of learning in the curriculum, and almost all of my subsequent scholarship has been in nursing curricula.

2. And that includes the Quality Safety and Education in Nursing (QSEN) program?

From the PTLC, I was invited to be involved in Quality and Safety Education for Nurses (QSEN), a Robert Wood Johnson Foundation national initiative. There were some significant Institute of Medicine reports that highlighted the amount of preventable harm there is in United States hospitals. QSEN emerged from nursing thought-leaders coming together and looking at how we teach quality and safety in nursing programs across the country. My involvement in QSEN came from my practice, where quite a few safety issues had emerged over a short period of time. My clinical colleagues and I were thinking about how to improve our system, and at the same time, QSEN was examining what schools were teaching nursing students about quality and safety and how to improve it. It was a beautiful convergence. I’m still involved with the QSEN initiative. The Institute of Medicine recommended that all health profession programs teach students about five competencies in quality and safety; QSEN effectively created a system for nurse educators to do that. The foundation for this transformational curricular work came from some of the stimuli I was exposed to in PTLC.

How to teach updated quality and safety is the same for all schools because all health care systems are struggling with the same kind of gaps. One of the ways adverse events in health care are measured is through sentinel events -- when you have a patient who either dies or is substantially harmed from care that was intended to help them. The Joint Commission that accredits hospital associations tracks these sentinel events, and initiatives like National Patient Safety Goals are the mechanism through which all health care systems focus on the same kinds of health care system gaps occurring across the country.

Examples of health care system issues that everyone faces include how to reduce medication errors, how to reduce falls that happen in the hospital, how to reduce hospital-acquired pressure ulcers, and how to improve communication among health care teams.

One of the brilliant visions of the principle investigator in QSEN was to create common resources that all nursing programs across the country could use, available via the website. For example, there are more than 100 peer-reviewed teaching strategies that are free for all nurse educators. We all have the same students, whether it’s Colorado or Indiana or California or Texas, and we’re struggling with the same issues. So it’s all about being a resource-sharing culture.

3. How else have you kept up with the challenges that the nursing profession and nursing education have presented?

I’ve been a nurse for 21 years. As our hospital environment has become more complex, our education models have worked hard to keep up. I graduated with a nursing doctorate in 1995, but in 2004, the accrediting body for nursing programs decided that the DNP degree would become the clinical doctorate of nursing practice. In order to update my ND to DNP, I had to go back to school to get a master’s of science degree. I finished my master’s in 2010, but I realized that I really wanted to do hospital-based nursing research, so that year I matriculated into the Vanderbilt University Ph.D. program. I’m working on my dissertation now and hope to graduate in 2015.

All of this education – of which I’ve had plenty -- has kept me close to all of the improvements happening that continue to prepare students for this increasingly complex hospital environment.

4. What is the focus of your research now?

My Ph.D. research is focused on what contributes to medication errors in the hospital setting. I was a medical/surgical nurse for more than 10 years. Some of my best instructors were my patients; I always felt it was such a privilege to provide care. But when I started my Ph.D., I stepped away from the bedside to balance being a student with my full-time faculty position. My specific focus has changed from understanding/improving care at the bedside, individual patient level to looking at improving care at the systems level.

One of the things I’m doing now is working on an initiative on the Anschutz campus called the Institute for Healthcare Quality Safety and Efficiency (IHQSE). IHQSE is working with interdisciplinary clinical teams from Children’s Colorado and from the University of Colorado Hospital. These teams of clinicians commit to 12 months of training and projects to improve the quality and safety of their unit. The IHQSE Certificate Training Program just launched its second cohort, and I’m the nurse on the faculty, teaching with physicians and process improvement experts. The teams commit to eight hours of class each month while working on these improvement projects.  Being on the faculty for this program has been challenging and very enlightening about the need for education not only for our nursing students and also our pre-licensure students, but also clinicians who maybe weren’t educated in quality, safety and efficiency.

There is a lot of momentum behind this work and many stakeholders are invested in this important education for clinicians. I’m grateful for the opportunity to teach quality and safety right now and work with clinician groups that are engaging and learning.

5. You mentioned that some of your best instructors were your patients. Can you tell me about an instance where a patient made an impression on you or your career?

It’s hard to pick out one; there are so many. But, there was one patient, John, on our med/surg unit who was diagnosed with polycythemia. Basically he had too many red blood cells and the treatment is one where you drain blood from the patient, which effectively dilutes their blood. Every month or so John would come to our Ambulatory Care Center for an IV and a therapeutic phlebotomy. During his appointments, we had this nice, light rapport, and shared a lot of humor. I had probably known him for 10 months and when Christmas came along, he had a present for me. He was so serious, which was unlike him. He told me that I had been a lifesaver. It was heartfelt and I was very touched. The gift was a mug that was decorated with enamel Lifesavers and was filled with Lifesavers.

John’s mug sits on my desk at work and I always think of that comment about how important my care had been to him. That’s the potential that every nurse holds when he or she cares for a patient. I would never in a million years say that I would be a lifesaver. But it reminds me that what matters is the patient and the patient’s perspective of how we help them. And in every interaction, a nurse has the potential of being a lifesaver.

My quality and safety work can be a literal application of that metaphor as well: With rapid response teams and early identification of change of status, we really can save patients’ lives.