Credentialing: The need for a national research agenda

A national research agenda is needed to promote inquiry into the impact of credentialing on health care outcomes for nurses, patients, and organizations. Credentialing is used here to refer to individual credentialing, such as certification for nurses, and organizational credentialing, such as American Nurses Credentialing Center Magnet recognition for health care organizations or accreditation of providers of continuing education in nursing. Although it is hypothesized that credentialing leads to a higher quality of care, more uniform practice, and better patient outcomes, the research evidence to validate these views is limited. This article proposes a conceptual model in which both credentials and standards are posited to affect outcomes in health care. Potential research questions as well as issues in research design, measurement, data collection, and analysis are discussed. Credentialing in nursing has implications for the health care professions and national policy. A growing body of independent research that clarifies the relationship of credentialing in nursing to outcomes can make important contributions to the improvement of health care quality.     

The current state of nursing performance measurement, public reporting, and value-based purchasing

Over the last decade, there has been a substantial investment in holding health care providers accountable for the quality of care provided in hospitals and other settings of care. This investment has been realized through the proliferation of national policies that address performance measurement, public reporting, and value-based purchasing. Although nurses represent the largest segment of the health care workforce and despite their acknowledged role in patient safety and health care outcomes, they have been largely absent from policy setting in these areas. This article provides an analysis of current nursing performance measurement and public reporting initiatives and presents a summary of emerging trends in value-based purchasing, with an emphasis on activities in the United States. The article synthesizes issues of relevance to advancing the current climate for nursing quality and concludes with key issues for future policy setting.     

Nurses' Effect on Changing Patient Outcomes

Emphasis on examining provider effects and resulting patient outcomes has grown considerably in the past several decades. This paper highlights the effect of nurses on changing patient outcomes. The most important issues raised include the types of patient outcomes that should be measured; the amount and type of nursing (or "nurse dose") needed to effect patient outcomes; the nurse dose needed in a given health care environment to demonstrate an effect; and the nurse dose needed for effects with differing patient groups.     

Oncology nursing: Finding the balance in a changing health care system.

Health care restructuring has resulted in significant changes in the workload and work environment for oncology nurses. While recent studies describe the impact of these changes on the general nursing workforce in several countries, there have been no published studies that have focused on worklife issues of Canadian oncology nurses. Therefore, a qualitative study was conducted to gain insight about how oncology nursing has changed over the past decade and how Canadian oncology nurses are managing these changes. Analysis of telephone interviews with 51 practising oncology nurses employed across Canada revealed three major themes. The first theme, "health care milieu", portrayed a picture of the cancer care environment and patient and professional changes that occurred over the past decade. The second theme, "conflicting demands", reflects how the elements of change and social forces have challenged professional oncology nursing practice. The third theme, "finding the way", describes the patterns of behaviour that nurses used to manage the changing health care environment and make meaning out of nurses' work in cancer care. Overall, the findings portray a picture of Canadian oncology nurses in "survival mode". They face many workplace challenges, but are able to keep going "for now" because they find ways to balance their responsibilities on a daily basis and because they know and believe that their specialized nursing knowledge and skills make a difference in patient care.     

Outcomes and effectiveness research: capacity building for nurse researchers at the Agency for Healthcare Research and Quality

Several of AHRQ's priority areas including disease prevention, health promotion, primary care, quality of care, service delivery, and patient safety are particularly relevant to nurse researchers. With much national attention focused on nursing-related issues such as staff shortages, training, mandatory overtime, working conditions, and autonomy, it is mandatory that nursing research be conducted to inform healthcare delivery and policy. Nurses also need to contribute to the health services literature so that an even balance of discipline perspective is represented. AHRQ's mandate is represented by the slogan "quality research for quality health care." Although our understanding has expanded of contributors to and determinants of evidence-based practice and the relationship between clinical care and improved outcomes, we have much to learn. Appreciating how and which components of nursing care influence patient outcomes represents an essential area of research in need of development. While clarifying nursing contributions to improved outcomes is not the sole purview of nurse researchers, it is plausible to assume that a clinical background in nursing combined with strong methodological skills can help policy makers and health system leaders understand how nurses can most effectively contribute to outcomes and quality improvement. AHRQ is clearly interested in capacity building of researchers from all relevant disciplines. Nurses, the largest provider of healthcare, need to build capacity and develop a much stronger presence in the health services research community of scholars.     

National quality efforts: what continuing and staff development educators need to know

In 1994, the American Nurses Association initiated a series of activities currently referred to as Nursing's Quality Initiative. This first step toward public accountability was based on the premise that all nurses must become more knowledgeable about the measurement, improvement, and benchmarking of clinical costs, quality, and outcomes specific to nursing. The American Nurses Association has not been working alone to advance quality health care. Rather, it has taken an active role in several collaborative activities, including those of the National Quality Forum. The National Quality Forum has focused on a variety of issues, including nursing care performance measurement, an activity in which the American Nurses Association has been involved. It is up to professional nursing, the National Quality Forum, and all who have interest in the provision (or receipt) of quality health care to advance quality in a collaborative, coordinated way.     

Investing in human capital: an academic-service partnership to address the nursing shortage

The well-documented shortage of nurses and the impact of educational preparation of nurses on patient care outcomes provide a compelling argument for the need to increase the number of registered nurses and to advance their educational preparation. This article describes the application of human capital theory in a creative venture between a health system and a school of nursing that has demonstrated success in addressing these issues. A tuition advancement program was developed to support interested personnel in attaining the associate degree in nursing and to support current RNs in attaining the baccalaureate degree. The venture included support for graduate preparation of nurses interested in becoming faculty.     

Patient transfers in Australia: implications for nursing workload and patient outcomes

blay n., duffield c.m. & gallagher r. (2012) Journal of Nursing Management 20, 302–310
Patient transfers in Australia: implications for nursing workload and patient outcomes Aim To discuss the impact of patient transfers on patient outcomes and nursing workload. Background Many patient transfers are essential and occur in response to patients’ clinical changes. However, increasingly within Australia transfers are performed in response to reductions in bed numbers, resulting in ‘bed block’. Evaluation A discussion of the literature related to inpatient transfers, nursing workload and patient safety. Key issues Measures to increase patient flow such as short-stay units may result in an increase in patient transfers and nursing workload. Frequent patient transfers may also increase the risk of medication incidents, health-care acquired infections and patient falls. Conclusions The continuing demand for health care has led to a reactionary bed management system that, in an attempt to accommodate patients, has resulted in increased transfers between wards. This can have a negative effect on nursing workload and affect patient outcomes. Implications for nursing management High nursing workload is cited as one reason for nurses leaving the profession. Reductions in non-essential transfers may reduce nurse workload, improve patient outcomes and enhance continuity of patient care.     

Nurses’ perceptions of the impact of continuing professional education on the quality of nursing care*

The purpose of this study was to understand what impact nurses perceived continuing professional education (CPE) to have on the quality of nursing care Given that CPE will become mandatory once the necessary legislation has been implemented, the value and worth of CPE with regard to the quality of nursing care, in both a consumer-led and financially-driven NHS, merits serious consideration Little research has been conducted into the real impact that CPE has on the quality of nursing care and this paper begins by providing an overview of the current debate within the profession The method chosen for the study was qualitative and 18 nurses from a large hospital in the South of England were interviewed The data were analysed using the grounded theory method and three categories emerged The categories are descnbed in detail and reveal some of the problems with which the nursing profession is faced The study demonstrates how issues of finance were particularly high, with service managers sometimes negating nurses’ CPE needs However, the study reveals the real importance that nurses attatched to CPE in supporting their professional status and the real impact that CPE and knowledge have on professional competence and the quality of patient care     

Trialing collaborative nursing Models of Care: the impact of change.

OBJECTIVE: The aim of the project was to develop and trial a nursing Model of Care (MoC) and devise a framework to investigate the impact of nursing staff mix on patient outcomes and job satisfaction (nurses). SETTING AND SUBJECTS: In 2001-2002 a pilot project was undertaken to explore issues related to the delivery of patient care by nurses on two medical inpatient wards, one acute and one subacute, at a referral teaching hospital in New South Wales (NSW), Australia. The framework employed was an adaptation of, and based on, the Clinical Practice Improvement (CPI) model developed by NSW Health. PRIMARY ARGUMENT: Countries across the world are seeking solutions to a shortage of registered nurses and their ability to sustain quality care services. It becomes imperative that organisations develop strategies to attract and retain nurses in the health care system. CONCLUSIONS: Results of the project highlighted areas related to the quality of care delivery: clinical supervision; continuity of staffing; trust; employer of choice; more effective nurse to patient ratios; educational preparation; and recognition of prior experience.     

Nursing Research Priorities for Ireland

PURPOSE: The purpose of the study was to identify and rate clinical, managerial, and educational nursing research priorities in Ireland. DESIGN: The study design was a three-round, decision Delphi survey to identify and rate the importance of clinical, managerial, and educational research issues. A discussion group workshop was also undertaken to identify timeframes within which research on the issues identified should be conducted. A total of 1,695 nurses from all divisions of the nursing register in Ireland were initially surveyed. Response rates varied over the three rounds of the Delphi survey. A total of 122 nurses attended the discussion group workshop. This is the largest known survey of nurses to identify research priorities reported in the literature. RESULTS: Twenty-four nursing research priorities were identified. The five highest priorities were three clinical issues: outcomes of care delivery, staffing issues in practice, communication in clinical practice; and two managerial issues: recruitment and retention of nurses, and nursing input into health policy and decision-making. CONCLUSIONS: These research priorities identified for nursing in Ireland indicate, to an extent, the nursing research priorities identified in other European countries and in North America. The research priorities identified in this survey indicate that outcomes of care and the need to make nursing visible are attaining a higher priority than seen in previous studies. Also evident is that nursing shortages and increasing skill-mix in the clinical area have indicated a need for research into nurse recruitment, staff turnover, and staffing levels and how these issues affect patient outcomes. The priorities suggest research programmes that target the health service concerns identified in the national health agenda, such as the need to identify protocols and procedures that improve patient and client care outcomes and to examine and test solutions to workforce problems.     

Health Outcomes for Better Information and Care (HOBIC): integrating patient outcome information into nursing undergraduate curricula

Nursing-sensitive outcomes provide common information across sectors, thus eliminating duplication that frequently occurs as individuals move across settings. These outcomes also facilitate increased trust among colleagues and support common understandings of patient care needs, thus enhancing continuity of care. Outcomes-oriented information is also likely to increase patient safety and improve overall quality of care. Shared standards and data support consistent decision-making, as nursing decisions can be tracked back over time to assess patient care outcomes. Consequently, nurses will have the means to determine the impact of their interventions on patient outcomes. At the same time, adoption of common approaches to patient assessment leads to greater professional accountability and moves nursing care from a task orientation to an outcomes focus. For administrators, such improvements in monitoring and evaluating patient outcomes translate into improvements in efficiencies and effectiveness, thus providing a return on investment in implementing these outcomes within their agency. For nurses, integration and utilization of outcomes information increases the visibility and significance of their decision-making and patient care. Together with patients, nurses can utilize the outcomes information to make evidence-based decisions and advocate for appropriate care. At an aggregate level, the use of outcomes information creates a continuous feedback loop that is essential to ensuring evidence-based care and the best possible patient outcomes, not only for individuals, but also for families, communities and populations. Outcomes-oriented care provides a gateway for transforming the way we care for patients; puts safe, ethical, high-quality care for patients first; embodies the principles of evidence-based practice; ensures that the value of nursing is clearly understood within the larger system; and ensures that the requirements for measurability and accountability can be achieved. This journey is continuous and is being expanded to engage all other health disciplines in understanding and documenting their contributions to patient care, both as individual practitioners and as members of a healthcare team. Preparing nursing students in an outcomes approach will facilitate systemwide adoption of HOBIC patient outcomes over time and provide a means to determine the impact of nursing care on our patients.     

Empowering nurses. Patient satisfaction with primary nursing in home health

Responsibility, accountability, and authority are the tools of primary nursing that enable nurses to impact patient care. It is important to determine if nurses empowered by a primary nursing care delivery system can positively influence patient outcomes. The authors describe an outcome audit conducted to study patient satisfaction with nursing care, one indicator of quality patient care.     

Compassion fatigue and nursing work: Can we accurately capture the consequences of caring work?

Health outcomes and, in particular, patient health outcomes have become a driving force within health-care delivery. Little emphasis has been placed on the potential health consequences for nurses providing care and caring within the health-care system. Compassion fatigue (or secondary traumatic stress) has emerged as a natural consequence of caring for clients who are in pain, suffering or traumatized. This paper sheds light on how nursing work might impact the health of nurses by exploring the concept of compassion fatigue. Limitations of current instruments to measure compassion fatigue are highlighted, and suggestions for future direction are presented.     

Patient outcomes in the field of nursing: A concept analysis

PurposeThis paper reports an analysis of the concept of patient outcomes.MethodsThe Walker and Avant concept analysis approach was applied.ResultsThe attributes of patient outcomes include (1) patient functional status (maintained or improved), (2) patient safety (protected or unharmed), and (3) patient satisfaction (patient reporting of comfort and contentment). These attributes are influenced by the antecedents of individual patient characteristics and health problems, the structure of healthcare organizations and received health interventions. Additionally, patient outcomes do significantly impact the quality of nursing care, the cost of effective care and healthcare policy making formulation.ConclusionProviding good nursing care to all patients is a central goal of nursing. Patient outcomes in nursing are primarily about the results for the patient receiving nursing care. This analysis provides nurses with a new perspective by helping them to understand all the components within the concept of patient outcomes.     

The role of internationally educated nurses in a quality,safe workforce

Migration and globalization of the nursing workforce affect source countries and destination countries. Policies and regulations governing the movement of nurses from one country to another safeguard the public by ensuring educational comparability and competence. The global movement of nurses and other health care workers calls for quality and safety competencies that meet standards such as those defined by the Institute of Medicine. This article examines nurse migration and employment of internationally educated nurses (IENs) in the context of supporting and maintaining safe, quality patient care environments. Migration to the United States is featured as an exemplar to consider the following key factors: the impact of nurse migration on the nursing workforce; issues in determining educational comparability of nursing programs between countries; quality and safety concerns in transitioning IENs into the workforce; and strategies for helping IENs transition as safe, qualified members of the nursing workforce in the destination country.     

Going blank: factors contributing to interruptions to nurses' work and related outcomes

hall l.m., ferguson-paré m., peter e., white d., besner j., chisholm a., ferris e., fryers m., macleod m., mildon b., pedersen c. & hemingway a. (2010) Journal of Nursing Management 18, 1040–1047
Going blank: factors contributing to interruptions to nurses’ work and related outcomes Aim To examine interruptions to nurses’ work, the systems issues related to these and the associated outcomes. Background While some research has described the role interruptions play in medication errors, work is needed to examine specific factors in the nursing work environment that cause interruptions and to assess the impact of these on nurses’ work and patient outcomes. Methods The present study utilized a mixed method design that involved work observation to detect nursing interruptions in the workplace followed by focus groups with a subsample of nurses. Results A total of 13 025 interruptions were observed. Equal numbers of these took place on medical and surgical units. The predominant source of interruptions was members of the health team, who interrupted more frequently on medical units. Conclusions Differences in the type of patient and the care needs between medical and surgical units may be a contributing factor to these findings. As members of the health team were among the leading source of interruptions, an interdisciplinary team-based approach to changing the organization and design of work should be explored. Implications for nursing management Nurse leaders should examine ways in which nurses’ work can benefit from system improvements to reduce interruptions that lead to patient safety issues such as treatment delays and loss of concentration.     

The effect of a teamwork intervention on staff perception of teamwork and patient care on a medical surgical unit

As a result of the ever‐changing health care environment and patient complexity, it is difficult for nursing teams to provide safe quality care and complete all tasks, also known as missed nursing care. Missed nursing care is a global health care issue and defined as any aspect of care missed in part, in whole, or delayed. Teamwork has been found to not only positively impact the performance of a team, but also patient outcomes. Teamwork strategies are needed to help nursing teams provide the best care to their patients. Inpatient nursing teams work in complex environments and handle many patient issues making it difficult to find one workable solution. The purpose of this study was to determine if a teamwork intervention would impact the nursing team’s perception of teamwork and missed nursing care on a medical surgical unit. In this quasi‐experimental design study there was an increase in both teamwork and missed nursing care pretest and posttest survey scores. Despite the increase not being statistically significant, based on the staff feedback, the intervention shows promise to be a viable teamwork strategy. Future studies should include larger sample size and longer duration.     

Mitigating the impact of hospital restructuring on nurses: the responsibility of emotionally intelligent leadership

BACKGROUND: A decade of North American hospital restructuring in the 1990s resulted in the layoff of thousands of nurses, leading to documented negative consequences for both nurses and patients. Nurses who remained employed experienced significant negative physical and emotional health, decreased job satisfaction, and decreased opportunity to provide quality care. OBJECTIVE: To develop a theoretical model of the impact of hospital restructuring on nurses and determine the extent to which emotionally intelligent nursing leadership mitigated any of these impacts. METHODS: The sample was drawn from all registered nurses in acute care hospitals in Alberta, Canada, accessed through their professional licensing body (N = 6,526 nurses; 53% response rate). Thirteen leadership competencies (founded on emotional intelligence) were used to create 7 data sets reflecting different leadership styles: 4 resonant, 2 dissonant, and 1 mixed. The theoretical model was then estimated 7 times using structural equation modeling and the seven data sets. RESULTS: Nurses working for resonant leaders reported significantly less emotional exhaustion and psychosomatic symptoms, better emotional health, greater workgroup collaboration and teamwork with physicians, more satisfaction with supervision and their jobs, and fewer unmet patient care needs than did nurses working for dissonant leaders. DISCUSSION: Resonant leadership styles mitigated the impact of hospital restructuring on nurses, while dissonant leadership intensified this impact. These findings have implications for future hospital restructuring, accountabilities of hospital leaders, the achievement of positive patient outcomes, the development of practice environments, the emotional health and well-being of nurses, and ultimately patient care outcomes.