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Abstract
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.
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Mallidou AA, Cummings GG, Estabrooks CA, Giovannetti PB. Nurse specialty subcultures and patient outcomes in acute care hospitals: A multiple-group structural equation modeling. Int J Nurs Stud 2010; 48:81-93. [PMID: 20598308 DOI: 10.1016/j.ijnurstu.2010.06.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 05/08/2010] [Accepted: 06/01/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hospital organizational culture is widely held to matter to the delivery of services, their effectiveness, and system performance in general. However, little empirical evidence exists to support that culture affects provider and patient outcomes; even less evidence exists to support how this occurs. OBJECTIVES To explore causal relationships and mechanisms between nursing specialty subcultures and selected patient outcomes (i.e., quality of care, adverse patient events). METHOD Martin's differentiation perspective of culture (nested subcultures within organizations) was used as a theoretical framework to develop and test a model. Hospital nurse subcultures were identified as being reflected in formal practices (i.e., satisfactory salary, continuing education, quality assurance program, preceptorship), informal practices (i.e., autonomy, control over practice, nurse-physician relationships), and content themes (i.e., emotional exhaustion). A series of structural equation models were assessed using LISREL on a large nurse survey database representing four specialties (i.e., medical, surgical, intensive care, emergency) in acute care hospitals in Alberta, Canada. RESULTS Nursing specialty subcultures differentially influenced patient outcomes. Specifically, quality of care (a) was affected by nurses' control over practice, (b) was better in intensive care than in medical specialty, and (c) was related to lower adverse patient events; nurses in intensive care and emergency specialties reported fewer adverse events than did their counterparts in medical specialties. CONCLUSIONS Understanding the meaning of subcultures in clinical settings would influence nurses and administrators efforts to implement clinical change and affect outcomes. More research is needed on nested subcultures within healthcare organizations for better understanding differentiated subspecialty effects on complexity of care and outcomes in hospitals.
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Frequencies of falls in Swiss hospitals: Concordance between nurses’ estimates and fall incident reports. Int J Nurs Stud 2009; 46:164-71. [DOI: 10.1016/j.ijnurstu.2008.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Revised: 09/11/2008] [Accepted: 09/12/2008] [Indexed: 11/17/2022]
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Manojlovich M, DeCicco B. Healthy Work Environments, Nurse-Physician Communication, and Patients’ Outcomes. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.6.536] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background Adverse events and serious errors are common in critical care. Although factors in the work environment are important predictors of adverse outcomes for patients, communication between nurses and physicians may be the most significant factor associated with excess hospital mortality in critical care settings.
Objectives To examine the relationships between nurses’ perceptions of their practice environment, nurse-physician communication, and selected patients’ outcomes.
Methods A nonexperimental, descriptive design was used, and all nurses (N=866) working in 25 intensive care units in southeastern Michigan were surveyed. The Conditions for Work Effectiveness Questionnaire-II and the Practice Environment Scale of the Nursing Work Index were used to measure characteristics of the work environment; the ICU Nurse-Physician Questionnaire was used to measure nurse-physician communication. Nurses self-rated the frequency of ventilator-associated pneumonia, catheter-related sepsis, and medication errors in patients under their care.
Results A total of 462 nurses (53%) responded. According to multilevel modeling, both practice environment scales accounted for 47% of the variance in nurse-physician communication scores (P=.001). Nurse-physician communication was predictive of nurse-assessed medication errors only (R2=0.11). Neither environment scale was predictive of any of the patient outcomes.
Conclusions Healthy work environments are important for nurse-physician communication. In intensive care units, characteristics of the work environment did not vary enough to be significantly predictive of outcomes, suggesting that even in various types of critical care units, characteristics of the work environment may be more similar than different.
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Affiliation(s)
- Milisa Manojlovich
- Milisa Manojlovich is an assistant professor in the School of Nursing, University of Michigan
| | - Barry DeCicco
- Barry DeCicco is a statistician staff specialist in the customer research section of the quality improvement department at the University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan
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Kovner C, Gergen PJ. Nurse Staffing Levels and Adverse Events Following Surgery in U.S. Hospitals. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1547-5069.1998.tb01326.x] [Citation(s) in RCA: 239] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lee B. Identifying outcomes from the nursing outcomes classification as indicators of quality of care in Korea: A modified delphi study. Int J Nurs Stud 2007; 44:1021-8. [DOI: 10.1016/j.ijnurstu.2006.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2005] [Revised: 01/21/2006] [Accepted: 03/28/2006] [Indexed: 10/24/2022]
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Abstract
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.
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Manojlovich M. Linking the practice environment to nurses' job satisfaction through nurse-physician communication. J Nurs Scholarsh 2006; 37:367-73. [PMID: 16396411 DOI: 10.1111/j.1547-5069.2005.00063.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate direct and indirect relationships among the practice environment, nurse-physician (RN-MD) communication, and job satisfaction, as is posited in the nursing role effectiveness model (NREM). DESIGN Survey. METHODS Surveys were sent to a random sample of 500 hospital nurses throughout Michigan, and 332 (66%) responded. Main study instruments were the Conditions for Work Effectiveness Questionnaire-II (CWEQ-II), the Practice Environment Scale of the Nursing Work Index (PES-NWI), the ICU Nurse-Physician Questionnaire, and the Index of Work Satisfaction (IWS), Part B. Inferential statistical tests included multiple regression, t tests, and one-way analysis of variance. FINDINGS Practice environment (PES-NWI) and empowerment (CWEQ-II) scales explained 20% of the variance in RN-MD communication. The combination of both environment scales (PES-NWI and CWEQ-II) and RN-MD communication explained 61% of the variance in nursing job satisfaction scores. RN-MD communication was also a significant mediating variable in the relationship between structure (practice environment and empowerment scales) and outcome (nursing job satisfaction). CONCLUSIONS Factors in the practice environment contributed both directly to nursing job satisfaction and also indirectly through RN-MD communication. Study findings showed that a practice environment favorable to nurses improved both nurses' perceptions of their communications with physicians and their job satisfaction.
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Affiliation(s)
- Milisa Manojlovich
- University of Michigan, School of Nursing, Ann Arbor, MI 48109-0482, USA.
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McBride-Henry K, Foureur M. Organisational culture, medication administration and the role of nurses. ACTA ACUST UNITED AC 2006. [DOI: 10.1002/pdh.207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Schwendimann R, Joos F, Geest SD, Milisen K. Are patient falls in the hospital associated with lunar cycles? A retrospective observational study. BMC Nurs 2005; 4:5. [PMID: 16225704 PMCID: PMC1274330 DOI: 10.1186/1472-6955-4-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Accepted: 10/17/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Falls and associated negative outcomes in hospitalized patients are of significant concerns. The etiology of hospital inpatient falls is multifactorial, including both intrinsic and extrinsic factors. Anecdotes from clinical practice exist in which health care professionals express the idea that the number of patient falls increases during times of full moon. The aim of this study was to examine in-hospital patient fall rates and their associations with days of the week, months, seasons and lunar cycles. METHODS 3,842 fall incident reports of adult in-patients who fell while hospitalized in a 300-bed urban public hospital in Zurich, Switzerland were included. Adjusted fall rates per 1'000 patient days were compared with days of the week, months, and 62 complete lunar cycles from 1999 to 2003. RESULTS The fall rate per 1000 patient days fluctuated slightly over the entire observation time, ranging from 8.4 falls to 9.7 falls per month (P = 0.757), and from 8.3 falls on Mondays to 9.3 falls on Saturdays (P = 0.587). The fall rate per 1000 patient days within the lunar days ranged from 7.2 falls on lunar day 17 to 10.6 falls on lunar day 20 (P = 0.575). CONCLUSION The inpatient fall rates in this hospital were neither associated with days of the week, months, or seasons nor with lunar cycles such as full moon or new moon. Preventive strategies should be focused on patients' modifiable fall risk factors and the provision of organizational conditions which support a safe hospital environment.
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Affiliation(s)
- René Schwendimann
- Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
- Stadtspital Waid Zurich, Switzerland
| | - Franco Joos
- Institute of Astronomy, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Sabina De Geest
- Institute of Nursing Science, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
- Center for Health Services and Nursing Research, Catholic University of Leuven, Leuven, Belgium
| | - Koen Milisen
- Center for Health Services and Nursing Research, Catholic University of Leuven, Leuven, Belgium
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Abstract
Outcome research in nursing has been criticized for being atheoretical. Although there has been research investigating patient mortality as an outcome, there has been little discussion about models or theories of nursing-related determinants of mortality for hospitalized patients. Yet, unnecessary patient mortality is an important patient safety outcome. This article describes development of beginning theory of determinants of patient mortality culminating with a revised mortality model. Conclusions are made related to plans for further testing and refinement of the revised mortality model. Further, the utility of the proposed model in practice is discussed.
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Affiliation(s)
- Ann E Tourangeau
- Faculty of Nursing, University of Toronto, Ontario Ministry of Health and Long-term Care, and Institute for Clinical Evaluative Sciences in Ontario, Toronto, Canada.
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12
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Abstract
This article describes one risk-adjustment method useful for minimizing threats to internal validity that stem from the impact on the outcomes under investigation from patients' own characteristics and their associated risks. Mortality is the outcome used to illustrate the risk-adjustment approach. A two-step approach to outcomes research is suggested. The first step includes risk-adjusting outcomes for patient characteristics by developing standard mortality rates. In the second step these risk-adjusted standard rates can be used as dependent variables in outcomes analytic models. This article focuses on the first step. In the current study risk adjustment resulted in changes in both absolute values and rank ordering of hospital mortality rates compared to crude rates. This procedure is useful for developing risk-adjusted outcomes with administrative data similar to those used in this study.
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Affiliation(s)
- Ann E Tourangeau
- Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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Abstract
BACKGROUND DATA Limited research has been conducted examining the effect of nurse staffing models on costs and patient outcomes. OBJECTIVE The objective of this study was to evaluate the effect of different nurse staffing models on costs and the patient outcomes of patient falls, medication errors, wound infections, and urinary tract infections. METHODS A descriptive correlational study was conducted in all of the 19 teaching hospitals in Ontario, Canada. The sample comprised hospitals and adult medical, surgical, and obstetric inpatients within those hospitals. RESULTS The lower the proportion of professional nursing staff employed on a unit, the higher the number of medication errors and wound infections. The less experienced the nurse, the higher the number of wound infections. Nurse staffing models that included a lower proportion of professional nursing staff in the mix used more nursing hours in this study. CONCLUSIONS The results of this study suggest that a higher proportion of professional nurses in the staff mix (RNs/RPNs) on medical and surgical units in Ontario teaching hospitals are associated with lower rates of medication errors and wound infections. Higher patient complexity was associated with greater patient use of nursing care resources.
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Affiliation(s)
- Linda McGillis Hall
- Nursing Effectiveness, Utilization, and Outcomes Research Unit, Faculty of Nursing, University of Toronto, Ontario.
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Abstract
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.
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Affiliation(s)
- L McGillis Hall
- Canadian Institutes of Health Research, Faculty of Nursing, Nursing Effectiveness, Utilization, and Outcomes Research Unit, University of Toronto, Ontario.
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Jackson M, Chiarello LA, Gaynes RP, Gerberding JL. Nurse staffing and health care-associated infections: Proceedings from a working group meeting. Am J Infect Control 2002; 30:199-206. [PMID: 12032494 DOI: 10.1067/mic.2002.123416] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The nation is facing a nursing shortage that is creating a crisis for quality health care and patient safety. Research has documented that problems with nurse staffing are associated with health care-associated infections and other adverse events that affect patient outcomes. These ominous facts, stated during the opening of an expert consultants meeting convened by the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, laid the foundation for a day-long discussion and a call to action to address a growing crisis in health care. The authors summarize the proceedings of this meeting and present the consultants' suggestions for drawing national attention to this issue.
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Affiliation(s)
- Marguerite Jackson
- Department of Education Development and Research, University of California at San Diego, CA, USA
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Jackson M, Chiarello LA, Gaynes RP, Gerberding JL. Nurse staffing and healthcare-associated infections: proceedings from a working group meeting. J Nurs Adm 2002; 32:314-22. [PMID: 12055487 DOI: 10.1097/00005110-200206000-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The nation is facing a nursing shortage that is creating a crisis for quality healthcare and patient safety. Research has documented that problems with nurse staffing are associated with healthcare-associated infections and other adverse events that affect patient outcomes. These ominous facts, stated during the opening of an expert consultants meeting convened by the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, laid the foundation for a day-long discussion and a call to action to address a growing crisis in healthcare. The authors summarize the proceedings of this meeting and present the consultants' suggestions for drawing national attention to this issue.
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Affiliation(s)
- Marguerite Jackson
- Department of Education Development and Research, University of California at San Diego, Calif , USA
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17
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Kovner C, Jones C, Zhan C, Gergen PJ, Basu J. Nurse staffing and postsurgical adverse events: an analysis of administrative data from a sample of U.S. hospitals, 1990-1996. Health Serv Res 2002; 37:611-29. [PMID: 12132597 PMCID: PMC1434654 DOI: 10.1111/1475-6773.00040] [Citation(s) in RCA: 158] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the impact of nurse staffing on selected adverse events hypothesized to be sensitive to nursing care between 1990 and 1996, after controlling for hospital characteristics. DATA SOURCES/STUDY SETTING The yearly cross-sectional samples of hospital discharges for states participating in the National Inpatient Sample (NIS) from 1990-1996 were combined to form the analytic sample. Six states were included for 1990-1992, four states were added for the period 1993-1994, and three additional states were added in 1995-1996. STUDY DESIGN The study design was cross-sectional descriptive. DATA COLLECTION/EXTRACTION METHODS Data for patients aged 18 years and older who were discharged between 1990 and 1996 were used to create hospital-level adverse event indicators. Hospital-level adverse event data were defined by quality indicators developed by the Health Care Utilization Project (HCUP). These data were matched to American Hospital Association (AHA) data on community hospital characteristics, including registered nurse (RN) and licensed practical/vocational nurse (LPN) staffing hours, to examine the relationship between nurse staffing and four postsurgical adverse events: venous thrombosis/pulmonary embolism, pulmonary compromise after surgery, urinary tract infection, and pneumonia. Multivariate modeling using Poisson regression techniques was used. PRINCIPAL FINDINGS An inverse relationship was found between RN hours per adjusted inpatient day and pneumonia (p < .05) for routine and emergency patient admissions. CONCLUSIONS The inverse relationship between pneumonia and nurse staffing are consistent with previous findings in the literature. The results provide additional evidence for health policy makers to consider when making decisions about required staffing levels to minimize adverse events.
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Affiliation(s)
- Christine Kovner
- Division of Nursing, School of Education, New York University, New York 10003-6677, USA
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Breslin E, Burns M, Moores P. Challenges of outcomes research for nurse practitioners. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2002; 14:138-43. [PMID: 11924337 DOI: 10.1111/j.1745-7599.2002.tb00105.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe the numerous methodological challenges nurse practitioners (NPs) face in designing and conducting outcomes research and provide practical tips to implement an outcomes study within an institution. DATA SOURCES Review of world wide scientific literature on outcomes research. CONCLUSIONS Nurse practitioners must be aware of the challenges of conducting outcomes research. Challenges associated with variable definition, designing outcomes studies, use of data sets, and instrument development and selection must be understood prior to undertaking an outcome study. IMPLICATIONS FOR PRACTICE Valuable studies have laid a foundation for evidence of quality care provision by NPs. Now is the time to measure patient outcomes of the NP care longitudinally over significant periods of time.
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Affiliation(s)
- Eileen Breslin
- University of Massachusetts, School of Nursing, Amherst, Mass., USA.
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Abstract
AIM To describe the proposed Culturally Competent Community Care (CCCC) model, and the process of development and testing of the model. BACKGROUND Community health nurses are challenged to provide culturally competent care in all types of communities. However, existing models have not provided community nurses with specific guidelines, and none attempt to explain the effects of culturally competent care on populations in community settings. Therefore, it is necessary to develop a model that is comprehensive in its description of the dimensions of culturally competent care in community-based settings and that also requires a focus on ethnic populations. The model is essential for reducing racial and ethnic health disparities. METHODS Based on literature review and concept analysis, three constructs of the Culturally Competent Community Care Model were developed. Two of the constructs, the health care system and health outcomes, were developed based on a literature review. The main construct of the model, cultural competence, was developed after a concept analysis, following the development and testing of the Cultural Competence Scale (CCS). Interviews with eight community health nurses and a survey by five community nurse experts were conducted in order to refine and confirm the dimensions of cultural competence and its impact on health outcomes. CONCLUSIONS The proposed dimensions of culturally competent care are caring, cultural sensitivity, cultural knowledge, and cultural skills. This model focuses on the relationship between cultural competence and health outcomes for culturally diverse populations. The framework provides specific guidelines for community nurses in developing and assessing cultural competence and meeting the health needs of diverse communities.
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Affiliation(s)
- Y S Kim-Godwin
- School of Nursing, University of North Carolina at Wilmington, North Carolina 28403, USA.
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Kovner C. The impact of staffing and the organization of work on patient outcomes and health care workers in health care organizations. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 2001; 27:458-68. [PMID: 11556255 DOI: 10.1016/s1070-3241(01)27040-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Numerous reports in the popular press express concern about the restructuring or lowering of staffing levels in health care organizations and the impact on the quality of patient care. Overtime and other extended shifts also represent work stresses for health care workers. This article reviews the research literature on the relationships among staffing, organization of work, and patient outcomes, and it discusses research findings on the relationship between staffing and the health of health care workers. RESEARCH ON STAFFING, ORGANIZATION, AND PATIENT OUTCOMES/STAFF WELL-BEING: Safe staffing level requirements have been identified for nursing homes, but only in extremely limited cases for hospitals, home care, or other health settings. There is little information about the impact of staffing levels and the organization of work on health personnel or on patient outcomes. There is almost no information about staffing and patient outcomes in home health and ambulatory care. Much of the research on staffing and quality has been discipline specific; future research should reflect the interdisciplinary nature of health care delivery rather than the impact of a particular occupation. RESEARCH USE Research is conducted to increase the scientific base per se and to inform decision making. Who should decide staffing levels and the organization of work? Professionals, employers/owners, the government, and consumers all have significant interest in staffing levels and the organization of care. Improving health care quality requires research about the critical staffing and organization of work variables. This requires obtaining appropriate data, conducting the research, and widely disseminating the findings.
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Affiliation(s)
- C Kovner
- Hartford Institute for Geriatric Nursing, Division of Nursing, School of Education, New York University, New York City, USA.
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Abstract
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.
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Affiliation(s)
- G R Whitman
- University of Pittsburgh, School of Nursing, Pennsylvania, USA
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Abstract
Advanced practice nurses (APNs) in the USA are registered nurses who hold masters or doctoral degrees in a specialized area of nursing. They provide advanced clinical care to clients, manage health care systems and influence health care decision-making through expert clinical reasoning and research and theory-based action. APN impact on health care outcomes is supported by studies using physician-focused indicators, although a few studies have identified several that are sensitive to or reflective of advanced practice nursing. A modified Delphi survey was conducted during May 1997-December 1998 to determine the outcome indicators APNs recommend for use in measuring their effect on care delivery outcomes. A convenience sample of 66 APNs attending a statewide outcomes conference identified 27 potential outcome indicators. These indicators were included in a mailed survey sent to APNs working in Tennessee. Respondents were asked to rate each indicator for validity, sensitivity, feasibility, utility and cost. In the second round of the survey, they were asked whether or not they agreed with the rank ordering of indicators, which was determined by the means calculated from responses in the first round. The 10 highest ranked indicators were satisfaction with care delivery, symptom resolution/reduction, perception of being well cared for, compliance/adherence with treatment plan, knowledge of patients and families, trust of care provider, collaboration among care providers, frequency and type of procedures ordered and quality of life. APNs identified both direct and indirect measures of effect on care delivery outcomes. Some of these are currently used as indicators of advanced practice, but many are not. Additional research is needed to determine whether the indicators proposed are valid and sensitive to advanced practice care by nurses.
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Affiliation(s)
- G L Ingersoll
- Director of Clinical Nursing Research, Strong Memorial Hospital, Rochester, New York, USA.
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Perkins SB, Connerney I, Hastings CE. Outcomes management: from concepts to application. AACN CLINICAL ISSUES 2000; 11:339-50. [PMID: 11276649 DOI: 10.1097/00044067-200008000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- S B Perkins
- University of Maryland Medical Center, 29 S. Greene Street, Baltimore, MD 21201, USA.
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Baker CM, Messmer PL, Gyurko CC, Domagala SE, Conly FM, Eads TS, Harshman KS, Layne MK. Hospital ownership, performance, and outcomes: assessing the state-of-the-science. J Nurs Adm 2000; 30:227-40. [PMID: 10823176 DOI: 10.1097/00005110-200005000-00004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study 1) identified the research evidence; 2) assessed the state-of-the-science surrounding hospital ownership, performance, and outcomes in acute care hospitals in the United States; and 3) identified measurable components of hospital performance and outcomes for the organization, patient, and community. BACKGROUND As the size of the nonprofit sector decreases and the size of the for-profit sector increases, hospital ownership warrants examination. Most research has focused on either ownership and performance or ownership and outcomes, rather than the potential interaction of all three variables. METHODS A comprehensive, computerized search of the healthcare research literature yielded 69 data-based references published between 1985 and 1999. Coding sheets were developed to abstract the articles. Analysis involved synthesizing the research evidence for each of the three major variables and their components. RESULTS Hospital ownership has an impact on hospital performance in relation to system operations; costs, prices, and financial management practices; and personnel issues. Organizational outcomes are similar among hospital ownership types in relation to increasing administrative costs and overall mediocre efficiency. Organizational outcomes differ among hospital ownership types in relation to nursing staff mix and professional satisfaction. The association of hospital ownership with patient outcomes varies depending on the dimension measured. The evidence is mixed or inconclusive regarding hospital ownership and access to care, morbidity, and mortality. The association of hospital ownership and adverse events is consistently supported. Hospital ownership status has an impact on the type and magnitude of community benefits. Differences among the three hospital ownership types are minimized in a competitive market. CONCLUSIONS This study reinforces the position that nurse researchers need to include hospital ownership as an important structural variable in their studies of hospital-based nursing. Examining the conceptual links between ownership, performance, and outcomes requires the integration of macro-level and micro-level theory.
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Affiliation(s)
- C M Baker
- Indiana University School of Nursing, Indianapolis, USA.
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Jennings BM, Staggers N, Brosch LR. A classification scheme for outcome indicators. IMAGE--THE JOURNAL OF NURSING SCHOLARSHIP 2000; 31:381-8. [PMID: 10628106 DOI: 10.1111/j.1547-5069.1999.tb00524.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Abstract
OBJECTIVE The purpose of this study was to develop an easy, practical list of outcomes amenable to community health nursing interventions. This study sought to answer the following question: What outcomes are sensitive to nursing interventions in the community health setting? SUMMARY BACKGROUND DATA Nursing literature discusses many client outcomes. However, available outcome lists are not always sensitive to nursing interventions by community health nurses. Nurses need a precise list to measure client outcomes resulting from contact between nurses and clients in a variety of community health settings. METHODS AND SUBJECTS The study used a modified Delphi technique to ensure adequate response from the subjects. Initially, focus groups generated items for the Delphi questionnaires. Using items from the focus groups, the researchers developed three rounds of questionnaires. In each round, nurses stated a level of agreement with each item as an outcome for community health nurses. Twenty-two community health nurses in one Southeastern state participated in four focus groups. One hundred fifty-two community health nurses returned round 1 questionnaires, 68 nurses returned round 2 questionnaires, and 48 nurses returned round 3 questionnaires. RESULTS The researchers grouped the outcomes into four domains: client's psychosocial components of care, client's physiologic components of care, nursing intervention/implementation components of care, and environmental/community safety components of care. CONCLUSIONS The findings produced an easy, practical list of 48 nursing outcomes for use in decision making and research by community health nurses in all settings.
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Affiliation(s)
- J Alexander
- College of Nursing, University of South Carolina, Columbia, USA.
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Abstract
Measuring nursing-sensitive patient outcomes using publicly available data provides exciting opportunities for the nursing profession to quantify the patient care impact of staffing changes at individual hospitals and to make comparisons among hospitals with differing staffing patterns. Using data from California and New York, this study tested the feasibility of measuring such outcomes in acute care hospitals and examining relationships between these outcomes and nurse staffing. Nursing intensity weights were used to acuity-adjust the patient data. Both higher nurse staffing and higher proportion of RNs were significantly related to shorter lengths of stay. Lower adverse outcome rates were more consistently related to a higher proportion of RNs.
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Abstract
OBJECTIVE The purpose of this study was to describe relationships among adverse patient occurrences aggregated at the unit level of measurement. Relationships between adverse occurrences and a patient acuity measure were also described. BACKGROUND Adverse patient occurrence data have been traditionally a major indicator of quality care in hospitals; however, few studies have examined relationships among these indicators or the usefulness of these indicators for assessing the quality of nursing care. METHODS A correlational design was used to examine and describe patterns of relationships among in-patient units in a tertiary care hospital. The results demonstrated positive correlations between medication error rates and patient falls; these adverse occurrences correlated negatively with pressure ulcers, infections, patient complaints, and death. Pressure ulcers, infections, patient complaints and death intercorrelated positively and also related positively to patient acuity levels. RESULTS An examination of these same rates for a subset of units with similar patient acuity levels revealed that most of the interrelationships among the entire set of adverse occurrence indicators were positive. When patient acuity was taken into account, these adverse outcomes appeared to indicate some common underlying characteristic of the units, such as quality of nursing care. CONCLUSIONS This study suggests a relationship between the adverse occurrences that were correlated (pressure ulcers, patient complaints, infection, and death) and the severity of patient illness. Medication error rates and patient fall rates were not correlated with patient acuity and are more likely to indicate quality of nursing care across all types of units.
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Affiliation(s)
- L Reed
- University of Iowa Hospitals and Clinics, USA
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Affiliation(s)
- G L Ingersoll
- Vanderbilt University School of Nursing, Nashville, TN, USA
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Abstract
BACKGROUND Nursing studies have shown that nursing care delivery changes affect staff and organizational outcomes, but the effects on client outcomes have not been studied sufficiently. OBJECTIVE To describe, at the level of the nursing care unit, the relationships among total hours of nursing care, registered nurse (RN) skill mix, and adverse patient outcomes. METHODS The adverse outcomes included unit rates of medication errors, patient falls, skin breakdown, patient and family complaints, infections, and deaths. The correlations among staffing variables and outcome variables were determined, and multivariate analyses, controlling for patient acuity, were completed. RESULTS Units with higher average patient acuity had lower rates of medication errors and patient falls but higher rates of the other adverse outcomes. With average patient acuity on the unit controlled, the proportion of hours of care delivered by RNs was inversely related to the unit rates of medication errors, decubiti, and patient complaints. Total hours of care from all nursing personnel were associated directly with the rates of decubiti, complaints, and mortality. An unexpected finding was that the relationship between RN proportion of care was curvilinear; as the RN proportion increased, rates of adverse outcomes decreased up to 87.5%. Above that level, as RN proportion increased, the adverse outcome rates also increased. CONCLUSIONS The higher the RN skill mix, the lower the incidence of adverse occurrences on inpatient care units.
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Affiliation(s)
- M A Blegen
- College of Nursing, University of Iowa, Iowa City, USA
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Abstract
It is increasingly more important that nurse executives systematically evaluate innovations and changes in nursing practice and management. To plan effectively, data elements that are most appropriate for decision making must be identified and strategies for data collection and analysis must be formulated. The author describes a model in which an identifiable group of clinical, fiscal, quality, productivity, and care provider variables serve as data for baseline and later comparative evaluations.
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Affiliation(s)
- L D Urden
- Patient Care Services, Butterworth Hospital, Grand Rapids, Michigan, USA
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Burns M, Moores P, Breslin E. Outcomes research: contemporary issues and historical significance for nurse practitioners. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 1996; 8:107-12. [PMID: 8788723 DOI: 10.1111/j.1745-7599.1996.tb00640.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Outcomes research is not new to the discipline of nursing. However, the driving forces of today's health care environment are resulting in increased emphasis on the study of outcomes. This article presents an overview of the scope of outcomes research, including a historical perspective and contemporary issues. Outcomes research provides an opportunity to demonstrate the effectiveness of nurse practitioner practice.
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Affiliation(s)
- M Burns
- Medical, Surgical and Critical Care Nursing Family Health, Baystate Medical Center, Springfield, Massachusetts, USA
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