Measuring nurses' impact on health care quality: progress, challenges, and future directions

Patient-reported outcomes of psychiatric and/or mental health nursing in hospitals: a systematic review protocol

INTRODUCTION

There is a lack of distinct and measurable outcomes in psychiatric and/or mental health nursing which negatively impacts guiding clinical practice, assessing evidence-based nursing interventions, ensuring future-proof nursing education and establishing visibility as a profession and discipline. Psychiatric and/or mental health nursing struggle to demonstrate patient-reported outcomes to assess the effectiveness of their practice. A systematic review that summarising patient-reported outcomes, associated factors, measured nursing care/interventions and used measurement scales of psychiatric and/or mental health nursing in the adult population in acute, intensive and forensic psychiatric wards in hospitals will capture important information on how care can be improved by better understanding what matters and what is important to patients themselves. This review can contribute to the design, planning, delivery and assessment of the quality of current and future nursing care METHODS AND ANALYSIS: This protocol follows the Cochrane methodological guidance on systematic reviews of interventions and The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. The search strategy will be identified by consultations with clinical and methodological experts and by exploring the literature. The databases Ovid MEDLINE, CINAHL, EMBASE, APA PsychARTICLES, Web of Science and Scopus will be searched for all published studies. Studies will be screened and selected with criteria described in the population, intervention, control and outcomes format after a pilot test by two researchers. Studies will be screened in two stages: (1) title and abstract screening and (2) full-text screening. Data extraction and the quality assessment based on the Johanna Briggs Institute guidelines will be conducted by two researchers. Data will be presented in a narrative synthesis.

ETHICS AND DISSEMINATION

No ethical approval is needed since all data are already publicly accessible. The results of this work will be published in a peer-reviewed scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42023363806.

Nursing knowledge captured in electronic health records

PURPOSE

The purpose of this study was to describe the extent to which nursing assessment data was present in the electronic health record and linked to NANDA-I, NIC, and NOC.

METHODS

This retrospective review used a descriptive approach to examine documentation in the electronic health records (EHR) of 10 hospitalized patients requiring cardiac surgery. A team of experts applied a Delphi consensus-building process to identify the supports and barriers for nursing documentation.

FINDINGS

Collection of the health history was organized using Gordon's Functional Health Pattern (FHP) Framework. Seventy-five fields were noted for the entry of nursing assessment data of which 65 focused on health history data and 30 documented physical findings and observations. There were no references to the defining characteristics or etiologies with any of the diagnostic labels used. Care plans included the nursing diagnoses, goals of care, and interventions, although there was a lack of clear alignment between the assessment, NANDA-I, NIC, and NOC and the care plan. Progress note documentation addressed significant events in the patient's clinical course; however, these were not nursing problem or diagnosis focused. Four expert reviewers arrived at consensus regarding the supports and challenges impacting nurses' ability to document data depicting nursing's contribution to care using a FHP and standardized nursing language in the EHR.

CONCLUSIONS

The EHR provides an opportunity to reflect nursing clinical judgment and make nursing care visible. These findings suggest there are challenges to capturing nurse focused data elements in the EHR.

IMPLICATIONS FOR NURSING PRACTICE

This work has important implications for clinicians, educators, and administrators alike. EHR systems must accurately capture nurses' contribution to patient care to plan for resource allocation and quality care delivery. Ultimately, the development of standardized data sources reflecting the outcomes of nursing care will expand the opportunities to advance nursing knowledge.

Readiness-Based Implementation of Electronic Health Records: A Survey of Jordanian Nurses

Electronic health record (EHR) implementation is expanding worldwide to achieve the benefits of that technology, but it is reported in the literature as a "disruptive" change to the work environment in which all health-care workers need to be ready for the change, to enhance adoption and harvest the benefits. Jordan has rolled out a national EHR system. This study explored EHR implementation readiness, levels of realizing the benefits of EHR, and adoption among Jordanian nurses, using a self-report questionnaire at nine governmental hospitals in Jordan. A total of 462 registered nurses participated in the study. Results showed that nurses have moderate levels of readiness for EHR implementation, but higher levels of EHR benefits realization and adoption. All health-care workers' readiness for EHR implementation must be assessed regularly before, during, and after EHR implementation. Readiness-based roll-out can be used as a strategy in implementing EHR systems. Introducing a large-scale change management program is recommended to assess readiness, guide roll-out plans, enhance EHR implementation readiness, improve benefits realization, and increase EHR adoption levels, to help move health-care systems into the digital era.

The development and psychometric evaluation of the Mental Health Nurse-Sensitive Patient Outcome-Scale (MH-NURSE-POS) for inpatient psychiatric hospital settings

Mental health nurses are struggling to describe their nursing identity as professional discipline in a changing mental health care. Measuring nurse-sensitive patient outcomes and demonstrating nursing's effect(s) experienced by patients contribute to (re)discover the specific nursing identity. However, a valid and reliable scale is currently lacking. The aim of this study was the development and psychometric evaluation of the Mental Health Nurse-Sensitive Patient Outcome Scale (MH-NURSE-POS) for inpatient psychiatric hospital settings. This three-staged study resulted in a scale capturing how inpatients experience the contribution of nurses in their treatment in psychiatric hospitals. First, a draft questionnaire was developed based on a literature review, an independent expert's advice, and an experts panel. Second, the content validity was tested in a two-round Delphi-procedure and focus groups with patients. A pilot test, based on cognitive interviews, confirmed the feasibility of the questionnaire. Third, the psychometric properties of the mental health nurse-sensitive patient outcomes were determined in a sample of 353 patients. The cross-sectional study included a convenience sample of five psychiatric hospitals (Belgium). The factor structure (Kaiser-Meyer-Olkin measure of sampling adequacy 0.924; Bartlett's test of sphericity χ²  = 4162.537; df = 231; P < 0.001), convergent validity by the Individualized Care Scale (Pearson correlation 0.660; P < 0.001), and reliability (Cronbach's Alpha 0.854) were evaluated. The factor analysis resulted in a four-factor solution representing growth, expression, control, and motivation. The Mental Health Nurse-Sensitive Patient Outcome Scale is a valid and reliable tool to measure the effectiveness of mental health nurses from the patient perspective.

Current status and future directions of U.S. genomic nursing health care policy

BACKGROUND

As genomic science moves beyond government-academic collaborations into routine healthcare operations, nursing's holistic philosophy and evidence-based practice approach positions nurses as leaders to advance genomics and precision health care in routine patient care.

PURPOSE

To examine the status of and identify gaps for U.S. genomic nursing health care policy and precision health clinical practice implementation.

METHODS

We conducted a scoping review and policy priorities analysis to clarify key genomic policy concepts and definitions, and to examine trends and utilization of health care quality benchmarking used in precision health.

FINDINGS

Genomic nursing health care policy is an emerging area. Educating and training the nursing workforce to achieve full dissemination and integration of precision health into clinical practice remains an ongoing challenge. Use of health care quality measurement principles and federal benchmarking performance evaluation criteria for precision health implementation are not developed.

DISCUSSION

Nine recommendations were formed with calls to action across nursing practice workforce and education, nursing research, and health care policy arenas.

CONCLUSIONS

To advance genomic nursing health care policy, it is imperative to develop genomic performance measurement tools for clinicians, purchasers, regulators and policymakers and to adequately prepare the nursing workforce.

Nurse-Sensitive Quality Metrics to Benchmark in Pediatric Cardiovascular Care

BACKGROUND

Associations between the quality of nursing care and patient outcomes have been demonstrated globally. However, translation and application of this evidence to robust measurement in pediatric specialty nursing care has been limited.

OBJECTIVES

To test the feasibility and performance of nurse-sensitive measures in pediatric cardiovascular programs.

METHODS

Ten nurse-sensitive measures targeting nursing workforce, care process, and patient outcomes were implemented, and measurement data were collected for 6 months across 9 children's hospitals in the Consortium of Congenital Cardiac Care-Measurement of Nursing Practice (C4-MNP). Participating sites evaluated the feasibility of collecting data and the usability of the data.

RESULTS

Variations in nursing workforce characteristics were reported across sites, including proportion of registered nurses with 0 to 2 years of experience, nursing education, and nursing certification. Clinical measurement data on weight gain in infants who have undergone cardiac surgery, unplanned transfer to the cardiac intensive care unit, and pain management highlighted opportunities for improvement in care processes. Overall, each measure received a score of 75% or greater in feasibility and usability.

CONCLUSIONS

Collaborative evaluation of measurement performance, feasibility, and usability provided important information for continued refinement of the measures, development of systems to support data collection, and selection of benchmarks across C4-MNP. Results supported the development of target benchmarks for C4-MNP sites to compare performance, share best practices for improving the quality of pediatric cardiovascular nursing care, and inform nurse staffing models.

Dissemination and Implementation of Patient-centered Indicators of Pain Care Quality and Outcomes

BACKGROUND

Previous approaches to measuring and improving nursing-sensitive, patient-centered metrics of pain quality and outcomes in hospitalized patients have been limited.

METHODS

In this translational research study, we disseminated and implemented pain quality indicators in 1611 medical and/or surgical, step-down, rehabilitation, critical access, and obstetrical (postpartum) units from 326 US hospitals participating in the National Database of Nursing Quality Indicators. Eligible patients were English-speaking adults in pain. Trained nurses collected patients' perceptions via structured interview including 9 pain quality indicators, demographic, and clinical variables; these patient experience data were merged with unit and hospital level data. Analyses included geographic mapping; summary statistics and 3-level mixed effects modeling.

RESULTS

Hospitals in 45 states and District of Columbia participated. Of 22,293 screened patients, 15,012 were eligible; 82% verbally consented and participated. Pain prevalence was 72%. Participants were 59.4% female; ages ranged from 19 to 90+ (median: 59 y); 27.3% were nonwhite and 6.5% were Hispanic. Pain intensity on average over the past 24 hours was 6.03 (SD=2.45) on a 0-10 scale. 28.5% of patients were in severe pain frequently or constantly. Race (nonwhite), younger age, being female and nonsurgical were associated (P<0.001) with greater pain. Care quality indicators ranking lowest related to discussion of analgesic side effects and use of nonpharmacologic approaches.

CONCLUSIONS

Unrelieved pain remains a high-volume problem. Individual factors and unit type were significantly associated with pain outcomes. Hospitals can employ these quality indicators to direct continuous quality improvement targeting pain care quality.

Effectiveness of Discharge Education on Postpartum Depression

PURPOSE

To determine effectiveness of an educational intervention in reducing or preventing symptoms of postpartum depression (PPD).

STUDY DESIGN AND METHODS

English-speaking women age 18 or older with a singleton, term, healthy newborn were recruited from an 11-bed maternity unit in Southern New Hampshire. Using a quasi-experimental design, the first 120 respondents received usual care (control), and the following 120 respondents received the education (treatment) including PPD predictors, symptoms, prevention, and management. Current risk factors were measured using the Postpartum Depression Predictors Inventory-Revised (PDPI-R). Symptoms of depression were measured using the Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks, 3 months, and 6 months postpartum. Two-proportion z-tests were used to determine whether the education had a significant impact on EPDS scores at each of the three follow-ups.

RESULTS

There was no significant difference in symptoms of depression as measured by the EPDS between the treatment and control group at 6 weeks, 3 months, or 6 months postpartum. However, consistent with previous studies, low socioeconomic status and a history of depression or anxiety prior to or during the pregnancy were significant predictors of PPD.

CLINICAL IMPLICATIONS

Postpartum nursing discharge education did not decrease depression symptoms up to 6 months after discharge. More research is needed to determine the most appropriate timing and content of education about PPD. Many women at risk can be identified prior to birth. Education to improve literacy about PPD may need to be provided prenatally and reinforced during postpartum hospitalization and after discharge.

Care quality instruments

PURPOSE

The purpose of this paper is to describe instruments used for quality assessment in acute care. Quality care assessment is essential for improving care delivery. Quality instruments can be used to evaluate nurse and patient perspectives in multi-professional care. Therefore, valid and reliable measurement instruments are vital.

DESIGN/METHODOLOGY/APPROACH

A literature search identified several instruments that measure quality from a nurse and patient perspectives. The questionnaires were appraised in several steps with specific criteria: psychometric properties, underlying construct or test theory, study context, sample characteristics and target population.

FINDINGS

Overall, 14 instruments were evaluated, but only eight questionnaires represented nurse and patient views regarding quality. Instruments showed several disparities in their theoretical foundations and their psychometric properties. Two instruments did not provide validity data and one questionnaire did not report reliability data.

PRACTICAL IMPLICATIONS

To inform healthcare managers about acute care quality, the authors demonstrated the need for more valid and reliable measurements by using the Guidelines for Critiquing Instrument Development and Validation Reports to evaluate quality care instruments' psychometric properties.

ORIGINALITY/VALUE

There is a long tradition in quality care evaluations using questionnaires. Only a few instruments can be recommended for practical use.

Nursing-sensitive indicators: a concept analysis

AIM

To report a concept analysis of nursing-sensitive indicators within the applied context of the acute care setting.

BACKGROUND

The concept of 'nursing sensitive indicators' is valuable to elaborate nursing care performance. The conceptual foundation, theoretical role, meaning, use and interpretation of the concept tend to differ. The elusiveness of the concept and the ambiguity of its attributes may have hindered research efforts to advance its application in practice.

DESIGN

Concept analysis.

DATA SOURCES

Using 'clinical indicators' or 'quality of nursing care' as subject headings and incorporating keyword combinations of 'acute care' and 'nurs*', CINAHL and MEDLINE with full text in EBSCOhost databases were searched for English language journal articles published between 2000-2012. Only primary research articles were selected.

METHODS

A hybrid approach was undertaken, incorporating traditional strategies as per Walker and Avant and a conceptual matrix based on Holzemer's Outcomes Model for Health Care Research.

RESULTS

The analysis revealed two main attributes of nursing-sensitive indicators. Structural attributes related to health service operation included: hours of nursing care per patient day, nurse staffing. Outcome attributes related to patient care included: the prevalence of pressure ulcer, falls and falls with injury, nosocomial selective infection and patient/family satisfaction with nursing care.

CONCLUSION

This concept analysis may be used as a basis to advance understandings of the theoretical structures that underpin both research and practical application of quality dimensions of nursing care performance.

Games for Health

How to reduce cost, improve quality, and improve customer engagement are top of mind for healthcare leaders. Healthcare organizations are developing and testing comprehensive engagement strategies to support consumers across the care continuum. In this environment some form of priority setting must occur, and it requires establishing connections between proposed innovation to a process of care and the outcomes. Digital tools offer a promise of meaningful measures that are affordable, embedded in the care delivery system and truly reflect patients’ experiences through the patient journey. This paper proposes a pragmatic path for building a business case for innovative digital health tools in community care settings. It overlays value model for healthcare IT investments with patient activation measures and innovation management techniques. It proposes that the intersection of system-generated measures and psychometric methods for data collection and analysis may lead to development of feasible patient engagement measures for healthcare.

Introduction: the Interdisciplinary Nursing Quality Research Initiative

BACKGROUND

The Robert Wood Johnson Foundation launched the Interdisciplinary Nursing Quality Research Initiative (INQRI) program in 2005 to generate, disseminate, and translate research to understand how nurses contribute to and can improve patient care quality. This special edition of Medical Care provides an overview of the program's strategy, goals, and impact, highlighting cross-cutting issues addressed by the initiative.

METHODS

INQRI's leadership and select grantees discuss the implications of a collection of studies on the following: advances in the science of nursing's contribution to quality, measurement of quality, interdisciplinary collaboration, implementation methodology, dissemination and translation of findings, and the business case for nursing.

RESULTS

A comprehensive review of the scholarly literature published in 2004 and 2009 found that the evidence linking nursing to quality of care has grown. The second paper discusses INQRI's work on measurement of quality of care, revealing the need for additional comprehensive measures. The third paper examines INQRI's focus on interdisciplinary collaboration, finding that it can enhance methodological approaches and result in substantive changes in health delivery systems. The fourth paper presents methodological challenges faced in health care implementation, emphasizing the need for standardized terms and research designs. The fifth paper addresses INQRI's commitment to translating research into practice, illustrating dissemination strategies and lessons learned. The final paper discusses how the INQRI program has contributed to the current evidence regarding the business case for nursing.

DISCUSSION

This supplement describes the accomplishments of the INQRI program, discusses current issues in research design and implementation, and places INQRI research within the larger context regarding advances in nursing science.