Nursing-Sensitive Indicators for Community-based Non-Acute Care Settings and ANA's Safety & Quality Initiative

Purpose

This fact sheet describes nursing-sensitive indicators in non-acute settings, the relation of these indicators to other quality initiatives, and ANA's role in these efforts. While all nurses can use this information, those nurses who work in these settings-community, home, public, and school health, as well as home care-will find it particularly useful in understanding the connection between nursing quality indicators and safe staffing, the need for data collection to substantiate that connection, and the implications for nurses and patients alike, including the nurse's role in contributing to these efforts.

Background

Nurses know on a daily basis how their profession is being transformed. Health care systems have been undergoing massive changes in both financing and service delivery. Acting more like corporations, they continuously emphasize cost-cutting measures that adversely impact registered nurses (RNs) providing patient care services in both acute and non-acute settings.

Many of our community-based care settings have been particularly affected. When the health care delivery system began major restructuring in the 90s, cost-cutting measures led to a reduction in the number of RNs providing direct patient care. Simultaneously, RNs were replaced with unlicenced assistive personnel (UAPs) during restructuring and downsizing, while individual nurses were required to care for greater numbers of patients who were more acutely ill. With shortened lengths of stays in hospitals, patients were discharged to the community setting sicker and in need of more complex care. The rapidly increasing demand for care caused increased demand for RNs and UAPs in community settings.

As we entered the new millennium, we began to see the chilling effects of the cutbacks of the 90s. With threats of an impending nursing shortage, health care systems must now deal with the backlash from the environments they helped create. A report released March 1, 2001, by the Institute of Medicine of the National Academies of Sciences stated that the nation's health care industry has failed in its ability to consistently provide safe, high-quality care and is a "disjointed and inefficient system."

Nurses are well aware of the inefficiencies within the health care system and have been voicing their concern for years. Unfortunately, things don't seem to be improving. Fewer persons are entering the nursing profession, and recruiting and retaining nurses is becoming more difficult due to poor working conditions. Regardless of the setting, nurses are being forced to work mandatory overtime to compensate for inadequate staffing and RNs are feeling the pressure of being overworked, exhausted and required to manage increased client loads. Nurses' frustrations were evident in the results of a national Staffing Study conduct by the American Nurses Association (ANA) and completed in 2001. Of the 7,299 nurses responding to the survey, 75 percent felt the quality of nursing care at their facilities had declined over the past two years, while 56 percent believed that the time they have available for patient care has decreased. In addition, more than 40 percent of nurses surveyed said they would not feel comfortable having a family member or someone close to them cared for in their facility. With fewer RNs caring for sicker clients, and thus less skilled personnel providing care, client care can be jeopardized-a cause for concern by RNs, clients and their families. Tragically, profits are superseding the needs of patients and putting the emotional and physical well-being of nurses in jeopardy.

Nursing's Safety & Quality Initiative

In March 1994, the ANA Board of Directors launched a major multi-phase initiative to investigate the impact of health care restructuring on the safety and quality of patient/client care and the nurses who provide that care. Through Nursing's Safety & Quality Initiative, ANA is leading the nursing community in the design and implementation of ongoing, comprehensive research efforts to establish and quantify the impact of RN staffing on processes of care and client outcomes.

The Safety & Quality Initiative has focused on educating RNs about quality measurement, informing public and purchasing/regulating constituencies about safe, quality health care, and investigating research methods and data sources to empirically evaluate the safety and quality of client care. Some of these efforts include:

• The ANA publications (1995-2000) listed at the end of this fact sheet.
• Continuing education programs on Nursing Quality Outcomes provided by Constituent Member Associations (CMAs) and ANA (1995-1998).
• Nursing Quality Report Card Request for Data Collection Planning Proposals to financially support the implementation of pilot studies in a sample of hospitals (1996-1999).
• National Database of Nursing-Sensitive Quality Indicators (1998-present).
• Continual lobbying by ANA and the CMAs for federal and state legislation requiring the collection, dissemination, and publication of hospital data. Some CMAs have been successful in passing state legislation to protect nurses who speak out about unsafe care. Ongoing efforts are underway to have similar legislation passed nationwide.
• ANA efforts to free nurses to speak out on behalf of those for whom they care through the introduction of federal whistle-blower protection and patient safety legislation.
• Development and pilot testing of community indicators to monitor the quality of patient/client care delivered outside of the acute care hospital setting.

All of these projects contribute to the profession's efforts to focus the nation's attention on the most critical issues in health care-the safety and quality of patient/client care and the measurement of outcomes of care.

What are Nursing-Sensitive Quality Indicators?

Nursing-sensitive indicators are those indicators that capture care or its outcomes most affected by nursing care. In 1997, an Advisory Committee to identify indicators sensitive to the impact of nursing practice in community-based non-acute settings was appointed by the ANA Congress of Nursing Practice. In late 1999, ten nursing-sensitive indicators for community-based non-acute settings were identified by the Advisory Committee and approved by the Congress of Nursing Practice and Economics. To date, the following represent the Nursing-Sensitive Quality Indicators for Community-based Non-acute Care Indicators :

• Pain management (symptom severity) - The treatment and prevention of pain and discomfort. Effectiveness is related to level of functioning and activities of daily living and includes measures of frequency, intensity and duration of pain symptoms.
• Consistency of communication (strength of therapeutic alliance) - Consistent RN/advanced practice registered nurses (APRN) provider identified in the data/record.
• Staff mix (utilization of services) - Total number of direct care hours or total number of encounters provided by RN or APRN staff who have client care responsibilities (per episode/encounter/case as appropriate to the setting) and (RNs, LPNs, UAPs caring for clients) - The percent of registered nursing care hours as a total of all nursing care hours; secondary measure - percent of APRNs.
• Client satisfaction - The degree to which the care received met client expectations regarding nursing care, pain management, patient education and overall care.
• Prevention of tobacco use (risk reduction) - The number of clients attending educational sessions per year provided and/or coordinated by RNs about the risks of tobacco use (includes: coordination of educational sessions/programs either with individuals or groups).
• Cardiovascular prevention (risk reduction) - The number of clients attending educational sessions per year provided and/or coordinated by RNs about risks of cardiovascular disease.
• Care giver activity (protective factors) - The existence or frequency of primary care giver involvement.
• Identification of primary care giver (protective factors)
• ADL/IADL (level of function) - The degree to which the normal physical or entire action of a system occurs (physical or psychological).
• Psychosocial interaction (level of function) - The degree to which the normal action of a system occurs.

Importance of Nursing-Sensitive Data

While ANA works to ensure that nursing-sensitive indicators are included in data collected by the federal government and accrediting organizations and that the data are shared with key groups, ANA is asking all RNs to call for the collection of nursing-sensitive indicators in their own facilities/agencies. Articulating nursing-sensitive measures for use in publicly available report cards is vitally important. Since RNs are an integral part of our health care delivery system, both in terms of client contact and spending, they can make a tremendous impact in pushing for data collection.

In 1998, ANA funded the development of the National Center for Nursing Quality and a national database to house nursing-sensitive quality indicators. The database is housed at the University of Kansas Medical Center Research Institute (KUMCRI) and of the University of Kansas School of Nursing (KUMCRI). The goals of the National Database of Nursing Quality Indicators (NDNQI) are to promote and facilitate the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes. Data on nursing-sensitive indicators are collected and stored in NDNQI. To date, more than 235 hospitals from across the United States are participating in data collection on adult medical- surgical, and critical care populations. Data are reported to the database on a quarterly basis and quarterly feedback reports are provided to the hospitals.

The unique features of this database are that nursing-sensitive indicators are collected and reported at the unit level, stratified by type of unit and size of hospital, and confidential benchmarking reports are provided to the participating hospitals. The reports can be used by the hospitals to examine their own process of care with feedback to their nursing care units and support systems and potential relationships to nurse staffing levels. The database is actively recruiting new hospitals. A series of rigorous procedures has been developed to ensure that institutional identity will not be disclosed through data transmission, data storage, or NDNQI reports. The community-based non-acute care indicators will also be sorted and analyzed at NDNQI. Reports to each participating agency/facility will be provided quarterly. Following pilot testing of the indicators, all agencies/facilities wishing to participate and willing to follow the protocols will be able to submit data to NDNQI.

Issues of Concern

ANA is at the forefront of policy initiatives pertaining to health care. A number of the policy initiatives address the need to expand the scientific and research bases of nursing practice. Nevertheless, so much more needs to be done. When it comes to quality health care, in light of cutbacks and recent shortages, consumer confidence has been shaken. The health care industry continues to be plagued with numerous problems that need to be addressed. Among these are:

• Large gaps exist between the care people should receive and the care they do receive according to a Rand Corporation survey. These gaps are present in different types of health care facilities and in different types of health insurance, for all age groups, throughout the entire country.
• More and more Americans are concerned about shrinking health care benefits and spiraling insurance premiums.
• More and more individuals do not have health care benefits at all. By 2002, 45.6 million Americans are expected to be without health insurance, according to the American Hospital Association.
• Americans are worried about many of the changes in our health care delivery system and how they affect the quality of patient care, according to a 1996 survey commissioned by ANA. Three-quarters of the adults polled indicated serious concern that the quality of patient care is being diminished by some cost-cutting practices-a concern that has increased significantly since 1994 (Princeton Survey Research Associates, 1996).
• The Center for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA) , insurers and managed care organizations are ratcheting down reimbursement rates and reducing the number of services covered.
• Care settings have been reacting to cost pressures by looking at the cost of labor, in particular that of RNs, as the primary target area for cutbacks in an effort to streamline expenses and remain competitive. In addition, RNs with special skills are in short supply.
• Short-term financial gains may be achieved by cutting back on the number of RNs, but long-term savings are far from a reality. These short-sighted decisions may eventually play out in increased costs as a result of increased complications, increased readmissions, increased lengths of stay, increased legal liability, and increased mortality rates and overall human suffering.

How Does the Collection of Data Address these Concerns?

Studies comparing hospital staffing information and information on patient outcomes show that when there are more RNs, patients experience fewer complications, shorter lengths of stays, decreased mortality rates, and even lower overall costs. ANA has conducted two hospital studies in an effort to demonstrate these linkages. These studies' findings support similar findings in studies by Aiken, Blegen, and others. Research in community-based settings is sparse and uneven. A great need exists to increase the focus of researchers on measuring quality of care in the community. However, a critical need remains for more definitive data to demonstrate the clear linkages between nursing interventions, staffing levels, and patient outcomes in all care settings.

Solutions

The nursing community is constantly searching for and initiating research that further substantiates the linkages between nursing interventions and improved client outcomes. When it comes to determining the appropriate staffing mix, finding solutions that are amenable to the nursing workforce and administrators continues to be a struggle, especially in today's working environment when health care agencies are focusing on the bottom line. Data collection will assist in supporting research efforts; however, other things are being done and can be done to contribute to safe, quality health care.

• RNs are insisting that an appropriate number and mix of nursing personnel (RNs, LPNs, and unlicensed staff) be used to deliver safe, cost-effective, quality client care.
• Nursing needs to continue to implement research projects that will collect data to establish the relationship between the right mix of licensed and unlicensed staff and positive client outcomes in an effort to lobby more effectively for change.
• Nursing's Safety & Quality Initiative provides a framework for educating nurses, consumers, and policymakers about nursing's contributions to safe, quality health care, and the application of Beyond Acute Care: Community-based Non-acute Care Indicators (ANA, 2000)

Individual Actions - WHAT YOU CAN DO!

• Ask RNs to become active members of their Constituent Member Association and work together with other nurses locally and across the country to fight for safe, quality client care.
• Encourage RNs to push for the enactment of federal and state legislation requiring the collection, dissemination, and publication of data and staffing information.
• Determine which data are collected in your facility, who collects the data, and where the data go once summarized.
• Advocate for nursing-sensitive indicators to be included in health care facility/agency improvement programs.
• Demand that the facility/agency data are shared with the public in a meaningful format.
• Sign up for workshops on nursing-sensitive indicators.
• Inform clients, neighbors, legislators, and your community about the problems that result from inappropriate staffing.
• Campaign and advocate for standardized state and federal accountability for the safety and quality of client care delivered in all settings.
• Work with your CMA to seek state laws or regulations to ensure safe, quality client care.

Call your Constituent Member Association for more information on how you can protect the safety and quality of client care and preserve nursing practice.

For more information on quality or a listing of CMAs, please call the American Nurses Association at 1-800-274-4ANA, or go to http://www.nursingworld.org.

References

Adams, Robin Williams. (1997, July 13). Unhealthy Trend. The Lakeland Ledger, p. A1.

Aiken, Linda H., Sochalski, Julie, and Anderson, Gerard F. (1996). Downsizing the Hospital Nursing Workforce. Health Affairs 15 (4): 88-92.

Aiken, Linda H., Smith, Herbert L., and Lake, Eileen T. (1994). Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care. Medical Care 32: 771-787.

American Nurses Association. (1995). Nursing Care Report Card For Acute Care. Washington, DC: ANA.

(1996). Nursing Quality Indicators: Definitions and Implications. Washington, DC: ANA.

(1996). Nursing Quality Indicators: Guide for Implementation. Washington, DC: ANA.

(1997). Implementing Nursing's Report Card. Washington, DC: ANA.

(1999). Principles for Nurse Staffing (1999). Washington, DC: ANA.

(2000). Nursing Quality Indicators Beyond Acute Care: Literature Review (2000). Washington, DC: ANA

(2000). Nursing Quality Indicators Beyond Acute Care: Measurement Instruments (2000). Washington, DC: ANA

(2000) Nurse Staffing and Patient Outcomes in the Inpatient Hospital Setting (2000). Washington, DC: ANA

Barter, Marjorie, McLaughlin, Frank E., and Thomas, Sue A. (1994). Use of Unlicensed Assistive Personnel by Hospitals. Nursing Economic$ 12 (2): 82-87.

Blegen, Mary A. and Vaughn, Tom. (1998). A Multi-site Study of Nurse Staffing and Patient Occurrences. Nursing Economic$ 16 (4): 196-203.

Blegen, Mary A., Goode, Colleen J., and Reed, Laura. (1998). Nurse Staffing and Patient Outcomes. Nursing Research Jan./Feb. 47(1): 43-50.

Burda, David. (1998, Jan. 12). A Fat Year for Hospitals. Modern Healthcare: 28(2): 2.

Institute of Medicine (2001). Bridging the Quality Chasm. Washington, DC: National Academy Press.

Princeton Survey Research Associates. (1996). Nursing and the Quality of Patient Care 1996 Survey. Princeton, NJ.

Rothschild, Judith-Shindul. (1996). What's Happening to Patient Care? Final Results of the AJN Survey. American Journal of Nursing 96 (11): 24-39.

Single copies of this brochure (item PR-30) are available free to ANA constituent member association members only by calling 1-800-274-4ANA. Ask for item PR-30.

Multiple copies of this brochure and information about ordering other ANA publications can be obtained by calling 1-800-637-0323.

February 2002.

THIS INFORMATION COPYRIGHT 2002 AMERICAN NURSES ASSOCIATION

The American Nurses Association is the only full-service professional organization representing the nation's 2.7 million Registered Nurses through its constituent member state nurses associations. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public.

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