Implementation of the ANA report card

Nursing-sensitive indicators for nursing care: A systematic review (1997-2017)

AIM

To provide a systematic review of the literature from 1997 to 2017 on nursing-sensitive indicators.

DESIGN

A qualitative design with a deductive approach was used.

DATA SOURCES

Original and Grey Literature references from Cochrane Library, Medline/PubMed, Embase, and CINAHL, Google Scholar Original and Grey Literature.

REVIEW METHODS

Quality assessment was performed using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

A total of 3,633 articles were identified, and thirty-nine studies met the inclusion criteria. The quantitative assessment of investigated relationships in these studies suggests that nursing staffing, mortality, and nosocomial infections were the most frequently reported nursing-sensitive indicators.

CONCLUSION

This review provides a comprehensive list of nursing-sensitive indicators, their frequency of use, and the associations between these indicators and various outcome variables. Stakeholders of nursing research may use the findings to streamline the indicator development efforts and standardization of nursing-sensitive indicators.

IMPACT

This review provides evidence-based results that health organizations can benefit from nursing care quality.

A survey of critical care nurses' practices and perceptions surrounding early intravenous antibiotic initiation during septic shock

BACKGROUND

Delays in antibiotic administration after severe sepsis recognition increases mortality. While physician and pharmacy-related barriers to early antibiotic initiation have been well evaluated, those factors that affect the speed by which critical care nurses working in either the emergency department or the intensive care unit setting initiate antibiotic therapy remains poorly characterized.

AIM

To evaluate the knowledge, practices and perceptions of critical care nurses regarding antibiotic initiation in patients with newly recognised septic shock.

METHODS

A validated survey was distributed to 122 critical care nurses at one 320-bed academic institution with a sepsis protocol advocating intravenous(IV) antibiotic initiation within 1hour of shock recognition.

RESULTS

Among 100 (82%) critical care nurses responding, nearly all (98%) knew of the existence of the sepsis protocol. However, many critical care nurses stated they would optimise blood pressure [with either fluid (38%) or both fluid and a vasopressor (23%)] before antibiotic initiation. Communicated barriers to rapid antibiotic initiation included: excessive patient workload (74%), lack of awareness IV antibiotic(s) ordered (57%) or delivered (69%), need for administration of multiple non-antibiotic IV medications (54%) and no IV access (51%).

CONCLUSIONS

Multiple nurse-related factors influence IV antibiotic(s) initiation speed and should be incorporated into sepsis quality improvement efforts.

Performance Measurement of Nursing Care

Concerns about nurse staffing in hospitals, nursing's influence on patient safety and health care outcomes, and nurses' work environment (e.g., equipment failures, documentation burden) have led to increased interest in measuring and reporting nursing's performance. This article reviews recent efforts and issues involved in identifying a set of nursing-sensitive performance measures. Sustaining and strengthening current efforts requires developing measures that address all the domains of nursing, addressing technical issues needed to analyze the impact of nursing on patient safety and health care outcomes, developing data systems that provide the information needed to implement the model system, regularly improving the set of endorsed standards to reflect the most current science and empirical evidence, and persuading all health care stakeholders that measurement and reporting nursing-sensitive standards make a difference in the care and quality that are delivered. Each of these tasks requires substantial development work and construction and maintenance of the infrastructure to sustain the performance measurement efforts.

The Deserved Care Framework for Evaluating Health Care Quality

Excessively narrow definitions of health care quality do not identify certain important components of health care for clinicians, providers, or patients. Excessively broad definitions drive up health care costs and encourage unjustified interventions. This article proposes a framework for examining health care quality that distinguishes between what patients need, want, and deserve, and it advances the idea that deserved care is the relevant concept of care to inform health policy debates.

Designing and evaluating an electronic patient falls reporting system: perspectives for the implementation of health information technology in long-term residential care facilities

BACKGROUND AND PURPOSE

Patient falls are the leading cause of unintentional injury and death among older adults. In 2000, falls resulted in over 10,300 elderly deaths, costing the United States approximately $179 million in incidence and medical costs. Furthermore, non-fatal injuries caused by falls cost the United States $19 billion annually. Health information technology (IT) applications, specifically electronic falls reporting systems, can aid quality improvement efforts to prevent patient falls. Yet, long-term residential care facilities (LTRCFs) often do not have the financial resources to implement health IT, and workers in these settings are often not ready to adopt such systems. Additionally, most health IT evaluations are conducted in large acute-care settings, so LTRCF administrators currently lack evidence to support the value of health IT.

METHODS

In this paper, we detail the development of a novel, easy-to-use system to facilitate electronic patient falls reporting within a LTRCF using off-the-shelf technology that can be inexpensively implemented in a wide variety of settings. We report the results of four complimentary system evaluation measures that take into consideration varied organizational stakeholders' perspectives: (1) System-level benefits and costs, (2) system usability, via scenario-based use cases, (3) a holistic assessment of users' physical, cognitive, and marcoergonomic (work system) challenges in using the system, and (4) user technology acceptance. We report the viability of collecting and analyzing data specific to each evaluation measure and detail the relative merits of each measure in judging whether the system is acceptable to each stakeholder.

RESULTS AND CONCLUSIONS

The electronic falls reporting system was successfully implemented, with 100% reporting at 3-months post-implementation. The system-level benefits and costs approach showed that the electronic system required no initial investment costs aside from personnel costs and significant benefits accrued from user time savings. The usability analysis revealed several fixable design flaws and demonstrated the importance of scenario-based user training. The technology acceptance model showed that users perceived the reporting system to be useful and easy to use, even more so after implementation. Finally, the holistic human factors evaluation identified challenges encountered when nurses used the system as a part of their daily work, guiding further system redesign. The four-pronged evaluation framework accounted for varied stakeholder perspectives and goals and is a highly scalable framework that can be easily applied to health IT implementations in other LTRCFs.

The perfect storm: managed care, aging adults, and a nursing shortage

The many issues managed care poses for providers and health networks are crystallized in the moral problems occasioned by its shifting of the financial risks of care from the insurer to the provider. Yet, of 257 data-based studies of nursing care quality identified, 135 investigated a process-outcome link but only 17 met study inclusion criteria. The literature provides evidence that the quality of nursing care processes affects health-related patient outcomes during and after hospitalization. Thus, California became the first state to mandate nurse staffing ratios on all units in 1997. All the while labor shortages, introduction of new technology, and the increased acuity of the inpatient population have contributed to the rising costs of hospital-based care. Another notable contribution to the financial and clinical pressures hospitals feel is the overall increased consumer demand for services: The aging of America's population portends an even greater demand for healthcare services. This situation will only grow worse as the demand generated by the growing gerontocracy increasingly outstrips an affordable supply of safe care. Little time and few resources are available for what we might all agree would be the desired level of comprehensive and coordinated care. What this means for patients is that they experience episodic acute care that is delivered in "spurts." No matter what actions are taken - or more likely not taken - to reform the Medicare program, the future holds shrinking reimbursement for hospitals, with a concurrent demand for investments in response to costly regulatory requirements, technologies, and other capital expenditures to accommodate the increasing demand for services generated by the growing numbers of politically active seniors who insist on the entitlements promised to them - and the quality of service they believe is their right. This is the Perfect Storm....

A conceptual framework contributing to nursing administration and research

The health care system has undergone major changes in the last decade. With greater acuity and complexity of illness, the adoption of innovative technologies and the shortage of health care personnel, the coordination and integration of health care services has become increasingly demanding for administrators. Growing dissatisfaction and concerns about safety issues are being expressed by the users of care who need to navigate through an increasingly complex system and by health care personnel who feel less efficient within the organization. Nursing administrators have a responsibility to address these issues but there is little scientific evidence to guide their actions. There are also few comprehensive models highlighting the main components of nursing administration - models that could guide nursing administration research. This paper presents a conceptual framework for nursing administration and research that links patient health care needs, nursing resources and the nursing care processes to the context of the health care system, and the social, political and cultural environments of care. A selected review of the oncology and cancer care literature is presented to demonstrate how this framework can organize existing knowledge about these concepts in the context of cancer care.

Maximizing the Utility of Interorganizational Data Using Concept Mapping

OBJECTIVE

The overall objective of this article was to apply an existing methodology (concept mapping) to a nonstandardized interorganizational data set. The specific aims were to (1) identify, define, and create a map that represented the common conceptual domains of patient satisfaction; (2)validate the relationships among concepts; and (3) use the map by testing the relationships of the patient satisfaction concepts to other patient outcomes.

BACKGROUND

The lack of standardized methodologies for collecting patient outcome data across multiple institutions poses threats to the validity and generalizability of research findings.

METHODS

The steps in concept mapping were used to explicate the common underlying conceptual dimensions from 3 patient satisfaction tools. The map was then used to evaluate the extent that patient satisfaction was related to outcomes of hospitalized patients. Each of 3 hospitals' measure of patient satisfaction varied in the number and type of items. All items were examined to identify potential areas of conceptual correspondence.

RESULTS

Items were grouped into 1 of the 3 identified categories that were consistent across sites: caring, communication, and responsiveness. Moderate correlations were found among the concepts of satisfaction and medication errors, nosocomial infections, and patient falls.

CONCLUSIONS

Concept mapping-more traditionally used for learning, project planning, and evaluation-is a technique that has demonstrated utility in multi-institutional research.

Hospital Nurse Staffing and Patient Mortality, Emotional Exhaustion, and Job Dissatisfaction

OBJECTIVE

To conduct an investigation similar to a landmark study that investigated the association between nurse-to-patient ratio and patient mortality, failure-to-rescue, emotional exhaustion and job satisfaction of nurses.

METHODS

Cross-sectional analysis of 2709 general, orthopedic, and vascular surgery patients, and 140 staff nurses (42% response rate) caring for these patients in a large Midwestern institution. The main outcome measures were mortality, failure-to-rescue, emotional exhaustion, and job dissatisfaction.

RESULTS AND CONCLUSIONS

Staffing was not a significant predictor of mortality or failure-to-rescue, nor did clinical specialty predict emotional exhaustion or job dissatisfaction. Although these findings reinforce adequate staffing ratios at this institution, programs that support nurses in their daily practice and positively impact job satisfaction need to be explored. The Nursing Research Council not only has heightened awareness of how staffing ratios affect patient and nurse outcomes, but also a broader understanding of how the research process can be used to effectively shape nurse's practice and work environments.

Nosocomial urinary tract infection: nursing-sensitive quality indicator in a Thai hospital

The purposes of this study were to examine relationships among 3 of the American Nurses Association's 10 nursing-sensitive quality indicators: nursing hours per patient day, percentage of RNs, and nosocomial urinary tract infection (NUTI), and to identify the best predictor of NUTI in a hospital in Thailand. The results showed a negative relationship between nursing hours per patient day and NUTIs, indicating that with more nursing hours per day, there were fewer NUTI. These findings document the importance of nursing staff in minimizing hospital-acquired urinary tract infection.

Review of Evidenced-Based Practice for the Prevention of Pressure Sores in Burn Patients

Pressure ulcers represent a complex clinical problem, with a reported incidence of 2.7% to 29.5% in hospitalized patients and an etiology that is multifactorial. The prevention of pressure sores in the burn patient population is clearly an area of practice in need of guidelines for care. A multidisciplinary group of advanced burn care professionals have compiled, critiqued, and summarized herein the current evidence of practice in nursing, nutrition, and rehabilitation as it pertains to the prevention of pressure sores after burn injuries. A broad overview of risk factors and assessment scales is described, and current intervention practices and recommendations for care are provided based, whenever possible, on research findings. In addition, research questions are generated in an attempt to move the specialty of burns toward the formal investigation of pressure sores with the ultimate goal being the development of evidence-based practice guidelines.

Development and testing of patient satisfaction measure for inpatient psychiatry care

Patient satisfaction is one of the most important indicators for service excellence. Investigations have been done with population-specific patient satisfaction tools for psychiatric patients; however, there are few published measures for evaluating inpatient care. We developed and tested a 15-item instrument to evaluate the interdisciplinary care model and therapeutic interventions. Results demonstrated reliability and validity of the tool.

Nurse Staffing and Patient Perceptions of Nursing Care

OBJECTIVE To examine the relationship between nurse staffing and patient perceptions of nursing care in a convenience sample of 40 California hospitals.

BACKGROUND

Growing concern about the adequacy of nurse staffing has led to an increased emphasis on research exploring the relationships between nurse staffing and patient outcomes. Patient satisfaction with nursing care is one of the 21 indicators identified by the American Nurses Association as having a strong "theoretical link to the availability and quality of professional nursing services in hospital settings." This prospective study examined the relationship between nurse staffing and patient perceptions of nursing care in multiple hospitals using common definitions of both nurse staffing and patient perceptions of care.

METHODS

Nurse staffing (structural variables) and patient perceptions of nursing care (outcome variables) from hospitals participating in both the ongoing California Nursing Outcomes Coalition statewide database project and the statewide Patients' Evaluation of Performance in California project, with data available on both measures for the same time periods, were examined. Analytic methods included both descriptive and inferential statistics.

RESULTS

Hospitals with wide ranges of staffing levels showed similar results in patient perceptions of nursing care. Regression analysis revealed a statistically significant relationship between nursing hours per patient day, and 1 of the 6 dimensions of care measured ("respect for patient's values, preferences, and expressed needs").

CONCLUSIONS

Nurse staffing alone showed a significant but weak relationship to patient perceptions of their care, indicating that staffing is likely only one of several relevant variables influencing patient perceptions of their nursing care. This research contributes data to the body of knowledge regarding nurse staffing. It is essential that nurse executives integrate results from this and other studies in developing strategic and tactical staffing plans that yield positive patient care outcomes.

Professional nursing practice: impact on organizational and patient outcomes

OBJECTIVE

To test a causal model of the impact of (a) nursing unit context on professional nursing practice; (b) professional practice on selected organizational (nurses' work satisfaction, nursing turnover, average length of patient stay) and patient outcomes (patient satisfaction, rate of reported medication errors, and falls); and (c) nursing unit context on these same organizational and patient outcomes.

SUMMARY BACKGROUND DATA

Professional nursing practice has been linked to positive outcomes for both nurses and patients. In contrast to other studies, this study focuses on professional nursing practice specifically at the nursing unit level, and uses a new analytic technique that permits examination of the simultaneous effects of professional nursing practice on both organizational and patient outcomes.

METHODS

Data were collected from 1682 registered nurses, and 1326 patients on 124 general medical-surgical nursing units in 64 general short-term acute care hospitals in the southeast. Multilevel structural equation modeling was used to analyze the data.

RESULTS

We found that professional nursing practice had consistent effects across model levels on nursing satisfaction, but very limited effects on other outcomes. Important differences in the hospital- and nursing unit level models support continued use of multilevel modeling techniques in the study of organizational and patient outcomes.

Report cards: relevance for nursing and patient care safety

The emergence of health care report cards in the North American environment is outlined. While it is evident that substantial activity has emerged, the majority of these initiatives excluded nursing, or use a broad indicator for nursing that may not provide meaningful representations of the quality of nursing care provided in the system and the relevance of this care to patient care safety. Given that nurses are the primary care provider in health care settings, this represents a significant gap in health care report cards. The pioneering work of the American Nurses Association (ANA) Nursing Report Card in the development and validation of report card indicators for nursing is discussed. Challenges related to data availability and data quality are identified. Potential opportunities for linking nursing practice outcomes to patient care quality and patient safety through a report card process are outlined.

Performance management data systems for nursing service organizations

Increasing demands are being placed on nursing administrators to manage the cost-efficiency and quality-effectiveness of the nursing service organization. One effective administrative tool that can be used for both internal management and external reporting of a nursing service organization performance is the performance management data system described in this article. While efforts are underway to build essential elements of a performance management data system, including the structure and content of nursing-sensitive databases and data management methods, no consensus has been reached. The author reviews the relevant literature and offers guidelines to take the nursing administrator through the process of developing a performance management data system. Beginning with a conceptualization of the nursing service organization as a system, the 5-phased process moves through data variable selection, data variable measurement, and data analysis to the final internal and external reporting of the organization's performance.

Lessons learned while collecting ANA indicator data

Realizing the importance of linking nursing's contribution to quality patient care, a pilot study was conducted to determine whether data regarding the quality indicators proposed by the American Nurses' Association (ANA) could be collected from five acute-care inpatient units at one medical center that is part of a multisite managed care system. Although it was determined that data regarding the ANA quality indicators could be collected at the study site, a variety of unanticipated findings emerged. These findings reflect both discrepancies and congruities between how the investigative team expected the ANA indicators to operate versus what was actually experienced. The lessons learned while collecting ANA indicator data are shared to assist future users and to advance the evolution of the ANA indicators.

Implementing nursing caring standards in the emergency department

Caring is a core characteristic of the profession of nursing. The author describes the implementation of performance and communication nursing caring standards in an emergency department (ED) to improve patient satisfaction, a significant quality outcome measure for healthcare providers. ED patient satisfaction with the "care and concern by nurses" increased 6.6% after the caring standards were implemented. The development of concrete ED customer service standards appears to be effective in improving caring behaviors by staff and patient satisfaction.

Developing a multi-institutional nursing report card

As regulatory and public interest groups demand information on the quality of patient care outcomes produced by their hospitals and care providers, nurse administrators are establishing processes for the effective and efficient definition, retrieval, and reporting of patient outcomes thought to be nursing-sensitive. The authors describe the administrative infrastructure and the data management processes used by one large integrated healthcare system to establish a nursing report card and maintain it for several years.

Outcomes management: from concepts to application

This article provides an introduction to the definition of and rationale for outcomes management and includes a brief review of the outcomes management literature. A model for outcomes management, which links processes that can be changed in care delivery to outcomes that can be measured in a patient population, is reviewed. Guidelines for application of the outcomes management model and practical examples of application to two surgical patient populations are presented. Finally, issues important to outcomes management as a tool for performance improvement are discussed.

The use of unlicensed assistive personnel: an update and skeptical look at a role that may present more problems than solutions

Patients implicitly rely on nurses to be their advocate. They trust nurses for health care information (92%). Approximately three fourths of Americans rated nurses' honesty and ethics as either "high" or "very high, placing them above any other profession. It is time to reconsider the full implication of Florence Nightingale's admonition to do the sick no harm in terms of staffing.

A classification scheme for outcome indicators

PURPOSE

To provide a framework for classifying outcome indicators for a more comprehensive view of outcomes and quality.

METHODS

Review of outcomes literature published since 1974 from medicine, nursing, and health services research to identify indicators. Outcome indicators were clustered inductively.

FINDINGS

Three groups of outcome indicators were identified: patient-focused, provider-focused, and organization-focused. Although investigators tend to focus on a select few outcome indicators, such as patient satisfaction, quality of life, and mortality, many indicators exist to measure outcomes.

CONCLUSIONS

Selecting and integrating a wide array of outcome indicators from the various categories will provide a more balanced view of health care delivery as compared with focusing on a few common indicators or only one category.