The Difference Nurses Are Making to Improve Quality of Care to Older Adults through the Interdisciplinary Nursing Quality Research Initiative

Translating the Research 

Ultimately, the goal of the INQRI work is that this investigator-initiated research will result in robust results that can be shared with policymakers, hospital administrators, and others who determine how nursing resources will be distributed to improve the quality and outcomes of patient care. To increase the probability that the findings of studies supported by the INQRI program are placed in the hands of and used by influential decision makers, INQRI is engaging key stakeholders on an ongoing basis to provide feedback and practical guidance to researcher teams. In addition to providing communications assistance to researchers to ensure that their work reaches a broad and diverse audience, the INQRI leadership team will produce syntheses that place the work of INQRI grantees in the context of similar research by others in the nursing and other health care fields.

In the Journal, we have pulled together the work from several of the INQRI projects that address care of older adults. I am thrilled to share these with our readership, because I believe they provide some very useful information for those of us to use in the field. The work by Bobay and colleagues in this issue, for example, provides a critical foundation for intervention work to improve discharge success following acute care admissions for older adults. Clearly, there is a need to review how discharge education is being done, particularly among those aged 85 years and older. In addition to what we have published in the Journal, the following projects are potentially relevant to older adults, and I encourage you all to monitor for publications on these projects in the near future and to reflect on and apply findings to how we can specifically address and improve the care provided to older adults across the entire health care continuum.

Linking Blood Stream Infection Rates to Intensive Care 

Johns Hopkins University

David Thompson and Jill Marsteller

The goal of this study was to implement a comprehensive safety program including an evidence-based intervention to reduce central-line-associated bloodstream infections while examining the context of nursing care delivery on patient outcomes. This interdisciplinary research team used the expertise of nurses to develop and deliver a quality improvement initiative that reflects the positive clinical contributions of nurses in the critical care setting. This study is likely to inform other nurse-led medical error reduction interventions and contribute to the quality improvement literature and the science of rigorously evaluated evidence-based interdisciplinary nursing practice.

Nurse-Sensitive Measurement of Hospital Care Coordination 

Emory University

Gerri Lamb and Francois Sainfort

An interdisciplinary team of nurse scientists and system engineers developed a new tool to capture what nurses do when they coordinate care for hospitalized patients. The tool, the first of its kind, will enable nurses and hospitals to document this important nursing work and will lead to a better understanding of how to improve care coordination and the quality of patient care in hospitals.

Improving the NQF Failure to Rescue Metric 

Mayo Clinic

Marcelline Harris and Jack Needleman

Led by scholars in nursing and health services research and informatics, the goal of this interdisciplinary team was to refine one of the most controversial measures of nursing-sensitive quality of care: failure to rescue. Refinement of this measure is expected to result in a measure of the quality of nursing care that is more likely to be used for quality improvement, public accountability, and pay for performance.

Quality Care on Acute Inpatient Units 

University of California

Mary Blegen and Tom Vaughn

The goal of this interdisciplinary project led by a nurse scholar was to test the power of the National Quality Forum–endorsed measures to advance quality nursing research and design, test other measures as potential indicators of nursing quality, and determine the impact of nurse staffing on these indicators in specific types of patient care units. Findings from this study are likely to inform the decisions of policy makers and others who are considering alternative proposals to ease the effects of current and future nursing shortages.

Developing and Testing Nursing Quality Measures with Consumers and Patients 

Baruch College

Shoshanna Sofaer and Jean Johnson

Led by scholars in health policy and public policy and nursing, the goal of this project was to develop nursing-sensitive quality measures that patients and other decision makers will find important and useful. In addition to existing nursing quality measures, the project also worked on new measures in an area that both patients and professionals often point to as critical: the coordination of their care.

Measuring Nursing Care Quality Related to Pain Management 

University of Utah

Susan Beck and Patricia Berry

The purpose of this study was to develop and test a questionnaire that can be used to measure opinions of patients about how their nurses manage their pain. Many patients in the hospital report significant pain, which can cause distress and limit their ability to carry out their usual activities. The information from this project will provide researchers with an understanding of how patients with pain understand and interpret questions related to the quality of their nursing care. This measure is likely to prove salient to consumers interested in selecting hospitals that can best address their care needs, as well as to hospital administrators and policy makers interested in improving the quality of nursing-related care.

Validating NQF Nursing-Sensitive Performance Measures 

University of Pennsylvania

Sean Clarke and Doug Sloane

Led by a nurse scholar, the goal of this interdisciplinary team was to analyze and validate measures from the National Quality Forum nursing-sensitive measure set using data collected from approximately 600 acute care hospitals in 3 states, as well as Medicare hospital performance measures, in 2005–2006. This validation study will be the foundation for blending new types of data on hospital quality in studies to help understand how staffing levels and the ways nursing services are organized influence the care patients receive and, ultimately, patient outcomes. The project also provided the first predictive validation for the National Quality Forum nursing measures against an external data set.

Lessons Learned from State Rollout of the National Quality Forum (NQF) Nursing Sensitive Measures 

Massachusetts Hospital Research and Education Association, Inc.

Pat Noga and Barry Kitch

Led by a team of health services researchers, the goal of this interdisciplinary team was to evaluate 2 statewide implementations of the NQF Nursing-Sensitive Measures created to provide hospitals and the public with comparative measures of nursing quality. The 2 statewide implementations were a voluntary effort in Massachusetts hospitals and a government-mandated effort in Maine hospitals. This study has the potential to inform policy makers and advocates in other states who seek to implement the nurse-sensitive measures endorsed by the NQF.

The Nursing Ambulatory to Hospital Transitions (NAHT) Program 

Massachusetts General Hospital

Barbara Roberge and Kenneth Minnaker

The goal of this nurse-led interdisciplinary research team was to validate and test the impact of identifying and communicating a prehospital preventive patient risk profile on nurse-sensitive outcomes for hospitalized older adults. Study findings have the potential to influence not only the quality of the transition from community to hospital but also nursing care delivered in the hospital, which will have a positive impact on the patient experience.

Translating Fall Risk Status into Interventions to Prevent Patient Falls 

Brigham and Women's Hospital

Patricia Dykes and Blackford Middleton

This project addressed gaps in knowledge by establishing linkages among nursing fall risk assessment, risk communication, and tailored interventions to prevent falls. The goal of this study was to prevent patient falls by translating an individual patient's fall risk assessment into a decision support intervention. This innovative intervention communicates fall risk status and creates a tailored evidence-based plan of care that is accessible to interdisciplinary team members, paraprofessionals, patients, and family members.

Rural Hospital Quality Collaborative on Evidence-Based Nursing 

University of Maryland

Robin Newhouse and Laura Morlock

Recent estimates indicate that people with chronic conditions receive 55% of the recommended care, with only 68% of patients with heart disease receiving the appropriate treatment. This interdisciplinary research team evaluated the effects of a rural hospital collaborative established to facilitate translation of evidence on heart failure (HF) patient care. Specifically, the team examined nursing characteristics that are associated with improvements in HF patient care.

Nursing Workforce Impact on Performance Improvement in the Centers for Medicare and Medicaid Services/Premier Hospital Quality 

Incentive Demonstration Project [Hospital Quality Incentive Demonstration]

University of Minnesota

Ira Moscovice and Mary Wakefield

The Deficit Reduction Act of 2005 directed the Secretary of Health and Human Services to implement a nationwide value-based purchasing program for all Prospective Payment System (PPS) hospitals beginning in fiscal year 2009. This interdisciplinary team examined the impact of nurse staffing and nurses' work environment on hospital performance improvement in the Centers for Medicare and Medicaid Services/Premier Inc. Hospital Quality Incentive Demonstration (HQID) project. HQID is the first CMS demonstration on the impact of hospital pay-for-performance.

Quality and Cost Outcomes of Hospital Supplemental Nurse Staffing 

University of Rochester

Ying Xue and Deborah Freund

Many hospitals use supplemental registered nurses (SRNs) hired from agencies to compensate for their nurse shortage, but their impact on quality and cost is not well understood. This interdisciplinary research team sought to understand the use of SRNs by hospitals and their impact on the quality of care and cost. The team described hospitals' uses of SRNs including economic consequences, examined the relationship between use of SRNs and patient outcomes, as well as voluntary nurse turnover.

Examining the Impact of Nursing Structures and Processes on Medication Errors 

Rutgers University

Linda Flynn and Dong Suh

The Institute of Medicine noted that a hospital patient on average is subject to at least 1 medication error per day, making medication errors the most common cause of preventable adverse events. This interdisciplinary study was designed to disentangle the effects of nursing structures and care processes on nonintercepted medication errors in acute care hospitals. The economic impact of nonintercepted medication errors was determined to explore the business case for evidence-based recommendations.

A Quality and Cost Analysis of Nurse Practice Predictors of Readiness for Hospital Discharge and Postdischarge Outcomes 

Marquette University

Marianne Weiss and Olga Yakusheva

Hospital readmission and emergency department utilization within the first 30 days following hospital discharge represent adverse, potentially avoidable, and costly outcomes of hospitalization. This interdisciplinary team broke new ground by linking the unit-level nurse practice environment and nursing care processes with patient outcomes at discharge and posthospitalization. Specifically, the study examined direct and indirect causal relationships between the nursing practice environment, the discharge teaching process, and readiness for hospital discharge with hospital readmission and emergency department utilization.

Linking Processes of Nursing Care and Patient Safety Outcomes: An Analysis of the Cause and Effect of Safe Practice 

Medical University of South Carolina

Richard Lindrooth and John Welton

This interdisciplinary team examined how adoption of the National Quality Forum safe practices affect nursing-sensitive patient safety outcomes. Barriers to adoption of these practices were also explored. This team took a step beyond existing literature by testing whether the implementation of safe practices leads to more effective use of nurses and whether this leads to better performance on patient safety outcomes.

Nursing Care Quality in Acute Care Hospitals: New Linkages to Patient Outcomes 

University of California

Arlyss Anderson Rothman and R. Adams Dudley

Increased public reporting of hospital performance and the emergence of hospital pay-for-performance initiatives provide new impetus to define and maximize all aspects of hospital care. This interdisciplinary team examined whether increases in nurse staffing and skill mix improve hospital performance on a subset of Joint Commission on Accreditation of Healthcare Organizations core measures, enhance patient perceptions of nursing performance, and improve overall nursing performance as measured by composite indicators that capture patients' perceptions of care, as well as other selected outcomes of care such as complication rates.

Impact of System-Centered Factors and Processes of Nursing Care on Fall Prevalence and Injuries from Falls 

University of Iowa

Marita Titler and Gary Rosenthal

Patient falls represent the largest category of hospital incident reports (70%–80%) and are among the most common adverse events. This interdisciplinary team examined linkages among selected NQF nurse-sensitive measures and processes of care to prevent falls. Specifically, the team investigated linkages between level of professional nursing practice and adoption of evidence-base practices, fall prevalence, and injury from falls.

Nursing-Pharmacy Collaboration on Medication Reconciliation: A Novel Approach to Information Management 

Johns Hopkins Hospital

Linda Costa and Robert Feroli

Deficits in communication across the continuum of care in regard to medication use can place patients at serious risk for harm. This interdisciplinary team examined how to support direct care providers economically in medication reconciliation to facilitate safe transition to and from hospital and community. The team evaluated the effectiveness of a nurse–pharmacist clinical information coordination team in improving drug information management on admission and discharge, quantified potential harm due to reconciliation failures, and determined cost–benefit related to averted harm.

The Impact of Nurse Staffing, Skill Mix, and Experience on Quality and Costs in Long-Term Care 

Palo Alto Institute for Research and Education

Patricia Stone and Ciaran Phibbs

This project will examine whether there is a causal relationship between nursing input (i.e., staffing and human capital characteristics) and patient outcomes in long-term care (LTC) facilities and will analyze efficiency by studying the trade-offs between nursing personnel costs and cost savings due to improved patient outcomes. Using a unique longitudinal database of the entire population of LTC facilities operated by the Veterans Administration in fiscal years 2003–2007, the team will link a variety of patient outcomes to detailed measures of the nursing input, controlling for other factors that can influence patient outcomes. Site visits will also be conducted and multivariate fixed-effect regressions will be estimated using monthly data.

The Effect of Off-Peak Hospital Environments on Nurses' Work: An Institutional Ethnography 

Midwestern State University

Patti Hamilton and Gretchen Gemeinhardt

This project uses institutional ethnography (IE) to situate nursing in the center of an interdisciplinary approach to learn how and why off-peak work environments are different and how they affect nurses' work and patient care. Two types of data will be collected. Level I data will be transcripts from individual and focus-group interviews. Level II will include managerial policies, documents, and other texts, used to improve quality and efficiency by standardizing and controlling the work of nurses. This project will provide researchers with insight into how to account for temporal variations in nurses' work environment when specifying causal models linking nursing care to patient outcomes. The project will also provide stakeholders with materials that help them identify, evaluate, and anticipate effects of initiatives to improve efficiency, effectiveness, quality, and cost on nursing care provided during off-peak periods.

Impact of Medical Surgical Acute Care Microsystem Nurse Characteristics and Practices on Patient Outcomes 

University of California, San Francisco

Nancy Donaldson and Carolyn Aydin

The aim of this project is to develop an empirically derived predictive model examining individual and collective effects of unit level nurse workload, staff nurse characteristics, selected risk assessment, and preventive intervention processes of care on variance in nurse sensitive outcomes of acute care medical-surgical units. The study uses community-based action research methods in a nonexperimental design that integrates quantitative and qualitative (observational) methods. As a secondary aim, the team will add a new measure, Hospital Acquired Stage 3–4 Pressure Ulcer Incidence, to the CalNOC dataset. This team is co-led by Nancy Donaldson, RN, DNSc, a nurse researcher, and Carolyn Aydin, PhD, a scholar with a background in humanities and communication theory research.

The Res-Care-AL Intervention Study 

University of Maryland, Baltimore

Barbara Resnick and Sheryl Zimmerman

This project is a randomized controlled trial to test a restorative care intervention in assisted living (AL) facilities. The project incorporates patient-centered outcomes (falls), nursing centered outcomes (restorative care services), and system-centered outcomes (staff turnover) as designated by the National Quality Forum. The primary aim of this study is to maintain or improve the residents' physical activity, physical status, function, and length of stay in the facility. The secondary aim related to residents focuses on mood, life satisfaction, resilience, self-efficacy and outcome expectations, social-support for exercise, and person–environment fit.

Multidisciplinary Organization and Outcomes for Chronic Heart Failure Patients in the Veterans Administration 

University of Minnesota

Joanne Disch and Douglas Wholey

This research team will test a theory of the effect of nurse–physician coleadership, the effective modeling by nurses and physicians of individual role behaviors, and a strong shared interprofessional relationship in chronic heart failure (CHF) care groups in Veterans Health Administration (VHA) medical centers. The outcomes will be waste in care processes, patient outcomes of receiving dietary and medication instructions at discharge, adult smoking cessation advice/counseling, readmissions, provider outcomes of nurse burnout, and CHF knowledge. The unit of analysis is patients and providers nested in VHA CHF care groups. The project has an observational design, with patient outcomes being followed for a year after a survey of CHF care groups.

The Effects of Nurse Presenteeism on Quality of Care and Patient Safety 

University of North Carolina, Greensboro

Susan Letvak and Christopher Ruhm

The primary aim of this project is to evaluate the influence of presenteeism (decreased productivity due to health problems) on hospital registered nurses' (RNs) quality of patient care. A secondary aim is to assess economic costs to the health care system associated with presenteeism. The study uses a mixed methods (quantitative survey and qualitative focus groups) design of RNs in North Carolina.

Small Troubles, Adaptive Responses [STAR]: Fostering a Quality Culture in Nursing 

University of Texas Health Science Center, San Antonio

Kathleen Stevens and Robert Ferrer

This project aims to improve nursing units' quality and efficiency. The research question is whether a program designed to identify and address small problems encountered by nurses in patient care occurring about once per hour per nurse and managed with workarounds in 95% of cases can lead to organizational learning that will drive large improvements in safety, quality, and efficiency. The intervention, adapted from theoretically based programs proved effective in other settings, combines a methodology for enhancing the underlying performance improvement capability of nursing units with a toolbox of quality improvement strategies relevant for tackling the small problems encountered in practice.

Empowering Home Care Nurses to Efficiently Resolve Medication Discrepancies 

Washington State University

Cynthia Corbett and Stephen Setter

To contribute to a better understanding of the potential for home care nurses to lead in the identification and resolution of medication discrepancies during transitions between hospital and home care providers, this team will conduct a clinical trial that investigates a new nurse-led, informatics-based intervention. The researchers hypothesize that with this improvement in their environment, home care nurses already on staff can enhance patients' outcomes, reduce health care costs, and eliminate the need for duplicative services by external consultants or specialty providers. Data analytic strategies will include analysis of variance, multifactor analysis of covariance, and linear regression analysis.

Nursing's Specific Contributions to Quality Palliative Care within the Context of Interdisciplinary Intensive Care Practice 

Oregon Health and Science University

Lissi Hansen and Richard Mularski

Little is known about the relationships between quality palliative nursing care delivered in intensive care units (ICUs) and patient and family outcomes and on how to measure and improve these outcomes. The purpose of this investigator-initiated study is to examine nursing's specific contributions to quality palliative care provided to patients in the ICU.

Nursing Intervention to Facilitate Patient Activation for Improved Pain Self-Management 

University of California, Davis

Deborah Ward

Richard Wanlass

This experimental study will evaluate an assessment-based counseling intervention to promote successful pain self-management in spine surgery patients. The team will evaluate for return on investment by measuring outcomes (pain, function, and depression) and value to the care delivery system as well as to patients. The team will track costs to patients (care utilization over and above usual postsurgical care), costs of the intervention, and opportunity costs.

Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers 

University of Cincinnati

Tracey Yap and Jay Kim

This nurse-led interdisciplinary research team will develop a sustainable, systemwide program for pressure ulcer prevention that enhances mobility of long-term care residents. The primary goal, under nursing's leadership, is to reduce long-term care facility–acquired pressure ulcer incidence by 50% using a cost-effective innovative program to increase resident active or passive movement.

SPEACS 2: Improving Patient Communication and Quality Outcomes in the Intensive Car Unit 

University of Pittsburgh

Mary Beth Happ and Amber Barnato

This project examines the value of a nurse-generated and nurse-led innovation by testing the impact of a computer-based nurse communication training and materials program (SPEACS-2) on patient care outcomes: nursing care quality (coma-free days, physical restraint use, pain symptom management, pressure ulcers, patient/family satisfaction with communication), clinical outcomes (ventilator-free days, intensive care unit/hospital days discharge disposition), and cost. The interdisciplinary research team from the University of Pittsburgh includes nurses, physicians, speech-language pathologists, and biostatisticians.

A Diabetes Prevention Program in the Community 

Yale University

Robin Whittemore and Alana Rosenberg

This team will conduct a randomized clinical trial to reduce the risk of type 2 diabetes (T2D) in at-risk adults with a diabetes prevention program provided by visiting nurses in subsidized housing units. They will modify a research-based diabetes prevention program; evaluate the preliminary effects of the modified diabetes prevention program provided by visiting nurses; and explore the reach, adoption, implementation, and cost of a diabetes prevention program delivered by visiting nurses to residents in subsidized housing units.