Nurse staffing and quality of care in Health Care Organizations Research Agenda of the Department of Health and Human Services, Agency for Health Care Policy and Research, National Institute for Nursing Research, Division of Nursing of HRSA

Nurse staffing and quality of care in Health Care Organizations Research Agenda of the Department of Health and Human Services, Agency for Health Care Policy and Research, National Institute for Nursing Research, Division of Nursing of HRSA

Nurse ScholarsProgramsfor 1998 The A A N is encouraging applications for three scholars programs: the Senior Scholar in Residence Program with the Ins...

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Nurse ScholarsProgramsfor 1998 The A A N is encouraging applications for three scholars programs: the Senior Scholar in Residence Program with the Institute of Medicine (IOM); the Senior Scholar in Residence Program with the Agency for Health Care

Policy and Research (AHCPR); and the Senior Scholar in Residence Program with the National Institute of Nursing Research (NINR). Application materials are due D e c e m b e r 18, 1997, for scholars programs starting in September

1998. To obtain application materials and additional information please call the A A N offices at (202) 651-7238; direct an e-mail message to [email protected]; or visit the website at www.nursingworld.org \ AAN.

Federal Agency Update Nurse Staffing and Quality of Care in Health Care Organizations Research Agenda of the Department of Health and Human Services, Agency for Health Care Policy and Research, National Institute for Nursing Research, Division of Nursing of HRSA*

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n response to a congressional directive, the Department requested that the Institute of Medicine (IOM) conduct a study on nurse staffing levels in hospitals and nursing homes. The IOM issued a report in January 1996, Nursing S taft in Hospitals and Nursing Homes: Is It Adequate ?1(the Report ). The Report notes a paucity of objective research on the relationships among restructuring, nurse staffing, and quality in hospitals. One of the recommendations of the Report is that the National Institute of Nursing Research (NINR) and other appropriate agencies fund scientifically sound research on the relationships between quality of care and nurses staffing levels and skill mix, taking into account organizational variables. The Report further recommends that the NINR, along with the Agency for Health Care Policy and Research (AHCPR) and private organizations, develop a research agenda on staffing and quality of care (see page 122 of the Report).

*This joint statement is the summation of efforts by many individuals and organizations. The American Academy of Nursing is pleased to be a part of this important effort. Christine Kovner, PhD, RN, FAAN, the AAN/AHCPR Senior Scholar in Residence, provided the necessary leadership to guide this initiative through the complexities of an open meeting and comment process to final completion. We acknowledge her efforts and applaud her contributions to the establishment of the AAN/AHCPR scholars program.

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In July 1996 the AHCPR, the Division of Nursing (DN) of Health Resources and Services Administration (HRSA), and the NINR jointly convened a group of research experts to discuss methodological issuesand key research questions on nurse staffingand quality of care in hospitals. Also discussedwere selected outcomes from a conference held by the American Academy of Nursing in June 1996, sponsored by AHCPR, the American Nurses' Association, and the American Organizations of Nurse Executives,entitled "Outcome Measures and Care Delivery Systems." Defining appropriate nurse staffing levels and mixes in hospitals in the United States has become an increasingly complex process. As cost-containment efforts during the past 15 years have led to more selective use of hospital services, hospital organizations have felt increasing financial pressure to modify their nursing service delivery patterns. Nurse staffing levels are also being influenced by the rapid development of technology; the growth ofsubacute, long.term, and home care use; and changes in the health care insurance market, including the transition to managed care systems. However, nurse staffing levels and mixes are frequently being altered in hospital settings in the absence of a sufficient assessment of the effectsof these changes on the quality of care delivered. Much work remains to be done in defining the nurse staffing levels and mixes that will optimize health care outcomes.

On November 13, 1996, a Proposed Research Agenda was published in the Federal Register. Public comments on this agenda were requested. The Research Agenda that follows incorporates comments about that Proposed Agenda. NURSE STAFFING

Research efforts in the area of nurse staffing will require refinement and standardization of conceptual as well as operational definitions of variables such as nurse staffing level and nursing skill mix. Included in this process must be an evaluation of the characteristics of the nurses providing care, such as level of education and psychological factors (e.g., nurse satisfaction with work). What nurses actually do (clinical vs. administrative vs. other duties), how nursing care is provided (staffing models used in each unit), and organizational characteristics (such as management or leadership style) are also important considerations. Q U A L I T Y OF NURSING CARE

The concept of health care quality is extremely complex and usually includes a consideration of the structure and process as well as the outcomes of care. Research focusing on nurse staffing and quality of care in hospitals may therefore be expected to include an evaluation of the organization and delivery of nursing care in the hospital setting.

VOLUME 45 • NUMBER 4

NURSING OUTLOOK

KEY Q U E S T I O N S On the basis of the expert discussions, the IOM Report, and a review of the published literature, the overarching questions to be addressed by research related to nurse staffing and quality of care in hospitals are: What is the contribution of nursing to the quality of care in hospitals, and what are the cost implications of this contribution? Within this area, a high research priority continues to be identifying patient outcomes that are sensitive to nursing care. Research pertaining to nurse staffing and quality in hospitals is a high priority; however, research pertaining to nurse staffing and quality in all delivery settings is also of interest. The primary areas proposed for future research focusing on the impact of nurse staffing on the quality of care include the following: • What is the relationship between the organization and delivery of nursing care and patient outcomes? What are the key organizational variables that influence staff performance and outcomes? Organization variables include both internal variables such as nursing service delivery model and external variables such as accreditation. • What are the unique skills and the mix of registered nurses, such as advanced nurse practice nurses, and o t h e r nursing and ancillary staff, such as unlicensed assistive personnel, that have an impact on outcomes? This includes the impact of unlicensed assistive personnel on outcomes and understanding what work needs to be done for patients to impact patient outcomes and who are the best people to do it. • What specific organizational variables and delivery of care variables are related to specific patient outcomes? Specific questions within this category include the following: What is the relationship between nursing skill mix

NURSING OUTLOOK

and achievement of outcomes such as appropriate self-care? What is the relative contribution of nurse, patient, other clinicians (e.g., MD) and organizational factors to specific patient outcomes ? • What is the impact of computer technology on patient outcomes? Included in this area are questions about the use of decision support that may extend offsite clinical expertise to hospital nursing staff. Also included are questions about the data elements about nursing and nurses that should be routinely collected. • What is the appropriate use of resources in an era when limited resources are available for health care? Although a nursing intervention may work for a clinical problem and even be more effective than other interven. tions, there may be other diseases or clinical problems that affect more people and also have cost-effective interventions. • What nursing care activities are directly related to patient issues or problems that impact the quality of clinical care? Particularly needed is research to address nursing interventions that result in differences in patient outcomes. Furthermore, the increasingly multidisciplinary nature of clinical care reinforces the need for an interdisciplinary approach to the development and evaluation of outcome measures. At the A A N Conference, the following patient outcomes were identified for further refinement by research teams: achievement of appropriate self-care, demonstration of health-promoting behaviors, health-related quality of life, perception of being well cared for (broadened beyond patient satisfaction), symptom management, and adverse outcomes. Other outcomes of interest relate to the patient's family and community. These outcomes are

JULY/AUGUST 1997

of interest for patients across the age continuum. A wide range of individuals and organizations are likely to find research on nurse staffing and quality in hospitals useful, including academic health centers, health care providers and their professional organizations, managed care organizations, insurers and other purchasers of health care, unions, consumers, and government agencies. • REFERENCE 1. Wunderlich GS, DavisCK. Nursing staffin hospitals and nursing homes: Is it adequate?Washington (DC): National Academy Press; 1996.

Direct inquires regarding this agenda to: Carolyn Clancy, MD Director, Center for Outcomes and Effectiveness Research Agency for Health Care Policy and Research 2101 East Jefferson Street Rockville, MD 20852 Phone: (301) 594-3721, ext. 1338 FAX: (301) 594-3721 e-mail: [email protected] Lynn M. Amende, PhD Director, Division of Extramural Activities National Institute of Nursing Research Building 45, Room 3AN-12 Bethesda, MD 20892-6300 Phone: (301) 594-5968 FAX: (301) 480-8260 e-mail: [email protected] Denise H. Geolot, PhD, RN, FAAN Deputy Director, Division of Nursing Bureau of Health Professions Health Resourcesand ServicesAdministration U.S. Public Health Service Parklawn Building, Room 9-35 5600 Fishers Lane Rockville, Maryland 20857 Phone: (301) 443-5688 FAX: (301) 443-8586 e-mail: [email protected]

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