Quality Watch

State Nurses Associations Work to Prove Nursing Quality

by Katrina Burtt

Quality-indicator research reveals what nurse leaders expected-- a positive correlation between RN care and good patient outcomes.

Responding to the lack of strong data linking positive patient outcomes with RN-delivered hospital care, the American Nurses Association launched its Nursing Safety and Quality Initiative in 1994. The goal of the initiative's research component has been to demonstrate with empirical data that good patient outcomes--defined by 10 quality indicators (see Nursing Quality Indicators For Acute Care Settings, page 59) such as lowered rates of pressure ulcers, patient injury, and readmission--occur when RNs care for patients. Not only are those outcomes desirable for patients, but they've already been linked to saving hospitals money.

The research portion of the initiative is one piece of a multi-pronged approach by the ANA to address threats to patient safety caused by a decreased nursing staff. Also included were development of a nursing report card, introduction of the Patient Safety Act in the U.S. Congress, and the highly successful "Every Patient Deserves a Nurse" education campaign.

Last July, Issues Update looked at how six state nurses associations (SNAs) spearheaded the research portion of the safety and quality initiative by collecting data on selected indicators. This research is beginning to prove that patient outcomes are strongly related to RN care. Here's an update on the SNAs' work.

Volunteers Launch California Research

The tremendous potential for helping hospital patients continue to receive quality RN care is based on strong data. This potential fueled the efforts of volunteers heading the quality-indicator project at the ANA\California, according to Nancy Donaldson, DNSc, RN, project coordinator for the California Nursing Outcomes Coalition (CalNOC).

"Nurse executives around the state are, on a daily basis, confronted with the demands and c hallenges of health care restructuring," she said. "They are eager for valid data that help them make decisions, that support meaningful decisions about cost and quality and outcome of care."

Until three months ago, CalNOC was made up entirely of volunteers. The group investigated four indicators--skin integrity, falls, hours per patient day, and skill-mix--with data collection for three months at 11 test sites. Donaldson said the success of the project's first phase has created a momentum for the project's second phase, which will include 30 to 40 new test sites and will use new indicators, including restraint use. CalNOC is now requesting proposals for data management consultation.

"The word on the street is that the Nursing Outcomes Coalition is doing good work--that the integrity and the collaboration of the work is speaking for itself," Donaldson said, adding that the group had adopted the spirit of "just do it" to accomplish their work. "If we had analyzed all t he forces that were restraining us . . . we wouldn't have gotten to first base. Our thing was, this is important, and this is the moment it has to happen. Let's collaborate. . . . We want a database for a national data center and for ourselves that is characterized by integrity. So, we are at a critical time of growth."

Texas Interests Medicine in Nursing Indicators

Stephanie Tabone, RN, director of practice for the Texas Nurses Association, said the Texas project collected data for six weeks in 12 hospitals in the first phase. The next step will be to expand the test sites to 20, which will represent each public health district in the state.

The first phase of the project demonstrated that the data could be collected in a variety of hospitals with a comfortable level of standardization, except for nursing care hours, Tabone said. The group will refine the tool for its second phase, which is building on the esteem that the first phase has garnered for the project.

"I expect that this time, we will have a pool of applicants, and we will have to choose for balance" in all the districts and their sizes, Tabone said, adding that the Texas Medical Association has expressed interest in nursing-sensitive indicators.

Although the findings have not yet been reported, Tabone said the most striking correlation was between nurse satisfaction and patient satisfaction.

Arizona Finds Link Between Frailty and Indicators

A unique aspect of the research con-ducted by the Arizona Nurses Association (AzNA) has been to discover the relationship between frailty and the quality indicators, according to Anne McNamara, PhD, RN, first vice president of the board of directors for AzNA. The project is focused on patients who are 65 years and older, in rural hospitals, and in a university hospital. That age group comprises 57% of Arizona's hospital population.

"We tried to identify what is critical to the nurses' role in hospitals and what it is that involves the most nursing time and nursing assessment," McNamara explained, adding that it's the complexity of a patient's condition that adds to the need for nursing intervention.

A multidisciplinary team of volunteers has guided AzNA in creating a model to collect the data. The tool includes such patient variables as hydration status, depression level, and functional status. The Arizona project also included variables concerning patients who don't speak English, by asking questions about culture and language. They're expected to reveal how well a patient would be able to follow discharge instructions if he spoke only Spanish.

The AzNA project expected to finish its data collection by mid-March, and McNamara sees the effect of the quality-indicator research to be far-reaching.

"I think they're going to allow for benchmarking between and among hospitals. . . . They're going to be helpful in determining if we agree upon a certain level of quality, then what the staffing needs will be to follow," she said.

Virginia's Environment Improving for Research

After finishing the first phase of a project that focused solely on rural hospitals, the Virginia Nurses Association will widen its research to include 15 hospitals throughout the state. Georgine Redmond, EdD, RN, and Jeanne M. Sorrell, PhD, RN, project codirectors, said the environment for conducting nursing quality-indicator research has improved significantly in recent years.

"We designed our project the way we did because of the climate at that point in Virginia for being able to implement this kind of project," Redmond said. "We felt it would be better to start in this rural area that was very receptive, and to do an in-depth study on quality. Right now, there really is a lot more interest and receptivity to allowing us in--to do what other states were able to do right out of the gate."

Sorrell said that each time they presented the project in public, they gained support for their work.

"We've presented the feasibility project quite often throughout the state," Sorrell said. "I think that was one way we got informal participation from around the state." The project will begin three months of data collection from medical-surgical and critical care units at 13 hospitals in June, adding two more hospitals for an additional quarter of data. Midwest Research Institute will analyze the data.

Redmond said a database on nursing quality will be valuable to RNs at all levels of care.

North Dakota Includes Nursing Homes in Research

North Dakota Nurses Association is the only state that has collected data from nursing homes as part of its project. Diane Langemo, PhD, RN, project director, said the first quarter of data collected at eight hospitals and six nursing homes is now being entered for analysis at the University of North Dakota School of Nursing. Langemo expected some analysis to be available this spring.

As the only state that requires a baccalaureate for entry into nursing, North Dakota is enjoying excellent participation from institutions interested in solid research data, Langemo said. "We've had really good support. A very high percentage of RNs in our state are baccalaureate-prepared, and I think that's definitely a factor," she explained. "[Getting these data] is important in establishing a nationwide database on outcomes. Getting the agencies involved and the nursing staff involved in a clinical outcomes research study is important. They're not only learning about the research process, but also the value--what this can do for their agency."

Minnesota Uses Indicators as Screening Tool

The Minnesota Nurses Association (MNA) has used the first phase of its research project to look for institutions that collect quality-indicator data that meet ANA definitions. Jeannette O'Brien, RN, BSN, project director, said the time it took to refine the tool was longer than expected. Six hospitals in the Twin Cities area are now in the process of completing the survey, as the MNA continues to add hospitals to the group.

"It takes extra time to fill out the survey--it turned out to be very long," O'Brien said. "In the end, though, I think that it will serve us well. . . . I look at phase one as a screening tool--to find the hospitals that already collect the data we need. We want to be sure that [quality indicators tracked by hospitals] are consistent with ANA definitions. Hopefully, that would make it easier for everyone to begin work on phase two."

ANA Begins Work on Community Indicators

As the six SNAs ready themselves to contribute data to the National Data Center for Nursing Quality Indicators, the ANA is planning to accumulate similar information from the community setting, according to Patricia Rowell, PhD, RN, senior policy fellow in the ANA's Department of Practice.

"The National Database of Nursing Quality Indicators is up and running now," Rowell said. "It's being prepared for data from the six initial states. As for the community indicators, the preliminary work is done." The new indicators are expected to be announced at the ANA's convention in June.

In March 1994, the ANA's Board of Directors launched its Nursing Safety and Quality Initiative, a major, multi-phase effort to investigate the impact of health care restructuring on the safety and quality of patient care and on the nursing profession. Through the initiative, the ANA has developed nursing's quality indicators for acute care settings to highlight the link between nursing actions and patient outcomes. Over the last year, the indicator definitions have been refined based upon experience in implementing them in the acute care setting. The following definitions reflect the ongoing nature of this process.

• Nosocomial infection rate (Bacteremia): the number of laboratory-confirmed bacteremias associated with sites of either peripheral or central intravenous lines per 1,000 patient days per unit. (This is currently under investigation for use as an indicator.) Patient injury rate: the rate per 1,000 patient days at which patients experience an unplanned descent to the floor during the course of their hospital stay.
• Patient satisfaction: This indicator was defined using the following sub-categories:
  • Patient satisfaction with nursing care: patient opinion and perception of care received from nursing staff during the hospital stay, as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding key elements of nursing care services.
  • Patient satisfaction with pain management: patient opinion and perception of how well nursing staff managed their pain, as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding specific aspects of pain management.
  • Patient satisfaction with educational information: patient opinion or perception of nursing staff efforts to educate them regarding their condition and care requirements, as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding specific aspects of patient education activities. Patient satisfaction with care: patient opinion or perception of the care received during the hospital stay, as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding global aspects of care.
  • Maintenance of skin integrity: the number of patients with NPUAP-AHCPR [National Pressure Ulcer Advisory Board and Agency for Health Care Policy and Research] stage I, II, III, or IV ulcers per the number of patients in a prevalence study. Nurse staff satisfaction: job satisfaction expressed by nurses working in hospital settings, as determined by scaled responses to a uniform series of questions designed to elicit nursing staff attitudes toward specific aspects of their employment situation. [The six State Nurses Associations currently funded to implement these indicators in acute care settings are using either Kramer and Schmalenberg's Nursing Work Index or Stamps and Piedmonts tool.]
  • Mix of RNs, LPNs, and unlicensed staff caring for patients in acute care settings: the percentage of registered nurse nursing care hours with direct patient care responsibilities of total nursing care hours. [Calculations require data on the percentage of registered nurse contracted hours of total nursing care hours.]
  • Total nursing care hours provided per patient day: total number of productive hours worked by nursing staff with direct patient care responsibilities on acute care units per patient day. [Calculations require data on the total Registered Nurse nursing care hours and contracted (both total and RN) hours.]

Two publications, available through American Nurses Publishing, provide additional, comprehensive information about the quality indicators. Nursing Quality Indicators: Definitions and Implications provides information for nurses and institutions to begin collecting the data to explore the links between nursing care and outcomes. Nursing Quality Indicators: Guide for Implementation follows up with information nurses can use to either advocate for the collection of the indicators in the workplace or to collect the data themselves. In addition, Implementing Nursing's Report Card: A Study of RN Staffing, Length of Stay and Patient Outcomes and Nursing Care Report Card for Acute Care are publications developed through the ANA's Safety and Quality Initiative. For more information on these publications, call (800) 637-0323.

Katrina Burtt, a member of the Mississippi Nurses Association, is an organ recovery coordinat or with the Mississippi Organ Recovery Agency.