ndnqi quality improvement analysis
THIS IS NOT DOCTORATE..PLEASE MAKE IT UNDERSTANDABLE! ;)I ATTACHED ALL REFERENCES FOR THIS MODULE. IF USING OTHER REFERENCES PLEASE LAST 5 YEARS.
- -Draft a 3- to 4 page paper analyzing areas where there is 1.) good performance and 2) areas of opportunity from the sample Dashboard (ATTACHED).
- Analyze the data provided in the Dashboard(ATTACHED) and select an area of performance that needs improvement (YOU CHOOSE 1 AREA NEEDING IMPROVEMENT). Include information on why this area was chosen.
- Develop a nursing plan that includes suggestions on how to improve performance on the selected indicator. Be sure to provide at least three (3) best practices from the evidenced-based literature to support your suggested nursing plan.
I ATTACHED THE SAMPLE DASHBOARD AND REFERENCES FOR THIS WEEK. YOU CAN USE OTHERS IF YOU WANT BUT MUST BE WITHIN LAST 5 YEARS
http://www.ihi.org/Pages/default.aspx
http://www.qualityforum.org/Home.aspx
`e Patient
Care Partnership
Understanding Expectations, Rights and Responsibilities
•
High quality hospital care.
•
A clean and safe environment.
•
Involvement in your care.
•
Protection of your privacy.
• Help when leaving the hospital.
• Help with your billing claims.
What to expect during
your hospital stay:
ur first priority is to provide you the care
you need, when you need it, with skill,
compassion and respect. Tell your caregivers if
you have concerns about your care or if you have
pain.
Y
ou have the right to know the identity
of doctors, nurses and others involved in your
care, and you have the right to know when they
are students, residents or other trainees.
ur hospital works hard to keep you safe.
We use special policies and procedures to
avoid mistakes in your care and keep you free
from abuse or neglect. If anything unexpected
and significant happens during your hospital
stay, you will be told what happened, and any
resulting changes in your care will be discussed
with you.
High quality hospital care.
A clean and safe environment.
What to Expect
During Your Hospital Stay
hen you need hospital care, your doctor
and the nurses and other professionals
at our hospital are committed to working with
you and your family to meet your health care
needs. Our dedicated doctors and staff serve
the community in all its ethnic, religious and
economic diversity. Our goal is for you and
your family to have the same care and attention
we would want for our families and ourselves.
The sections explain some of the basics about
how you can expect to be treated during your
hospital stay. They also cover what we will
need from you to care for you better. If you
have questions at any time, please ask them.
Unasked or unanswered questions can add
to the stress of being in the hospital. Your
comfort and confidence in your care are very
important to us.
W
O
O
Understanding Expectations, Rights and Responsibilities
`e Patient
Care Partnership
Involvement in your care.
ou and your doctor often make decisions about your care
before you go to the hospital. Other times, especially in emer-
gencies, those decisions are made during your hospital stay. When
decision-making takes place, it should include:
Y
• Discussing your medical condition and information
about medically appropriate treatment choices.
To make informed decisions with your doctor,
you need to understand:
• The benefits and risks of each treatment.
• Whether your treatment is experimental or
part of a research study.
• What you can reasonably expect from your
treatment and any long-term effects it might
have on your quality of life.
• What you and your family will need to do after
you leave the hospital.
• The financial consequences of using uncov-
ered services or out-of-network providers.
• Please tell your caregivers if you need more information
about treatment choices.
• Getting information from you. Your caregivers need complete and
correct information about your health and coverage so that they can
make good decisions about your care. That includes:
• Past illnesses, surgeries or hospital stays.
• Past allergic reactions.
• Any medicines or dietary supplements (such as vitamins and herbs)
that you are taking.
• Any network or admission requirements under your health plan.
Discussing your treatment plan. When you
enter the hospital, you sign a general consent
to treatment. In some cases, such as surgery or
experimental treatment, you may be asked to
confirm in writing that you understand what is
planned and agree to it. This process protects
your right to consent to or refuse a treatment.
Your doctor will explain the medical conse-
quences of refusing recommended treatment.
It also protects your right to decide if you want
to participate in a research study.
Understanding your health care goals and values.
You may have health care goals and values or
spiritual beliefs that are important to your
well-being. They will be taken into account as
much as possible throughout your hospital
stay. Make sure your doctor, your family and
your care team know your wishes.
Understanding who should make decisions when
you cannot. If you have signed a health care
power of attorney stating who should speak for
you if you become unable to make health care
decisions for yourself, or a “living will” or
“advance directive” that states your wishes about
end-of-life care; give copies to your doctor, your
family and your care team. If you or your family
need help making difficult decisions, counselors,
chaplains and others are available to help.
e respect the confidentiality of your
relationship with your doctor and other
caregivers, and the sensitive information
about your health and health care that are part
of that relationship. State and federal laws and
hospital operating policies protect the privacy
of your medical information. You will receive
a Notice of Privacy Practices that describes
the ways that we use, disclose and safeguard
patient information and that explains how you
can obtain a copy of information from our
records about your care.
Protection of your privacy.
our doctor works with hospital staff and
professionals in your community. You and
your family also play an important role in
your care. The success of your treatment often
depends on your efforts to follow medication,
diet and therapy plans. Your family may need
to help care for you at home.
You can expect us to help you identify sources
of follow-up care and to let you know if
our hospital has a financial interest in any
referrals. As long as you agree that we can
share information about your care with them,
we will coordinate our activities with your
caregivers outside the hospital. You can also
expect to receive information and, where
possible, training about the self-care you will
need when you go home.
Preparing you and your family for when you leave the hospital.
W
ur staff will file claims for you with health care insurers or other
programs such as Medicare and Medicaid. They also will help your
doctor with needed documentation. Hospital bills and insurance coverage
are often confusing. If you have questions about your bill, contact our
business office. If you need help understanding your insurance coverage
or health plan, start with your insurance company or health benefits
manager. If you do not have health coverage, we will try to help you and
your family find financial help or make other arrangements. We need
your help with collecting needed information and other requirements
to obtain coverage or assistance.
Help with your bill and filing insurance claims.
O
Y
While you are here, you will receive more
detailed notices about some of the rights you
have as a hospital patient and how to exercise
them. We are always interested in improving.
If you have questions, comments or concerns,
please contact:
©2003 American Hospital Association. All rights reserved.
Article
Problematising autonomy
and advocacy in nursing
Clare Cole, Sally Wellard and Jane Mummery
University of Ballarat, Australia
Abstract
Customarily patient advocacy is argued to be an essential part of nursing, and this is reinforced in
contemporary nursing codes of conduct, as well as codes of ethics and competency standards governing
practice. However, the role of the nurse as an advocate is not clearly understood. Autonomy is a key
concept in understanding advocacy, but traditional views of individual autonomy can be argued as being
outdated and misguided in nursing. Instead, the feminist perspective of relational autonomy is arguably
more relevant within the context of advocacy and nurses’ work in clinical healthcare settings. This
article serves to highlight and problematise some of the assumptions and influences around the
perceived role of the nurse as an advocate for patients in contemporary Western healthcare systems by
focusing on key assumptions concerning autonomy inherent in the role of the advocate.
Keywords
Advocacy, autonomy, nursing, relational autonomy
Introduction
Patient advocacy is portrayed in the nursing literature as an essential component of the role of the nurse
1,2
and reinforced in national and international codes of conduct and standards of practice.
3–5
Popular under-
graduate textbooks and university curricula promote the notion of patient advocacy as central in nursing.
The definition of advocacy is variable depending on the context in which it is used. Traditional definitions
of advocacy arise from the legal profession where a person’s rights are defended and their cause is argued
for.
6
The need for a patient advocate is closely related to the level of autonomy a person is presumed to have.
In contemporary Western healthcare practice, including nursing, ethical practices has been guided by
biomedical ethical principles articulated by Beauchamp and Childress.
7
These principles focus on the
concepts of autonomy, beneficence, justice and non-maleficence.
7
The principle of autonomy, supported
by the other ethical principles, is a predominant focus in Western healthcare with a key role of healthcare
understood as supporting patient autonomy, hence the centrality of patient advocacy.
To critically consider the role of advocacy in nursing, it is important to highlight and evaluate the con-
cept of patient autonomy and identify its role in the prevailing conceptualisation and promotion of the
nurse as an advocate for the patient. In particular, this article explores differing understandings of auton-
omy, contrasting liberal understandings of individual autonomy (as dominant in biomedical literature),
Corresponding author: Clare Cole, School of Health Sciences and School of Education & Arts, University of Ballarat, P.O. Box 663,
Mt Helen, Ballarat, VIC 3353, Australia.
Email: c.cole@ballarat.edu.au
Nursing Ethics
2014, Vol. 21(5) 576–
582
ª The Author(s) 2014
Reprints and permission:
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with feminist conceptions of relational autonomy, evaluating the implications of both for the practice of
advocacy in nursing. This analysis highlights and problematises some of the assumptions and influences
that surround the perceived role of nurses as advocate.
Advocacy
The idea of patient advocacy within nursing practice is embedded in nursing philosophical traditions and
reinforced in the educational preparation of nurses. In healthcare, however, advocacy has a broad range
of definitions, which are contextually based. Spence
6
highlights a range of definitions of advocacy used
in nursing which range from acting or interceding in the best interest of the patient, protection of patient’s
rights, to ensuring protection and comfort for patients unable to communicate. The multiple interpretations
of advocacy make analysis of the role of the nurse as an advocate difficult. For the purpose of this discus-
sion, advocacy in nursing is defined as a nurse actively supporting patients in relation to their rights and
choices, clarifying their healthcare decisions in support of their informed decision-making and protecting
basic human rights such as autonomy.
8
Issues with advocacy in healthcare
Nurses have argued that they are best placed to judge a patient’s capability to make and carry out auto-
nomous decisions because they have the greatest contact with patients compared with other healthcare
professions.
2,4,9
Early work of Bird
10
recognised that nurses attend to patients in vulnerable states, and for
sustained periods of time, and that this may contribute to the nursing profession’s adoption of the role of
patient advocate. In contemporary healthcare settings, intimate, physical and emotional care for patients
is still provided continuously by nurses. Davis et al.
11
acknowledge this point but argue nurses also have
an ethical obligation to be an advocate because of patient and family vulnerability in the context of the
environment and hierarchical systems of healthcare.
In cases of vulnerability, patient advocacy is seen as necessary due to the power differentials between
institutions, doctors, nurses and patients. Power distribution is unequal and nurses are arguably perceived
by patients as able to speak more effectively on their behalf than they may be able to do.
5
Under this framing
and justification of patient advocacy, the ethical obligation existing between nurses and patients is based on
patient rights and entails nurses supporting patients through their healthcare decision-making and illness
trajectory towards their achieving best outcomes for their health and autonomy.
11
Challengers to the notion of nurses as advocates have argued the role is a self-serving mechanism
adopted by nurses to position themselves for occupational advancement.
4,9,12
Mahlin
9
argued that adopting
the position of being a patient advocate is a way to increase the power and the professional status of nursing,
without damaging long-established images of the caring nursing profession. This, Mahlin
9
suggests, is the
reasoning behind the nursing profession maintaining its proprietary claim on the advocate role.
A question that requires further clarification concerns the above-mentioned unequal power distribution
and the relation between advocacy and contextual paternalism. To begin to unravel these questions, we need
to explore the concepts that influence the patient advocate role. One of the major influences within the
healthcare environment is that of autonomy.
Individual autonomy
The concept of autonomy is predominant in contemporary biomedical and nursing literature.
13
Commonly
defined as the ability for an individual to self-rule, self-govern or self-determine, this is typically recognised
as liberal individual autonomy.
7,14–17
Taylor
18
identifies autonomy as being the property of persons rather
Cole et al.
577
577
than non-persons, stating that persons are able to direct themselves, reflect and then make a decision. This
definition of individual autonomy assumes that each mature individual is independent and able to make deci-
sions that are rationally based (as opposed to based in emotion) and not determined by outside factors.
7,17,19,20
However, viewing autonomy with a liberal lens, Christman
19
argues, fails to recognise the fluidity and rela-
tionality of human nature that occurs as a consequence of the social circumstances in which a person finds
themselves.
Healthcare and individual autonomy
In healthcare, this notion of individual autonomy usually drives the rules surrounding informed consent.
15
Informed consent, as a basic interpretation, requires a patient be given appropriate information so that she or
he can make a voluntary decision based on that information.
21
Informed consent also relies on individuals
displaying competence to make that decision, shown by their demonstrated understanding of the risks,
benefits and the nature of the procedure they are consenting to.
21
However, understanding autonomy purely
in terms of informed consent is unsophisticated and is focused on legal protection for healthcare profession-
als.
4
The giving of informed consent is not necessarily a true indication of a patient’s ability or inability to be
autonomous within the healthcare setting. In healthcare, even the patient with specialised knowledge may
not be independently autonomous due to a variety of reasons.
Goering
15
highlighted organisational hierarchies within healthcare that can potentially limit a patient’s
individual autonomy. As argued, the choices available to an individual within a healthcare environment are
constrained by several factors, which all have the potential to adversely or positively influence autonomy.
These factors can include the ability to have privacy, access to visitors and the right to come and go or com-
municate as the individual pleases. For example, the organisational structure of hospitals dictates the timing
and nature of meals and limits individual choice in eating and nutrition. This is just one example of the
institutional control over an individual, which may constrain individuals’ ability to make meaningful and
autonomous decisions. For patients, this can be seen as a loss of personal control. These factors have many
intertwining aspects to them and can be related to the clinical environment, the acuity of the patient, the
nature of the admission and length of stay. Dodds
22
recognised that decisions made by individuals within
the healthcare environment are constrained by institutional frameworks and policies, available resources,
education and community involvement.
This argument proposed by Goering
15
highlights the ways in which individual autonomy can be and is
frequently compromised within the healthcare environment. Issues around healthcare such as anxiety, emo-
tional issues and the entrenched ideologies surrounding healthcare also have the potential to compromise
the ability to be autonomous.
15
If we look at the operational structure of medicine in terms of individual
autonomy, the choices that patients are able to make are limited as they are constructed within a paternalistic
framework and within given environmental constraints.
22
Paternalism traditionally has characterised therapeutic relationships in healthcare.
23
Early work done by
Melia
24
defined paternalism as making choices about treatment for patients which are considered by health-
care professionals to be in the patient’s best interest. Zomorodi and Foley
25
highlighted that paternalism
from a nursing perspective occurs when the preferences, decisions and actions of the patient are denied out
of a nursing concern for the patients’ well-being. Komrad
23
and Melia
24
identified the link between auton-
omy and paternalism as reciprocal; when autonomy is considered to be diminished, then paternalism is said
to be needed to care for the individual’s interests.
Waltho
26
identifies paternalism and its potential coercive treatment of patients as being of ethical
concern in healthcare. The narrow perception of healthcare professionals as acting in patients’ best interest
does not incorporate contextual and social influences that surround decision-making and autonomy. This can
also be linked to the liberal definitions of individual autonomy, which are not sufficient to understand and
578
Nursing Ethics 21(5)
578
demonstrate the complexities associated with decision-making.
15
When interpreting the social nature that con-
stitutes being human and the healthcare environment, it is evident that traditional liberal definitions of
individual autonomy are inadequate. Looking at the literature, a more appropriate definition of autonomy that
can be applied to the healthcare environment is that
of relational autonomy.
Relational autonomy
Human beings are intertwined in and constructed through both social and cultural relationships.
27
In this
sense, social relatedness and interdependence are not coherently able to be excised from the capacity for
autonomy,
28
rather the capacity to be autonomous is constitutively informed by social connections and
power relations, both of which inform the individual’s sense of self and reality.
27
Within the healthcare
context, considering the ability to be autonomous solely in terms of the concept of informed consent, also
neglects the intricate and complex social behaviours that may have the potential to both support and hinder
the process of individual autonomy.
Relational autonomy is a collective word derived from feminist arguments used to describe the social rela-
tionships and social context of individuals that inform an individual’s autonomous decision-making.
17,19,28–30
There is a focus on the social values, relationships and power structures in which an individual is embedded,
and recognition that these values, relationships and structures inform an individual’s decision-making.
22,28
Further defining relational autonomy, it can be viewed as the recognition that people who are important
within an individual’s social context influence decision-making. Important people can include but are not
limited to family, friends and professionals. It is within these social contexts and groups that an individual’s
identity is shaped.
17,31–33
Intersecting social determinants such as race, class, gender and ethnicity also
shape decision-making.
33
Therefore, relational autonomy describes an individual’s autonomy as being shaped by the social contexts
in which an individual is raised and live.
33
It involves the explicit recognition that autonomy can only be
defined and pursued within a social context and that this social context significantly influences the oppor-
tunities a person has to develop or express the necessary skills to be autonomous.
30
In the concept of rela-
tional autonomy, there is a close connection between the human interactions that occur in the social
environment that influence decision-making abilities.
28
Relational autonomy in the healthcare setting
Examining the relational aspects of being autonomous, we can begin to discover that social circumstances
and the skill and competency of the social individual also matter in the healthcare environment. Relational
autonomy still supports an individual’s ability to make and participate in healthcare choices
22
but recog-
nises the role of that individual’s social context. An example of this relationality of autonomy in the health-
care setting may be observed with the patient with cognitive decline or impairment. These patients rely on
the support of family to assist in the healthcare decision-making process. Relational autonomy also requires
the acknowledgement that healthcare providers and practices themselves contribute to the development and
shaping of an individual’s capacity to make autonomous decisions.
22
Relational autonomy highlights the role that healthcare professionals play in socialising individuals to
the specific context of the healthcare setting.
22
This can be clearly seen in maternity units where expectant
parents are given a tour of the ward facilities before the birth, which is an important socialisation of the
individuals to the environment. Walker
34
describes this as orientating information and that it is intended
to produce predictability and reduction of psychological distress. Such practices also support recognition
of relational autonomy.
Cole et al.
579
579
The social conditions recognised and supported within relational autonomy provide individuals with
reflective opportunities about the choices that they make.
31
But if we consider the points made above, the
choices available to patients are already limited by the institutional healthcare structures. Without the ability
to reflect on choices, the limitations placed on the autonomy of individuals become constraining and
oppressive.
Discussion
The dominance of a liberal conceptualisation of individual autonomy, where individuals are positioned as
needing to function without interference from outside influences, has been instrumental in supporting the
current views of the role of nurses as patient advocates in healthcare settings. Accordingly, when a person
becomes identified by nurses as unable to make autonomous decisions, then that person becomes reliant on
the nurse advocate to help them make decisions and to stand up for their views and beliefs. Advocates in
these circumstances act in a temporary capacity to assist patients to regain their independence and auton-
omy. In this context, patient advocacy arguably acts as a supportive mechanism for individual autonomy.
Patients in a healthcare setting are, however, at a disadvantage and potentially vulnerable because the envi-
ronment is foreign. Nurses have the benefit of intimate familiarity with the environment and its usual rules and
operation.
35
This disparity of knowledge and understanding of the environment can contribute to a patient’s
feelings of vulnerability associated with hospitalisation. Such feelings can occur due to deconstruction of the
social self, loss of autonomy and feelings of subordination and domination.
36
In many cases, although health-
care systems purport to support individual autonomous decision-making, a patient’s capacity for decision-
making may be limited by the context of the setting, putting them at risk of de-individualisation, increased
vulnerability and reduced autonomy.
36
A relational definition of autonomy introduces a broader view that can challenge both such de-
individualisation and the conventional view of advocacy in nursing practice. Humans are social in nature;
therefore, it is unimaginable that social contexts have no influence on a person’s autonomy. Feminist perspec-
tives of relational autonomy argue that the social context of the individual must be accepted as part of their
ability to be autonomous and to make autonomous decisions. Therefore, if we based our understanding of
autonomy on a relational view, then the potential role of a nurse advocate becomes substantially broader.
Viewing patients as relationally autonomous requires acknowledging the advocacy role of nurses as
being more complex and intricate than previously suggested. Under a relational conception of autonomy,
individuals are reliant on their social experiences and relationships to influence the healthcare decisions
that they make. Within healthcare settings, the focus shifts from simply assessing whether patients have
compromised autonomy and then taking on an advocacy role, to involving people who form part of the
social context of patients in the decision-making processes. This in turn supplies a new set of problems
regarding a patient’s healthcare experience, which influence the potential role of patient advocate. For
example, issues such as patient engagement in their decision-making, confidentiality and tensions that may
arise between caregivers and patients all become pertinent to the patient advocate role.
A relational autonomy perspective creates a challenge for how individuals are supported in decision-
making while in healthcare settings. Rather than an automatic assumption of the nurse being the advocate
of patients, there is need to develop an understanding that others in the patient’s relational world can also
actively contribute to advocacy for the patient where reduced autonomy is identified. The current emphasis
on individual autonomy may result in too easily assuming vulnerability and diminished capacity and blind
nurses to alternative ways of assessing and supporting decision-making for patients. Perhaps, the role of
advocacy for nurses is broader than currently espoused and could include advocating for the patient’s support
system as key in supporting patients.
580
Nursing Ethics 21(5)
580
Conclusion
Although nursing literature supports nurses undertaking a patient advocacy role, this role remains poorly
defined, and the expectations of such a role are varied and inconsistent. The role for nurses as patient advo-
cates in contemporary nursing practice is not only confusing, and potentially paternalistic, based as it is on
an individualistic view of autonomy, it needs further investigation and exploration. Arguably, a relational
view of autonomy suggests the need for a broader-based assessment and support system to assist patients
where needed in decision-making about their care.
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit
sectors.
References
1. Bu X and Jezewski A. Developing a mid-range theory of patient advocacy through concept analysis. J Adv Nurs
2006; 57(1): 101–110.
2. Hanks R. Development and testing of an instrument to measure protective nursing advocacy. Nurs Ethics 2010;
17(2): 255–267.
3. Breeding J and Turner D. Registered nurses’ lived experiences of advocacy within a critical care unit: a phenom-
enological study. Aust Crit Care 2002; 15(3): 110–117.
4. Hyland D. An exploration of the relationship between patient autonomy and patient advocacy: implications for
nursing practice. Nurs Ethics 2002; 9(5): 472–482.
5. Jugessur T and Iles I. Advocacy in mental health nursing: an integrative review of the literature. J Psychiatr Ment
Health Nurs 2009; 16(2): 187–195.
6. Spence K. Ethical advocacy based on caring: a model for neonatal and paediatric nurses. J Paediatr Child Health
2011; 47(9): 642–645.
7. Beauchamp T and Childress J. Principles of biomedical ethics. 5th ed. Oxford: Oxford University Press, 2001.
8. Hamric A. What is happening to advocacy? Nurs Outlook 2000; 48(3): 103–104.
9. Mahlin M. Individual patient advocacy, collective responsibility and activism within professional nursing associa-
tions. Nurs Ethics 2010; 17(2): 247–254.
10. Bird A. Enhancing patient wellbeing: advocacy or negotiation? J Med Ethics 1994; 20(3): 152–156.
11. Davis A, Konishi E and Tashiro M. A pilot study of selected Japanese nurses’ ideas on patient advocacy. Nurs
Ethics 2003; 10(4): 404–413.
12. Blackmore R. Advocacy in nursing: perceptions of learning disability nurses. J Intellect Disabil 2001; 5(3):
221–234.
13. MacKenzie C. Relational autonomy, normative authority and perfectionism. J Soc Philos 2008; 39(4): 512–533.
14. Friedman M. Feminism in ethics: conceptions of autonomy. In: Fricker M and Hornsby J (eds) The Cambridge com-
panion to feminism in philosophy. Cambridge: Cambridge University Press, 2000, pp. 205–224.
15. Goering S. Postnatal reproductive autonomy: promoting relational autonomy and self-trust in new parents.
Bioethics 2009; 23(1): 9–19.
16. MacKenzie C, McDowell C and Pittaway E. Beyond ‘do no harm’: the challenge of constructing ethical relation-
ships in refugee research. J Refug Stud 2007; 20(2): 299–319.
Cole et al.
581
581
17. MacKenzie C and Stoljar N. Introduction: autonomy refigured. In: MacKenzie C and Stoljar N (eds) Relational
autonomy: feminist perspectives on autonomy, agency and the social self. Oxford: Oxford University Press,
2000, pp. 3–34.
18. Taylor J. Practical autonomy and bioethics. New York: Routledge, 2009.
19. Christman J. Relational autonomy, liberal individualism, and the social constitution of selves. Philos Stud 2004;
117: 143–164.
20. Friedman M. Autonomy, gender, politics. Oxford: Oxford University Press, 2003.
21. Fry S and Johnstone M. Ethics in nursing practice: a guide to ethical decision making. 3rd ed. Oxford: Blackwell
Publishing, 2008.
22. Dodds S. Choice and control in feminist bioethics. In: MacKenzie C and Stoljar N (eds) Relational autonomy: fem-
inist perspectives on autonomy, agency and the social self. Oxford: Oxford University Press, 2000, pp. 213–235.
23. Komrad M. A defence of medical paternalism: maximizing patients’ autonomy. J Med Ethics 1983; 9: 38–44.
24. Melia K. Everyday nursing ethics. Basingstoke: McMillan Education, 1989.
25. Zomorodi M and Foley B. The nature of advocacy vs. paternalism in nursing: clarifying the ‘thin line’. J Adv Nurs
2009; 65(8): 1746–1752.
26. Waltho S. Rethinking paternalism: an exploration of responses to the Israel Patient’s Rights Act 1996. J Med Ethics
2011; 37: 540–543.
27. Nedelsky J. Reconceiving autonomy: sources, thoughts and possibilities. Yale J Law Fem 1989; 1(7): 7–36.
28. MacDonald C. Relational professional autonomy. Camb Q Healthc Ethics 2002; 11(3): 282–289.
29. Brison S. Relational autonomy and freedom of expression. In: MacKenzie C and Stoljar N (eds) Relational auton-
omy: feminist perspectives on autonomy, agency and the social self. Oxford: Oxford University Press, 2000, pp.
280–300.
30. McLeod C and Sherwin S. Relational autonomy, self-trust and healthcare for patients who are oppressed. In:
MacKenzie C and Stoljar N (eds) Relational autonomy: feminist perspectives on autonomy, agency and the
social self. Oxford: Oxford University Press, 2000, pp. 259–279.
31. Ball C. This is not your father’s autonomy: lesbian and gay rights from a feminist and relational perspective. Harv
J Law Gend 2005; 28(2): 345–379.
32. Barvosa-Carter E. Mestiza autonomy as relational autonomy: ambivalence and the social character of free will.
J Polit Philos 2007; 15(1): 1–21.
33. Baylis F, Kenny N and Sherwin S. A relational account of public health ethics. Publ Health Ethics 2008; 1(3):
196–209.
34. Walker A. Trajectory transition and vulnerability in adult medical-surgical patients: a framework for understanding
in-hospital convalescence. Contemp Nurse 2001; 11(2–3): 206–216.
35. Malik M. Advocacy in nursing: a review of the literature. J Adv Nurs 1997; 25(1): 130–138.
36. Scanlon A and Lee G. The use of the term vulnerability in acute care: why does it differ and what does it mean? Aust
J Adv Nurs 2007; 24(3): 54–59.
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permission.
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61.86 61.86 61.86 0.31 1.8 0.00 0.06 0.00 3.05 0.00 6.01 6.01 1.85 0.00 6.89 1.76 0.00 6.58 0.00 0.00 0.00 0.00 0.00 0.84 -0.84 0.00 0.00 0.00 0.00 12.85 4.17 0.00 0.00 23.53 2.84 2.84 0.00 2.84 2.84 0.00 4.76 0.00 15.00 15.00 0.00 8.70 8.70 0.00 33.33 0.00 5.56 0.00 0.00 0.00 0.00 17.65 0.00 0.00 0.00 6.58 0.00 5.26 6.58 0.00 0.00 0.00 0.00 4.35 100.00 0.00 100.00 100.00 100.00 100.00 100.00 0.00 100.00 100.00 0.00 100.00 100.00 0.00 100.00 100.00 0.00 100.00 100.00 0.00 100.00 100.00 0.00 100.00 7.35 7.73 1
7.46 7.46 6.96 3.14 0.00 3.14 3.14 3.14 100.00 100.00 0.00 100.00 100.00 100.00 92 100.00 100.00 80.00 -20.00 100.00 66.67 -33.33 100.00 100.00 0.00 100.00 100.00 0.00 100.00 80.00 -20.00 100.00 100.00 0.00 5
44.44 44.44 33.42 1.47 45.20 45.20 53.33 8.13 45.20 20.00 3 0.00 3
18.18 25.00 23.53 21.43 23.08 20.00 15.3 20.00 23.87 20.00 -3.87 14.65 23.87 20.00 -3.87 23.87 31.25 7.38 1.00 0.20 1.00 1.00 1.40 0.40 1.00 1.00 1.6 1.00 1.6 0.60 1.00 1.3 0.30 1.00 1.4 0.40 1.00 1.1 0.10 1.00 1.00 0.00 1.50 1.40 1.40 1.50 0.10 1.40 1.40 0.00 1.40 0.20 1.40 1.50 0.10 1.40 1.4 0.00 1.40 1.4 0.00 1.40 1.1 1.40 1.3 -0.10 1.40 1.2 1.40 1.50 0.10 4.00 11.80 8.78 11.80 11.80 8.28 0 1 -1 0 3 3 0 1 1 0 2 2 0 1 1 0 1 1 0 0 0 0 0 0 0 2 2 0 1 1 1 0 1 87.52 5.18 87.52 87.52 87.52 4.28 93.80 0.20 92.70 88.85 0
88.85 88.85 87.52 87.52 87.52 0
3.08 87.52 87.52 -5.00 84.50 85.75 0
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87.52 87.52 87.52 87.75 87.75 87.75 84.1 87.52 87.52 87.52 87.52 4.88 87.52 1.08 87.00 1.00 90.30 90.30 0.00 80.00 88.15 86.20 88.15 1.65 88.15 87.52 85.70 -1.82 87.52 84.40 87.52 87.52 87.52 89.30 89.60 0.30 88.55 87.80 88.55 91.4 2.85 88.55 87.52 84.70 87.52 87.50 87.52 0.38 87.52 89.20 1.68 87.52 90.20 88.00 0.30 89.35 89.35 90.6 1.25 89.35 89.2 Western Journal of Nursing Research © The Author(s) 2014 sagepub.com/journalsPermissions.nav 1
wjn.sagepub.com
Methods Research
Reliability and Validity of Lili Garrard1,2, Diane K. Boyle3, Michael Simon4,5, Abstract 1University of Kansas School of Nursing, Kansas City, US A
2University of Kansas School of Medicine, Kansas City, USA Corresponding Author: 542851WJNXXX10.1177/0193945914542851Western Journal of Nursing ResearchGarrard et al. mailto:lgarrard@kumc.edu http://crossmark.crossref.org/dialog/?doi=10.1177%2F0193945914542851&domain=pdf&date_stamp=2014-07-13 112 Western Journal of Nursing Research 38(1)
Keywords Falls are common adverse events experienced by patients in hospitals and National Database of Nursing Quality Indicators® NQF established a national framework to evaluate health care quality mea- Garrard et al. 113
and various national comparison data that were shown to be helpful in quality The NDNQI patient fall reliability study was conducted by Simon and Purpose
The purpose of the study was to investigate the reliability and validity of Method
Design
Data collection for the injury falls reliability study followed a similar process 114 Western Journal of Nursing Research 38(1)
occurred in a hospital, a detailed incident report regarding the fall would be Participants
Each NDNQI member hospital identifies a site coordinator whose primary In total, 1,159 site coordinators were invited to participate and 461 Survey Development
A Fall Injury Level Survey was generated using a convenience sample of de- Garrard et al. 115
validity of the fall scenarios on the survey. Twenty fall scenarios were selected Two senior NDNQI staff members served as fall experts for determining To address the first aim, survey participants were asked to classify the NDNQI Fall and Injury Level Definitions
The NQF-endorsed NDNQI fall and injury level definitions were given in the an unplanned descent to the floor (or extension of the floor, e.g., trash can or Injury levels are reported to NDNQI (2010) based on the following http://www.zoom-erang.com 116 Western Journal of Nursing Research 38(1)
Table 1. Expert Injury Level Classification and Mean Scale Score of Fall Scenarios.
Fall Scenario Classification (95% CI)
S1a Pt. found sitting on bathroom floor. Steri-strips applied Moderate 2.72 [2.26, 3.17]
S2a Pt. lost balance and fell backward. Complained of low Minor 2.02 [1.50, 2.55]
S3a Pt. was found on floor lying next to bed after a loud None 1.21 [0.63, 1.79]
S4 Pt. reported to nurse that she “hurt her arm” during fall None 1.59 [1.09, 2.09]
S5a Pt. stated he tripped on IV pump power cord and fell. None 1.05 [0.82, 1.27]
S6a Pt. reported she fell out of a chair to floor while None 1.10 [0.77, 1.42]
S7a Pt. states she fell on knees while reaching for shoes. No Minor 2.04 [1.68, 2.39]
S8a Pt. found on floor. Complained of pain on R side of Major 3.91 [3.58, 4.25]
S9a Pt. reported he tripped with walker on door jam and None 1.54 [0.54, 2.54]
S10a Pt. found on BR floor and states she hit head. Small Minor 2.09 (1.73, 2.46)
S11b Pt. found unconscious on BR floor after a loud sound Moderate 4.88 [4.32, 5.43]
S12a While pt. was assisted to BR with gait belt he became Major 3.75 [3.27, 4.23]
(continued) Garrard et al. 117
None—patient had no injuries (no signs or symptoms) resulting from the fall, Minor—resulted in application of a dressing, ice, cleaning of a wound, limb Moderate—resulted in suturing, application of steri-strips/skin glue, splinting Major—resulted in surgery, casting, traction, required consultation for Death—the patient died as a result of injuries sustained from the fall (not from Fall Scenario S13a Pt. walked unassisted to BR after returned to room Major 3.97 [3.78, 4.16]
S14b Pt. lost balance and fell to floor during transfer from None 3.60 [2.99, 4.21]
S15a Pt. became dizzy while walking to BR with assistance. Moderate 2.66 [2.18, 3.15]
Note. Injury level scale: 1 = none, 2 = minor, 3 = moderate, 4 = major, 5 = death. CI = confidence interval; Pt. Table 1. (continued) 118 Western Journal of Nursing Research 38(1)
Analysis
Coding of responses. Each respondent selected one out of five injury levels Reliability and validity analysis. The reliability of a measure is the “ability to In addition to reliability, the validity of the fall scenarios also was assessed. Garrard et al. 119
injury level (Table 2). Given the psychometric difficulties, a decision was Thirteen fall scenarios remained for assessment of construct validity, The construct validity computations were all performed using Mplus Table 2. 95% Confidence Interval for the Proportion of Exactly Correct and Fall Scenarioa Exactly Correct (%) Correct Within One Injury Level (%)
S1 [67.17, 75.44] [100.00, 100.00] a. Abbreviated descriptions of the scenarios are summarized in Table 1. 120 Western Journal of Nursing Research 38(1)
advanced statistical software recognized for its powerful ability to fit vari- For oblique rotations (correlated factors, for example, Promax), the con- Results
Reliability
The variance within each scenario was 0.252 and the variance between the 15 Garrard et al. 121
provided by Kline (2011). The ICC (1, 1) indicated a substantial reliability of As mentioned above, two scenarios (S11 and S14) were very complex and Validity
During the initial EFA conducted on the training data set, six factors with With the validation data set, the CFA model was specified using the three 122 Western Journal of Nursing Research 38(1)
CFA model was re-fitted after removing Scenario 4 and the confirmed struc- As mentioned above, Varimax factor solutions were used as a proxy to The construct validity analysis findings indicated that the final 12 fall sce- Table 3. Factor Loadings After Promax Rotation for Three-Factor Structure With Fall Scenarioa No Injury Minor Injury Moderate/Major Injuries Injury Level
S1 −0.078 0.239 0.801 Moderate Minor
S7 0.059 0.504 −0.005 Minor None
S4 0.758 −0.244 0.008 None a. Abbreviated descriptions of the scenarios are summarized in Table 1. Garrard et al. 123
the severity of the injury falls, and thus supporting the validity or accuracy of Discussion
The overall ICC estimate for the 15 fall scenarios fell between very good and A B
.541
.733
S1 S8 S12 S13 S15
Moderate/ .701.592 .563 .394
1 .098 .143 .113 .202 .095
S3 S4 S5
.950.758 -.021
S6
.817
None S9
.341
.091 .110 .123 .085 .124
S2 S7 S10
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.104 .148 .119
1 .739 .024
.538
.732
S1 S8 S12 S13 S15 .702.590 .564 .395
1 S3 S5
.951.760
S6 .818
None .342
.091 .123 .085 .124
S2 S7 S10 .581 .600 .749
.105 .149 .119
1 .734 .024
Figure 1. (A) Initial CFA model and (B) final CFA model. 124 Western Journal of Nursing Research 38(1)
respondents for each fall scenario. Results provided strong evidence for the From the results of the construct validity analysis, it was apparent that the The majority of fall scenarios had about 70% to 90% of respondents Garrard et al. 125
to confusion about the injury level assignment. These two scenarios were One limitation of this study comes from the usage of incident reports to Another limitation of this study comes from the sample selection bias. The In this study, the reliability and validity of the NDNQI falls with injury 126 Western Journal of Nursing Research 38(1)
the injury falls, particularly among non-injurious falls, minor injury falls, and An implication from this study is that the Falls Injury Level Survey can be Acknowledgments
Chenjuan Ma and Yu Jiang provided helpful comments on an earlier version of this Declaration of Conflicts of Interests
The author(s) declared no potential conflicts of interest with respect to the research, Funding
The author(s) disclosed receipt of the following financial support for the research, References
Bergquist-Beringer, S., Davidson, J., Agosto, C., Linde, N. K., Abel, M., Spurling, K., Garrard et al. 127
Indicators (NDNQI) training program on pressure ulcers. Journal of Continuing Bergquist-Beringer, S., Gajewski, B., Dunton, N., & Klaus, S. (2011). The reliability Bordens, K., & Abbott, B. B. (2011). Research design and methods: A process Centers for Disease Control and Prevention. (2013). Costs of falls among older adults. Centers for Medicare & Medicaid Services. (2012). Hospital-acquired conditions Currie, L. (2008). Fall and injury prevention. In R. G. Hughes (Ed.), Patient safety Englander, F., Hodson, T. J., & Terregrossa, R. A. (1996). Economic dimensions of Gajewski, B. J., Hart, S., Bergquist-Beringer, S., & Dunton, N. (2007). Inter-rater Hart, S., Bergquist, S., Gajewski, B., & Dunton, N. (2006). Reliability testing of the Inouye, S. K., Brown, C. J., & Tinetti, M. E. (2009). Medicare nonpayment, hospi- Kline, R. B. (2011). Principles and practice of structural equation modeling (3rd ed.). Lake, E. T., Shang, J., Klaus, S., & Dunton, N. E. (2010). Patient falls: Association MacCallum, R. C., Roznowski, M., & Necowitz, L. B. (1992). Model modifica- Mion, L. C., Chandler, A. M., Waters, T. M., Dietrich, M. S., Kessler, L. A., Miller, Montalvo, I. (2007). The National Database of Nursing Quality Indicators http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcq-Cond/Downloads/HACFactsheet http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcq-Cond/Downloads/HACFactsheet http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/nurseshdbk http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/nurseshdbk http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/nurseshdbk 128 Western Journal of Nursing Research 38(1)
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ Muthén, L. K., & Muthén, B. O. (1998-2009). Mplus user’s guide (5th ed.). Los National Database of Nursing Quality Indicators. (2010). Guidelines for data collec- National Priorities Partnership. (2011). Input to the Secretary of Health and Human National Quality Forum. (2002). A national framework for healthcare qual- National Quality Forum. (2004). National voluntary consensus standards for nurs- National Quality Forum. (2011). Serious reportable events in healthcare—2011 National Quality Forum. (2013a). Falls with injury. Retrieved from http://www.quality- National Quality Forum. (2013b). Patient fall rate. Retrieved from http://www.quality- Schwenk, M., Lauenroth, A., Stock, C., Moreno, R. R., Oster, P., McHugh, G., . . . Shorr, R. I., Mion, L. C., Chandler, A. M., Rosenblatt, L. C., Lynch, D., & Kessler, Simon, M., Klaus, S., Gajewski, B. J., & Dunton, N. (2013). Agreement of fall clas- Skrondal, A., & Rabe-Hesketh, S. (2004). Generalized latent variable modeling: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx?%3E http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx?%3E http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx?%3E http://www.qualityforum.org/WorkArea/linkit.aspx?ItemID=68238 http://www.qualityforum.org/WorkArea/linkit.aspx?ItemID=68238 http://www.qualityforum.org/Publications/2002/07/A_National_Framework_for_Healthcare_Quality_Measurement_and_Reporting.aspx http://www.qualityforum.org/Publications/2002/07/A_National_Framework_for_Healthcare_Quality_Measurement_and_Reporting.aspx http://www.qualityforum.org/Publications/2002/07/A_National_Framework_for_Healthcare_Quality_Measurement_and_Reporting.aspx http://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx http://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx http://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx http://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx http://www.qualityforum.org/Publications/2011/12/Serious_Reportable_Events_in_Healthcare_2011.aspx http://www.qualityforum.org/Publications/2011/12/Serious_Reportable_Events_in_Healthcare_2011.aspx http://www.qualityforum.org/QPS/0202 http://www.qualityforum.org/QPS/0202 http://www.qualityforum.org/QPS/0141 http://www.qualityforum.org/QPS/0141 Professional In fo rm ed Consent: A lmost all nurses are engaged in elements of informed consent with their patients at some point in their careers. From a legal perspective, History of Informed Consent to consent to medical treatment. The ethical principle of Historically, the right to consent was protected 191 4). Justice Every hum an being of adult years and sound m ind The court in Natanson v. Kline (1960) further defined Mary J. Rock, JD, MSN, RN, is Assistant Clinical Professor of Nursing, Roberta Hoebeke, PhD, FNP-BC, is Professor of Nursing, University of M ED 5U R G uprsimg. M a y -ju n e 2014 • Vol. 2 3 /N o . 3
hibit medical treatm ent expressly even if it is lifesaving. This comm on law right of consent later was extended During World War II, the issue of consent was brought More recently, m any states have enacted patient bill of The American Nurses Association (ANA, 2010) em pha Respect for hum an dignity requires the recognition 189 P r o fe s s io n a l Issues
nurses and other health professionals. Patients In fact, nurses are obligated to understand their Types o f C o n sen t sent can be an oral declaration of consent or it can be pro In health care, informed consent usually is provided Courts have supported the physician’s duty to disclose If proper informed consent is not obtained, the patient 190
from a claim based on the skill and care employed during Another theory of recovery for lack of proper consent D u ty o f Physician is involved in decisions about his or her health care. The Generally, the doctrine of informed consent requires test. examination, or test. ination, or test. dure, examination, or test. information for consent is measured from the patient’s
M ay-Ju ne 2014 • Vol. 2 3 /N o . 3 M ED 5U R G ̂ JTJRS INGi Informed Consent: Whose Duty to Inform?
point of view; in other jurisdictions, the duty is measured D u ty o f Nurse the patient’s signature on the consent form, he or she Accurately informing the patient about the particulars Although a physician may try to delegate informed MEDSURG JSI U H S I JSI& M ay-june 2014 • Vol. 23/N o. 3
and competent to give consent, and (c) the patient’s sig If the nurse has reason to believe the patient either is Conclusion was a somewhat automatic, habitual procedure. The REFERENCES ethics for nurses. Silver Spring, MD: Author. (4th ed.). Sudbury, MA: Jones & Bartlett Learning. MN: West. Saddle River, NJ: Pearson. (Neb.1998). Biomedical and Behavioral Research. (1979). Belmont report: Nuremberg Military Tribunals. (1949). The Nuremberg code. In Trials con tinu ed on pa ge 194
191 AMteiRr www.nursingeconomlcs.net/offer
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MEDSURG Copyright of MEDSURG Nursing is the property of Jannetti Publications, Inc. and its content Journal for Healthcare Quality
Quartile Dashboards: Translating Large t
Priorities n
Abstract: Quality professionals are the first to understand chal- frontline staff, operational managers, and governing bodies.To comparative performance from within large data sets, priori- presents a methodology for translating data from large data priorities, in a simple way that takes advantage of tools readily the California Nursing Outcomes Coalition.
Key Words dashboard radar diagrams
Dashboards have transformed the way that Understanding Performance Data for Healthcare Quality summarized using descriptive statistics such as
rcQuality
frequencies, averages, and standard deviations Those new to the field of healthcare quality Vol. ;ÎO N O . 6 November/December 20Ü 8
reference point for data sets when there are Understanding how the data acttially Most data sets report standard deviations 95%, between the mean and plus or mintis 2 An example of setting perfonnance met- As benchmarking data sets become more Percentiles
aie easier to explain to those who operationally When percentiles are available, quartiles Quartiles divide the data set into four quarters, with the UM Journal for Healthcare Quality
Figure 1. Data Distribution with Percentiles and Quartiles
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r- Figure 2. Summary Statisti
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Figure 3. Graph Report
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process. Continuing with the C âlNOCl example, to demonstrate a simple method to translate Vol. 30 No. 6 November/December 2008 r- Figure 6. Benchmarking Report
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2 28 Step 1: Príorítizatíon Step 2: Translating Performance into Quartiles into tbe spreadsheet. Tbis abstraction from As a practice example for translating quartile Journal for Healthcare Quality Figure 7. Worksheet for Capturing Performance by Indicator
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DutEomai QuaMlli Analysis Rertortninee Knaiysls Journal for Healthcare Quality performance targets oí being below the 75th Summary References lïufTiini, M.. & Saiullui. M. (2004). Crcntiiig and analy/- Briiwn. O. .S.. Doimldson. N.. .-Vydin, C. K., & Carlson, N. DawNon. B.. &• Trap]), R. (i. (200’4), liitsir antl ctiiiitnt bitntti- Donaldson, N., Bri>wn, D. .S., Ayditi, C K.. Bohon, M. [,.. Ü- , A. C:. (2OÜ2). Pertbrmaiue management data sys- lindenaner, l\ K,, Remas, I)., Sc Roman, S. (20()7). Public rc|xin- Meiriam Wehster onlitie dictitmtin. (2007). Retrieved Ocioljn Rosow, I!., Adam, J,, Coulnmbe, K., Race, K,, &- Anderson, Authors’ Biographies Carolyn E. Aydin, IViD, is a California Niunirig (hitcoines Nancy Domildsori, DNSc RN FAAN, is Ihe CaUfmnia For more informatitm on this article, rontact Diane Storer Joimial for 11 et ill h rare (¿uality is pleastd [o olí( r Core CPHQ Examination Content Area Workplace empowerment and nurses’ job satisfaction: a literature review
GIANCARLO CICOLINI R N , M S N , P h D 2
and VALENTINA
SIMONETTI R N , M S N 2
1Nurse Director and 2PhD Student, Center of Excellence on Aging, Clinical Research Center CRC-CeSI, Italy
Correspondence
Giancarlo Cicolini
Center of Excellence on Aging,
Clinical Research Center CRC-
CeSI
University of ‘G. d’Annunzio’
Chieti – Via dei Vestini 31
66013 Chieti Scalo
Italy E-mail: g.cicolini@unich.it
CICOLINI G., COMPARCINI D. & SIMONETTI V. (2014) Journal of Nursing Management Workplace empowerment and nurses’ job satisfaction: a systematic
literature review Aims This systematic review aimed to synthesize and analyse the studies that the nursing work environment.
Background Job dissatisfaction in the nursing work environment is the primary empowerment in nurses. tural empowerment, psychological empowerment and
nurses’ job satisfaction. Twelve articles were included in the final analysis.
Key issue A significant positive relation was found between empowerment and tural empowerment and psychological empowerment
affect job satisfaction differently. antecedent of psychological empowerment and this relationship culminates in satisfaction.
Implication for nursing management This review could be useful for guiding organisational and patient outcomes.
Keywords: job satisfaction, psychological empowerment, review, structural Accepted for publication: 18 September 2012
Background
Nursing shortage is increasing because nurses are
leaving the profession, particularly as a result of diffi-
cult working conditions (Buerhaus et al. 2000, 2006)
and unsatisfying workplaces (Hayes et al. 2006, Pur-
dy et al. 2010). A recent study showed that the fac-
tors causing this desertion could be: a high nurse
turnover (Hauck et al. 2011), heavy workloads and
lack of development opportunities (Laschinger et al.
2009a).
Job satisfaction is defined as the degree of affect
toward a job and its main components (Adams &
Bond 2000) and can be considered to be a positive
concept describing work behaviours in work settings
(Utriainen & Kyngas 2009). Nurses’ job satisfaction is
DOI: 10.1111/jonm.12028
ª 2013 John Wiley & Sons Ltd 855
Journal of Nursing Management, 2014, 22, 855–871 related to professional, personal and organisational
variables (Lu et al. 2005) and is influenced by both
nurses’ working environment and nurses’ personal
characteristics (Adams & Bond 2000).
Nurse managers have to maintain high-quality stan-
dards of care and job satisfaction among nurses, often
with a lack of human and financial resources (Lee &
Cummings 2008). Transformational leadership style
is based on principles of empowerment, and it is able to
support these organisational conditions. To date, trans-
formational leadership is the most effective model of
management in the healthcare system for developing a
positive relationship between managers and nursing
staff, to promote nurse satisfaction and organisational
commitment (Ellefsen & Hamilton 2000, Falk-Rafael
2001, Laschinger et al. 2001a).
Workplace structures can support healthier nurses,
reduce stress and increase commitment and job
satisfaction, and also improve organisational and
patient outcomes (Wagner et al. 2010). Nurse leaders
need to carry out evidence-based approaches for
empowering work environments that ensure satisfac-
tion, which in turn could ensure high quality care
(Laschinger 2008).
The term ‘empowerment’ in the organisational con-
text is used in two different perspectives: psychological
empowerment and structural empowerment. Structural
empowerment refers to the application of management
(Kanter 1977) and occurs when employees have access
to empowerment structures (Laschinger et al. 2004).
The psychological empowerment (Spreitzer 1995) deals
with ways in which these applications are experienced
and understood by workers (Cavus & Demir 2010)
and occurs when there is a sense of motivation in rela-
tion to the workplace environment (Manojlovich &
Laschinger 2007).
Based on previous studies on psychological empow-
erment (Conger & Kanungo 1988, Thomas & Velt-
house 1990), Spreitzer (1995, 1996) developed a
multidimensional instrument to measure the psycho-
logical empowerment in the workplace through four
cognitive dimensions reflecting why employees feel
empowered.
The first cognitive dimension is meaning, referring
to how much employees feel that their work is impor-
tant in relation to the congruence between workplace
requirements and one’s own beliefs, values and behav-
iours. The second is competence, referring to the level
of one’s capability to perform job requirements
successfully. The third is self-determination, referring
to the sense of autonomy that people have towards
their own work. The fourth dimension is impact,
referring to the level to which people feel that they are
able to have an influence on the workplace.
Kanter (1977) defined an empowering work environ-
ment as a workplace in which employees have access to
the four empowerment structures. The first structure is
information, referring to the data, technical knowledge
and expertise that are necessary effectively to fulfil
someone’s professional requirements (Laschinger &
Havens 1996). The second is resources, referring to
material, money, time, requirement and equipment
needed to accomplish the organisational goals. The
third is support, referring to feedback, leadership and
guidance received from superiors, peer and subordi-
nates. The last is opportunities referring to autonomy,
self-determination, a feeling of challenge and the oppor-
tunity to learn and grow. The access to these structures
is facilitated by two specific sources of power in organi-
sations: formal power (specific job characteristics) and
informal power (interpersonal relationships with supe-
riors, peers and subordinates) (Miller et al. 2000).
Chandler (1986) was the first to test Kanter’s theory
of organisational empowerment in nursing settings.
Based on Kanter’s (1977) theory and Chandler’s
(1986) work, the University of Western Ontario
Workplace Empowerment Research Programme has
been created. To date, the main studies testing Kan-
ter’s model of empowerment in health care settings
have been conducted by Laschinger and colleagues
(Laschinger and others, 2000–2011). Further research
(Laschinger et al. 2001a,c,d) has been carried out to
expand Kanter’s model with the addition of Spreitzer’s
(1995) model of psychological empowerment.
In the past two decades, researchers have integrated
both the structural and the psychological perspectives
of empowerment (Spreitzer 2007) in order to under-
stand empowerment at work.
Both perspectives are correlated with measurable
positive workplace outcomes, particularly with job
satisfaction (Stewart et al. 2010, Wagner et al. 2010),
which is essential to support changes at all levels of
the organisation and to achieve long-term outcomes
for managers, staff and patients (Laschinger & Havens
1996, Manojlovich & Laschinger 2002). Nurse manag-
ers have to incorporate empowerment techniques
into management strategies (Chang et al. 2011) to
increase nurse satisfaction within the work environment
(Upenieks 2003).
Significance
Many factors contribute to the current nursing short-
age, high nurse turnover is considered one of the main
ª 2013 John Wiley & Sons Ltd G. Cicolini et al. contributors (Hauck et al. 2011) while job dissatisfac-
tion is the primary cause of nursing turnover (Lautizi
et al. 2009).
Nursing retention is related to workplace variables
and to job satisfaction (Coomber & Barriball 2007).
Furthermore, nurses’ perceptions of workplace empow-
erment is related to intent to stay, independently of
individual factors (Nedd 2006).
Recent studies show that workplace empowerment
has a strong relationship with nurse retention and an
important impact on factors related to recruitment,
particularly on job satisfaction (Laschinger et al.
2001a, Faulkner & Laschinger 2008) and commit-
ment (McDermott et al. 1996).
The aim of the review was to identify and synthesize
recent studies on the relationship between nurse
empowerment and job satisfaction and to make rec-
ommendations for further research.
The following research questions guided this review:
● Can structural and psychological empowerment pro-
mote job satisfaction in nurses’ work environment?
● What is the relationship between structural empow-
erment and job satisfaction in nurses’ work environ-
ment? empowerment and job satisfaction in nurses’ work
environment? Methods
Design
A systematic literature review with narrative synthesis
was performed, because the methodologies of the
included studies were not appropriate for a statistical
summary of the studies. The integrative method pro-
posed by Whittemore and Knalf (2005) was used. This
method allows a combination of different method-
ologies to understand the varied perspectives on a spe-
cific phenomenon of concern better (Whittemore &
Knalf 2005).
Search strategy
The search included the following on-line databases:
MEDLINE (through PubMed), CINAHL (through EB-
SCOhost) and SCOPUS (through EBSCOhost). The
search period included articles published between
1998 and 2012 in order to select recent studies that
may have more relevance to the current nursing work-
place. The MeSH headings and free text terms were
combined to research the specific topic. Key search
terms included: workplace empowerment, nurse*, job satisfaction and work satisfaction. Two web sites
were searched for additional studies: Laschinger H.K.S.,
http://publish.uwo.ca/~hkl and Spreitzer G., http://webuser.
bus.umich.edu/spreitze/Empowerment_Research.htm.
For the search and retrieval process see Figure 1.
Inclusion criteria
The inclusion criteria for the studies were: (1) papers
published in English language, (2) with a study sample
that included nurses (no student nurses, no nurse edu-
cators, no nurse managers or assistant nurse managers),
(3) studies investigating the impact of empowerment
on job satisfaction and/or the relationship between
workplace empowerment and job satisfaction, (4) stud-
ies reporting direct measures of empowerment (struc-
tural and/or psychological) and job satisfaction, (5)
studies using CWEQ or CWEQ-II for measuring struc-
tural empowerment and studies using PES for measur-
ing psychological empowerment, (6) quantitative or
qualitative research designs, (7) peer reviewed research.
Screening
The selection of studies was conducted through an ini-
tial screening of the title and abstract in order to iden-
tify potentially relevant articles. Then, a screening was
carried out of all the full text articles identified as rele-
vant in the initial selection. Additional papers, not
identified in the initial literature search, were obtained
through examination of the references in the published
studies.
Each abstract was examined by two independent
reviewers according to the inclusion criteria. The
first author reviewed all titles and abstracts, deleted
duplication of articles and selected studies that
investigated the impact of empowerment on nurses’
job satisfaction. The second author, separately, eval-
uated a sample of titles and abstracts according to
the same inclusion criteria. Sixty-five titles and
abstracts were selected and full manuscripts were
retrieved for the first screening according to the
recruitment criteria. Twenty-three articles were
retained for the second screening using an inclusion
screening tool, adapted from Wagner et al. (2010)
(Figure 1).
Both reviewers agreed on which studies met the
inclusion criteria.
Fourteen articles were retained for quality assess-
ment and data extraction.
ª 2013 John Wiley & Sons Ltd Workplace empowerment – Review Quality assessment
All articles were screened for quality using the pub-
lished ‘Quality Assessment and Validity Tool for Cor-
relational Studies’ adapted from previous systematic
reviews (Cummings & Estabrooks 2003, Estabrooks
et al. 2003, Wong & Cummings 2007, Cummings
et al. 2008, 2010, Wagner et al. 2010, Cowden et al.
2011) (Figure 2).
The instrument included 13 questions to scruti-
nize and score the research design, sample, measure-
ment and statistical analysis of the studies. The
questions were in the dichotomous answer format
and a total of 14 points could be assigned for the
13 criteria. Twelve items were scored as 0 (=not scores assigned, the instrument classifies the articles
into three quality categories: low (0–4), medium (5–9)
and high (10–14).
Data extraction
Following the assessment for quality, 12 studies
remained for data extraction.
Data extracted from selected studies included:
author, year, journal, research question presented
(aim of the study), sample, response rate, independent
variable, dependent variable, measures, reliability and
validity of the instrument used, analysis and main
results.
Results
The electronic database search yielded over 1500
abstracts and titles. Following removal of duplicates,
the potentially eligible studies were screened. Some
573 studies were excluded. Quality assessments were
completed on 13 articles and following quality assess-
ment, one quantitative paper was excluded (Laschin-
ger et al. 2003). Twelve studies were included in the
final analysis. Figure 3 illustrates the search and retrieval process.
Summary of quality review
Five studies included in the review were rated
high quality (Laschinger et al. 2004, Laschinger et al.
2001a,b, 2011, Ning et al. 2009). The seven remain-
ing studies were rated medium quality (Manojlovich
& Laschinger 2002, Laschinger 2008, Laschinger et al.
2009a, Lautizi et al. 2009, Cai & Zhou 2009, Cai
et al. 2011, Ahmad et al. 2010).
Most of the studies utilized a non-experimental,
cross-sectional design. Only one study used a longitu-
dinal design (Laschinger et al. 2004). All studies
were prospective in design as data were collected
prospectively.
Study: First author:
Publication date: Instructions for completion: 2. Record inclusion decision: article must satisfy six criteria 3. Record if additional references are to be retrieved 1. Does the study measure structural empowerment using CWEQ or ONSEY?eulav-PaerehtsI.5 Which one(s)? ONSEYydutsedulcni:NOISICEDLANIF
Figure 1
Inclusion screening tool for correla-
tional studies.
ª 2013 John Wiley & Sons Ltd G. Cicolini et al. Study: First author: DESIGN: NO YES SAMPLE: MEASUREMENT: Influence on the measure of job satisfaction (DV)? 2. If a scale was used for measuring the dependent variable, was 0 2
3. Was a theoretical framework used for guidance? 0 1
STATISTICAL ANALYSIS Overall Study Validity Rating (circle one) TOTAL: Figure 2
Quality assessment and validity tool
for correlational studies.
Records identified through 1526
Additional records identified 92
596 57 3
Papers excluded
13 qualitative synthesis
1 excluded
12 23 screening tool
Figure 3
Search and retrieval process.
ª 2013 John Wiley & Sons Ltd Workplace empowerment – Review Table 1 illustrates a summary of quality assessment
of studies included.
Strengths and weaknesses
The strengths in the selected studies for the review
included: use of a prospective design; use of probabil-
ity sampling and multicentric design; use of reliable
and valid instruments for the measurement of struc-
tural empowerment, psychological empowerment and job satisfaction; study design based on theoretical
models to guide the research.
The most common weaknesses are related to sam-
pling and to the protection of anonymity. The selected
studies lack discussion about the protection of ano-
nymity of respondents and in probability sampling.
Furthermore there were no justifications of sample
size, based on appropriate power calculation.
Characteristics of selected studies
The characteristics of the studies included in this
review are summarized in Tables 2 and 3.
All studies had a quantitative research design and
were published between 2001 and 2011.
Seven studies were conducted in Canada (Laschinger
et al. 2011, Laschinger et al. 2001a, b, 2004, 2009a,
Laschinger 2008, Manojlovich & Laschinger 2002).
Three were conducted in China (Cai & Zhou 2009,
Cai et al. 2011, Ning et al. 2009), one in Italy (Lau-
tizi et al. 2009) and one in England and Malaysia
(Ahmad & Oranye 2010).
One study explored the correlation between empow-
erment and job satisfaction in psychiatric nurses from
both hospital wards and territorial health agencies
(Lautizi et al. 2009). The remaining 11 studies were
carried out in hospitals (Laschinger et al. 2009a, Ning
et al. 2009); in tertiary hospitals (Cai & Zhou 2009);
in acute care hospitals (Laschinger et al. 2011); in
urban teaching hospitals (Ahmad et al. 2010, Cai
et al. 2011) within different areas including medical-
surgical, critical care, maternal child and psychiatry
(Laschinger et al. 2001a,b, Laschinger et al. 2004,
Manojlovich & Laschinger 2002). Two studies examined the relationships between
both structural and psychological empowerment and
job satisfaction (Ahmad & Oranye 2010, Laschinger
et al. 2004). Two studies reported results on the rela-
tion between both structural and psychological empow-
erment, job satisfaction and other measured outcomes
(Laschinger et al. 2001a, Manojlovich & Laschinger
2002). The remaining studies analysed the correlations
between structural empowerment, job satisfaction
(Ning et al. 2009) and other outcomes (Cai & Zhou
2009, 2011, Lautizi et al. 2009, Laschinger 2008, Las-
chinger et al. 2001b, 2009a, 2011).
Theoretical frameworks
Seven studies used an explicit theoretical framework
to guide the research (Manojlovich & Laschinger
2002, Laschinger et al. 2001a,b, Laschinger et al.
2004, Laschinger 2008, Lautizi et al. 2009, Ning
et al. 2009). Most of the studies used the Kanter’s
organisational empowerment theoretical model to
analyze the relationship between empowerment and
job satisfaction (Laschinger 2008, Ning et al. 2009,
Lautizi et al. 2009, Laschinger et al. 2001b, 2009a).
Kanter argues that the impact of organisational
structures on employee behaviour is more important
than the impact of employee personality predisposi-
tions (Kanter 1977). According to Kanter, the man-
date of management is to develop conditions for work
effectiveness by ensuring that employees have access
to the structure.
In addition to the model of empowerment (access to
information, support, resources and opportunity to
learn and grow), psychological empowerment is an
outcome of structural empowerment, and is useful
better to understand the influence of structural work
conditions on job satisfaction and other organisational
outcomes better (Wagner et al. 2010).
In contrast to Kanter’s theory, Spreitzer (1995)
focused more on the affective state of employees who
Table 1
Summary of quality assessment
Criteria
Number of
studies No Yes
Design Prospective studies 0 12
Sample
Probably sampling 9 3
Appropriate sample size 10 2
Sample drawn for more than one site 0 12
Anonymity protected 10 2
Response rate > 60% 6 6 Reliable measure of outcome(s) 0 12
Valid measure of outcome(s) 0 12
Valid measure of empowerment 0 12
*Empowerment internal consistency � 70 0 12 Statistical analysis
Correlation analysis when multiple effect studied 0 12
Management of outliers addressed 10 2
*Scores 2 points.
ª 2013 John Wiley & Sons Ltd G. Cicolini et al. T 2 C o in
s A J A S M R C V C 1 )
In R C T m a th o e e (S th re b jo jo s g s a w m 2 n C II
o W
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studies used Kanter’s theory of structural empower-
ment in association with Spreitzer’s theory of psycho-
logical empowerment (Manojlovich & Laschinger
2002, Laschinger et al. 2004).
Laschinger et al. (2001a) used Kanter’s and Spreit-
zer’s theories and Karasek’s demands-control model
to explain the relationship between job strain in nursing
work environments, job satisfaction and structural and
psychological empowerment. Karasek (1979) argued
that job strain occurs when job demands are high and
job control is low within the work environment.
The results of this study suggested that the negative
relation between nurse empowerment and job strain is
consistent with both Kanter’s and Karasek’s theories.
Conceptual models
Four studies tested conceptual models (Laschinger
et al. 2004, Laschinger et al. 2009a, 2011, Laschinger
2008). Laschinger et al. (2001a,b) used a longitudinal pre-
dictive design to test a model that linked changes in
structural and psychological empowerment to the
changes in job satisfaction.
Laschinger (2008) tested an extension of Leiter and
Laschinger’s nursing worklife model (Leiter & Lasch-
inger 2006) by linking nurses’ work environment con-
ditions to job satisfaction and perceived nursing care
quality. The findings of the study revealed that the
relationship between structural empowerment and
both work satisfaction and perceived nurses’ care
quality was mediated by the professional practice
environment characteristics.
Laschinger et al. (2009a) hypothesized a model in
which empowerment, incivility and burnout are
related to three retention outcomes: job satisfaction,
organisational commitment and turnover intention.
The results of this study provided support for the
hypothesized model.
Laschinger et al. (2011) proposed a multilevel model
of structural empowerment examining the effect of
nursing unit leadership quality and empowerment on
nurses’ burnout and job satisfaction at the unit and
individual level.
Measuring instruments of empowerment and According to the inclusion criteria, all of the studies
included measured structural empowerment with
CWEQ or CWEQ II and psychological empowerment
with PES.T 2 o jo a d W S a S o a (2 C M R T n e a w o 4 C a P a F c S it In S 1 O (O Q e a N ª 2013 John Wiley & Sons Ltd Workplace empowerment – Review T R e e R b O R e 1 (r = C = = E e m p c o v G a to b <
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this review used five different measuring instruments.
Eight studies (Manojlovich & Laschinger 2002, Lasch-
inger et al. 2001a,b, Laschinger et al. 2004, Laschin-
ger et al. 2009a, 2011, Laschinger 2008, Lautizi et al.
2009) used a 4-item global measurement of work sat-
isfaction modified by Hackman and Oldham’s (1975)
job diagnostic survey. This measure has been used
previously in nursing populations (Laschinger &
Havens 1996) and it was found to have acceptable
internal consistency reliability (r = 0.83). All eight of >0.70. and Drasgows (1987) revision of the job diagnostic
survey. This tool measures both job characteristics
and outcomes which are job satisfaction (five items),
growth satisfaction (four items) and work motivation
(six items). The study reported alpha reliability coeffi-
cients of >0.70 for both job satisfaction and growth Ahmad and Oranye (2010) adapted the index of job
satisfaction scale (Stamps 1997) that measures job sat-
isfaction by six components: pay, autonomy, task
requirements, professional status, interaction and
organisational policies. In this study they reported a
Cronbach’s alpha coefficient in the range 0.79–0.81.
Ning et al. (2009) measured job satisfaction by the
Chinese version of the Minnesota satisfaction ques-
tionnaire (MSQ) (Jingji et al. 1980) consisting of 20
items. In this study the Cronbach alpha reliability of
the instrument was 0.94.
Another study, conducted in Central China (Cai &
Zhou 2009), used the global job satisfaction question-
naire with a 5-item global measure adapted from the
Revised Job Diagnostic Survey (Chinese version). In
previous studies the reported alpha reliability coeffi-
cients ranged from 0.71 to 0.86 and this study
reported a value of 0.80.
Correlations between empowerment and The relationship between empowerment and job satis-
faction has been studied in several countries, including
China, Italy and Malaysia, but the majority of the
research was carried out in Canada by Laschinger and
colleagues.
Several studies investigated the relation between
structural empowerment, job satisfaction and other
outcomes (Laschinger 2008, Cai et al. 2009, 2011,
Laschinger et al. 2001b, 2009a, Laschinger et al. 2011,T 3 9 p s P = (b – S o 2 F = S o in (a P o B S s o = M a n M n n th e M n w re S = = (r A n re a 1 P (b S (b in (b J P (b .4 N s th o a is s S d H a (b S s m In c S in p m S a = T a c = .1 ª 2013 John Wiley & Sons Ltd Workplace empowerment – Review Lautizi et al. 2009). Laschinger et al. (2001a,b) with job
satisfaction. Two studies correlated both structural and psycho-
logical empowerment with job satisfaction and other
nurses’ outcomes (Laschinger et al. 2001a, Manojlo-
vich & Laschinger 2002, Ahmad & Oranye 2010).
Only one of the twelve studies included investigated
the relationship between job satisfaction and struc-
tural empowerment exclusively (Ning et al. 2009).
All the studies showed a significant positive correlation
between structural and psychological empowerment and
job satisfaction. Structural empowerment, psychological
empowerment, job satisfaction and other organisational outcomes
The only study that investigated the relationship between
structural empowerment and job satisfaction reported a
significant positive correlation between the two vari-
ables. It also showed that some demographic variables,
such as age and educational level, were statistically sig-
nificant in relation to structural empowerment and job
satisfaction exclusively.
Laschinger et al. (2001a,b) analysed the relationship
and the influence of changes in structural and psycho-
logical empowerment on changes in job satisfaction.
The data analysis of this longitudinal study suggested
that changes in perceptions of structural empower-
ment, produced statistically significant changes in job
satisfaction and psychological empowerment. Struc-
tural empowerment was directly and positive corre-
lated with job satisfaction. Moreover, changes in
structural empowerment predicted changes in job
satisfaction. These findings are supported by the high
quality of the study.
Nurses’ perceptions of leader-member exchange
quality on the unit level positively influenced their per-
ception of structural empowerment which, in turn,
culminated in higher levels of individual nurse work
satisfaction (Laschinger et al. 2011).
High levels of structural empowerment, low work
stress and low levels of incivility and burnout, predicted
job satisfaction (Laschinger et al. 2009a, Lautizi et al.
2009), commitment and turnover intention (Laschinger
et al. 2009a). Furthermore, turnover intention was neg-
atively correlated with job satisfaction and job activities
(Cai & Zhou 2009). However, these findings are sup-
ported by the medium-quality subgroup of studies.
Five studies examined the correlations between empow-
erment, job satisfaction and other positive outcomes in
the workplace. Only one study analysed these correlations
in two different societies (Ahmad & Oryane 2010).
Nurses’ perceptions of empowerment were directly
related to both job satisfaction and organisational
commitment. In particular, structural empowerment
had a direct effect on affective commitment (Laschinger
et al. 2001b, 2009a). Affective commitment is a type of
organisational commitment based on an individual’s
emotional attachment, involvement and identification
with an organisation (Meyer & Allen 1991).
Ahmad and Oryane (2010) found that there are dif-
ferences in the relationship between empowerment and
commitment among nurses who come from two differ-
ent cultural contexts: Malaysia and England. Among
Malaysian nurses, organisational commitment was
more closely related to psychological empowerment,
whereas the opposite was true among English nurses.
Structural empowerment completely mediated the
impact of job characteristics on growth satisfaction,
whereas it partially mediated the impact of job char-
acteristics on internal work motivation and general
job satisfaction (Cai et al. 2011).
Empowering work environments were linked to job
satisfaction and positive evaluations of the quality of
nursing care. In fact, empowering working conditions
play an important role in creating supportive profes-
sional practice environments that improve nurse
assessed patient care quality (Laschinger 2008).
Moreover, another study examined whether the
effects of structural and psychological empowerment
were moderated by specific personal factors: mastery
and achievements. Data analysis revealed that this
interaction was not significant (Manojlovich &
Laschinger 2002). Structural empowerment had a direct, positive effect
on psychological empowerment that, in turn, had a
direct positive effect on job satisfaction and a direct
negative effect on job strain (Laschinger et al. 2001a).
Both structural and psychological empowerment were
significant predictors of job satisfaction. Although
structural empowerment predicted most of the
variance in job satisfaction by itself (Manojlovich &
Laschinger 2002). Psychological empowerment has a significant posi-
tive relationship with job satisfaction and it has a
greater correlation than structural empowerment with
commitment (Ahmad & Oranye 2010).
Among the high-quality subgroup of studies, the
only longitudinal conducted study revealed that struc-
tural empowerment and psychological empowerment play different roles in determining changes in the per-
ception of nurses’ empowerment and job satisfaction.
Structural empowerment directly affects job satisfac-
tion and at the same time produces changes in percep-
ª 2013 John Wiley & Sons Ltd G. Cicolini et al. tions of psychological empowerment. However, psy-
chological empowerment does not cause direct
changes on satisfaction than those determined by the
structural. These results differ from those reported in
previous cross-sectional included studies (Laschinger
et al. 2004). Discussion
The studies included in this systematic review exam-
ined the relationship between structural and/or psy-
chological empowerment and job satisfaction in the
nursing work environment. Most of the studies used a theoretical framework,
which should be used in future research because it
provides a rationale to hypothesize conceptual models
and to test the relationships between ideas and vari-
ables (LoBiondo-Wood & Haber 1998).
The majority of the studies included in this review
were conducted by Laschinger and colleagues and
analysed the correlation between structural empower-
ment, job satisfaction and other organisational out-
comes. Recently, other authors have studied the
correlation between workplace empowerment and job
satisfaction in different cultural and organisational
settings (Cai et al. 2011, Ahmad & Oryane 2010,
Lautizi et al. 2009, Ning et al. 2009). Structural
empowerment was a stronger predictor of job satisfac-
tion in various organisational contexts and had a
significant direct effect at the individual level of
nurses’ job satisfaction (Laschinger et al. 2009a, 2011,
Ning et al. 2009). In particular, in the study of Lautizi
et al. (2009), carried out in the Italian context, job
satisfaction was strongly associated with the access to
support and the opportunity to learn.
A recent study provides support to the evidence that
structural and psychological empowerment concepts
may vary across cultures (Ahmad & Oryane 2010).
Furthermore differences in organisational contexts and
cultural values that influence nurses’ perceptions of
empowerment, could also influence the association
with job satisfaction (Ahmad & Oryane 2010).
Evidence were found concerning the correlations
between empowerment, job satisfaction and other or-
ganisational outcomes. According to previous studies
of job satisfaction, structural empowerment was a
stronger predictor of organisational commitment (Las-
chinger et al. 2001b, 2009a, Ahmad & Oryane 2010).
Psychological empowerment had a significant positive
relationship with job satisfaction but had a greater
correlation than structural empowerment with commitment
(Ahmad & Oranye 2010). Furthermore, nurses with
low levels of self core evaluation (self-esteem, general-
ized self-efficacy, emotional stability and locus of con-
trol) were more likely to have high levels of emotional
exhaustion, cynicism, or both, which then reduced
their job satisfaction (Laschinger et al. 2011).
An empowering practice environment and a low
level of burnout in nursing settings were significant
predictors of job satisfaction, commitment and inten-
tion to leave (Laschinger et al. 2009a).
The combination of structural and psychological
empowerment was a strong predictor of positive
organisational outcomes, particularly job satisfaction
(Manojlovich & Laschinger 2002).
The link between structural and psychological
empowerment explained the empowerment process in
the work setting and how structural organisational fac-
tors are able to influence nurses’ feelings of personal
empowerment in workplaces (Laschinger et al. 2001a).
According to Kanter’s theory, social structural fac-
tors in the work environment are essential conditions
for empowering employees to accomplish their work.
The relationship with psychological empowerment is
consistent with Conger and Kanungo’s (1988) opin-
ion, which argues that removing disempowering struc-
tures from the work setting leads to a strong sense of
autonomy among employees, who have a strong belief
that they have an impact at work.
In the current context of the health care system, that
is under constant stress (Wagner et al. 2010) health
care managers have to consider the relationship
between empowerment and organisational outcomes,
and especially, they have to focus on job satisfaction
as a retention outcome.
To create an empowering work environment for
nurses, it is very important that nurse managers
(NMs) and assistant nurse managers (ANMs) are able
to obtain organisational support and to provide access
to resources and opportunity (Regan & Rodriguez
2011). Furthermore, a recent study has demonstrated
that empowered nurses are able to empower their
patients, and to obtain positive related health out-
comes (Laschinger et al. 2010).
Limitations
The review is limited to studies examining the relation-
ship between structural empowerment, psychological
empowerment and job satisfaction. Given that many
other organisational outcomes, such as intent to leave
(Fitzpatrick et al. 2010), respect (Faulkner & Laschin-
ger 2008), engagement (Laschinger et al. 2009b) and
ª 2013 John Wiley & Sons Ltd Workplace empowerment – Review trust in organisation (Laschinger et al. 2000), are con-
sidered retention outcomes, our findings represent a
narrower part of the outcomes that are related to
empowerment. Due to the nature of the variables investigated, no
randomized controlled trials (RCTs) were included in
the review. The majority of the studies used an obser-
vational, cross-sectional design. This factor could limit
the ability to estimate causation and decreased the
generalizability of the results (LoBiondo-Wood &
Haber 1998). Nurse perceptions of empowerment in work envi-
ronments and nurse job satisfaction are assessed by
self-report measures, which are often associated with
response bias.
Finally, the variability in the measurement of job sat-
isfaction may limit the generalisability of the findings.
Implications for nursing management
This review provides encouraging support for efforts to
create satisfying healthy work environments that support
nurses’ practice in the workplace. Identifying the link
among nurse empowerment, job satisfaction and other
organisational outcomes will assist health care managers
to understand how empowerment improves retention
outcomes. Furthermore, these findings could be the start-
ing point for future research on the relationship between
patient care quality and quality of the professional prac-
tice environments.
The positive or negative influences of leadership
style could have an indirect impact on patient out-
comes by directly working on the nursing population
(Wong & Cummings 2007). Understanding the rela-
tionship between empowerment and job satisfaction
could help leaders not just to implement strategy for
retaining nurses, but also to improve patient care out-
comes (Ellenbecker & Cushman 2012).
Recommendations for future research
Based on the synthesis of findings in this review, sev-
eral recommendations arise for future research in this
area. The studies included in the review were observa-
tional or cross-sectional in design and this factor could
limit the generalisability of the results (LoBiondo-
Wood & Haber 1998). Among the high-quality sub-
group of studies included in this review, only one
study was longitudinal (Laschinger et al. 2004), therefore
there is a need to carry out longitudinal, intervention stud-
ies, to evaluate the causal relationships between nurse
empowerment and job satisfaction. All the studies included in the review were multisite,
which should continue with further research, because
a diversity of multiple settings will add validity and
generalizability to the study findings (Cummings et al.
2010). However, sampling was collected from several
hospitals within the same system or region, and the
majority of the studies were conducted by Laschinger
and colleagues in Ontario (Canada) within an impor-
tant programme of research on workplace empower-
ment (Laschinger 2011). Further research is needed to
investigate the relationship between empowerment
and nurses’ job satisfaction in different countries. In
addition, most of the research was carried out in hos-
pital settings. To date, the relationship between struc-
tural and psychological empowerment and positive
organisational outcomes in different clinical settings
remains unknown.
Most of the studies used theoretical or conceptual
frameworks, which should continue to be used
because they provide a rationale to analyse the rela-
tionship between variables (LoBiondo-Wood & Haber
1998). Finally, the findings of this review showed that no
studies were carried out to investigate the relationship
between workplace empowerment, job satisfaction
and patient outcomes. The relationship between job
satisfaction, quality of patient care and patients has
been extensively established (Ellenbecker & Cushman
2012). Moreover, a recent systematic review showed
that empowering work conditions support changes at
all levels of the organisation, provide positive long-
term outcomes for both managers and nursing staff
and improve patient outcomes (Wagner et al. 2010).
Currently, the specific relationship between empower-
ment, nurse job satisfaction and patient outcomes
remain an unexplored research area. Further research
is needed to investigate this specific topic and to assess
the relationship between workplace empowerment,
job satisfaction and patient outcomes on a larger scale
in a more diverse sample.
The first recommendation concerns the need to
carry out longitudinal intervention studies, to evalu-
ate the causal relationships between nurse empower-
ment and job satisfaction. Moreover, major studies
were conducted by Laschinger and colleagues in
Ontario (Canada), within an important programme
of research on workplace empowerment. There is an
urgent need to investigate the relationship between
empowerment and nurses’ job satisfaction in differ-
ent countries. In addition, further research is needed
to assess the relationship between workplace empow-
erment, job satisfaction, turnover intention and
ª 2013 John Wiley & Sons Ltd G. Cicolini et al. patient outcomes on a larger scale in a more diverse
sample. The majority of the research was carried out in hos-
pital settings. To date, the relationship between
structural and psychological empowerment and posi-
tive organisational outcomes in different clinical set-
tings remains unknown.
The literature shows that empowering work condi-
tions support changes at all levels of the organisation,
provide positive long-term outcomes for both manag-
ers and nursing staff and improve patient outcomes
(Wagner et al. 2010). The relationship between job
satisfaction, quality of patient care and patients has Currently, the specific relationship between empow-
erment, nurse job satisfaction and patient outcomes
remained an unexplored research area.
Conclusion
The findings of this review provide evidence of the
importance of workplace empowerment to achieve
positive organisational outcomes in nursing. Exploring
the impact of empowerment on nurses’ work environ-
ments and understanding the correlation between
empowerment and job satisfaction might be useful for
creating a supportive and satisfying work environment
for nurses, which in turn could promote the intention
to stay.
Structural empowerment is an antecedent variable to
psychological empowerment and this relationship culmi-
nates in positive workplace retention outcomes.
In all the studies analysed, the results indicate a
positive correlation between both structural and psy-
chological empowerment and job satisfaction and
other organisational outcomes. In particular, struc-
tural empowerment was a stronger predictor of job
satisfaction and organisational commitment, whereas
high levels of psychological empowerment were asso-
ciated with low levels of burnout.
This review could be useful to guide leaders’ strate-
gies to develop and maintain empowering work, so
enhancing job satisfaction, in turn leading to nurse
retention and positive patient outcomes.
Some of the studies included suggested that the posi-
tive correlation between empowerment and job satisfac-
tion could lead to positive patient outcomes. Despite
this, further research is needed, because there are no
intervention studies focused on the influence of empow-
erment in nurses’ job satisfaction and how this relation-
ship can positively affect patient outcomes.
Funding
Authors declare that no funding has been received for
this work.
References
Adams A. & Bond S. (2000) Hospital nurses’ job satisfaction,
individual and organizational characteristics. Journal of
Advanced Nursing 32 (3), 536–543.
Ahmad N. & Oranye N.O. (2010) Empowerment, job satisfac-
tion and organizational commitment: a comparative analysis
of nurses working in Malaysia and England. Journal of Nurs-
ing Management 18 (5), 582–591.
Buerhaus P.I., Staiger D.O. & Auerbach D.I. (2000) Why are
shortages of hospital RNs concentrated in specialty care
units? Nursing Economics 18 (3), 111–116.
Buerhaus P.I., Donelan K., Ulrich B.T., Norman L. & Dittus R.
(2006) State of the registered nurse workforce in the United
States. Nursing Economics 24 (1), 6–12.
Cai C. & Zhou Z. (2009) Structural empowerment, job satisfac-
tion, and turnover intention of Chinese clinical nurse. Nursing
and Health Sciences 11 (4), 397–403.
Cai C.F., Zhou Z.K., Yeh H. & Hu J. (2011) Empowerment
and its effects on clinical nurses in central China. Interna-
tional Nursing Review 58 (1), 138–144.
Cavus M.F. & Demir Y. (2010) The impacts of structural and
psychological empowerment on burnout: a research on staff
nurses in Turkish state hospitals. Canadian Social Science 6
(4), 63–72.
Chandler G.E. (1986) The Relationship of Nursing Work
Environment to Empowerment and Powerlessness. Unpub-
lished Doctoral Dissertation, University of Utah, Salt Lake
City, UT.
Chang Y., Wang P.C., Li H.H. & Liu Y.C. (2011) Relations
among depressions, self-efficacy and optimism in a sample of
nurses in Taiwan. Journal of Nursing Management 19 (6),
769–776.
Conger J.A. & Kanungo R.N. (1988) The empowerment pro-
cess: integrating theory and practice. Academy of Manage-
ment Review 13 (3), 471–482.
Coomber B. & Barriball K.L. (2007) Impact of job satisfaction
components on intent to leave and turnover for hospital-
based nurses: a review of the research literature. International
Journal of Nursing Studies 44 (2), 297–314.
Cowden T., Cummings G.G. & Profetto-McGrath J. (2011) Lead-
ership practices and staff nurses’ intent to stay: a systematic
review. Journal of Nursing Management 19 (4), 461–477.
Cummings G.G. & Estabrooks C.A. (2003) The effects of
hospital restructuring including layoffs on nurses who
remained employed: a systematic review of impact. Interna-
tional Journal of Sociology and Social Policy 23 (8–9), 8–53.
Cummings G.G., Lee H., MacGregor T. et al. (2008) Factors
contributing to nursing leadership: a systematic review.
Journal of Health Services Research & Policy 13 (4), 240–
248.
Cummings G.G., MacGregor T., Davey M. et al. (2010) Lead-
ership styles and outcome patterns for the nursing workforce
and work environment: a systematic review. International
Journal of Nursing Studies 47 (3), 363–385.
ª 2013 John Wiley & Sons Ltd Workplace empowerment – Review Ellefsen B. & Hamilton G. (2000) Empowered nurses? Nurses
in Norway and the USA compared International Nursing
Review 47 (2), 106–120.
Ellenbecker C.H. & Cushman M. (2012) Home healthcare nurse
retention and patient outcome model: discussion and model
development. Journal of Advanced Nursing 68 (8), 1881–1893.
Estabrooks C.A., Floyd J.A., Scott-Findlay S., O’Leary K.A. &
Gushta M. (2003) Individual determinants of research utiliza-
tion: a systematic review. Journal of Advanced Nursing 43
(5), 506–520.
Falk-Rafael A.R. (2001) Empowerment as a process of evolving
consciousness: a model of empowered caring. Advances in
Nursing Science 24 (1), 1–16.
Faulkner J. & Laschinger H.H.S. (2008) The effects of struc-
tural and psychological empowerment on perceived respect in
acute care nurses. Journal of Nursing Management 16 (2),
214–221.
Fitzpatrick J., Campo T.M., Graham G. & Lavandero R.
(2010) Certification, empowerment and intent to leave cur-
rent position and the profession among critical care nurses.
American Journal of Critical Care 19 (3), 218–226.
Hackman J.R. & Oldham G.R. (1975) Motivation through the
design of work: testing of a theory. Organizational Behavior
and Human Performance 16 (2), 250–279.
Hauck A., Quinn Griffin M.T. & Fitzpatrick J.J. (2011) Struc-
tural empowerment and anticipated turnover among critical
care nursing. Journal of Nursing Management 19 (2), 269–276.
Hayes L.J., Orchard C.A., Hall L.M., Nincic V., O’Brien-Pallas
L. & Andrews G. (2006) Career intentions of nursing student
and new nurse graduates: a review of the literature. Interna-
tional Journal of Nursing Education Scholarship 3 (1), 1–15.
Idaszak J.R. & Drasgow F. (1987) A revision of the Job Diag-
nostic Survey: elimination of a measurement artifact. Journal
of Applied Psychology 72, 461–468.
Jingji W., Yangyuan P. & Wingxiang D. (1980) The relation-
ship among inside and outside control, job satisfaction and
job performance. State-run Policy University Transaction 41,
75–98.
Kanter R.M. (1977) . Men and Women of the Corporation.
Basic Books, New York NY.
Karasek R.A. (1979) Job demands, job decision latitude and
mental strain: implications for job redesign. Administrative
Science Quarterly 24 (2), 285–308.
Laschinger H.K.S. (2008) Effect of empowerment on profes-
sional practice environments, work satisfaction, and patient
care quality: further testing the nursing worklife model. Jour-
nal of Nursing Care Quality 23 (4), 322–330.
Laschinger H.K.S. (2011) UWO Workplace Empowerment Pro-
gram. Available at: http://publish.uwo.ca/~hkl/, accessed 15
December 2011.
Laschinger H.K.S. & Havens D. (1996) Staff nurse work
empowerment and perceived control over nursing practice
Conditions for work effectiveness. Journal of Nursing Admin-
istration 26 (9), 27–35.
Laschinger H.K.S., Finegan J., Shamian J. & Wilk P. (2000).
Testing a Model of Organizational Empowerment in Restruc-
tured Health Care Settings. Working paper. The University of
Western Ontario, London, ON.
Laschinger H.K.S., Finegan J. & Shamian J. (2001a) Promoting
nurses health: effect of empowerment on job strain and work
satisfaction. Nursing Economics 19 (2), 42–52.
Laschinger H.K.S., Finegan J. & Shamian J. (2001b) The impact
of workplace empowerment, organizational trust on staff
nurses’ work satisfaction and organizational commitment.
Health Care Management Review 26 (3), 7–23.
Laschinger H.K.S., Finegan J., Shamian J. & Almost J. (2001c)
Testing Karasek’s demands-control model in restructured
healthcare settings: effects of job strain on staff nurses’ qual-
ity of work life. Journal of Nursing Administration 31 (5),
233–243.
Laschinger H.K.S., Finegan J., Shamian J. & Wilk P. (2001d)
Impact of structural and psychological empowerment
on job strain in nursing work settings: expanding Kanter’s
model. Journal of Nursing Administration 31 (5), 260–
272.
Laschinger H.K.S., Finegan J., Shamian J. & Wilk P. (2003)
Workplace empowerment as a predictor of nurse burnout in
restructured healthcare settings. Longwoods Review 1 (3), 2–11;
Hospital Quarterly 6 (4).
Laschinger H.K.S., Finegan J., Shamian J. & Wilk P. (2004)
A longitudinal analysis of the impact of workplace empower-
on work satisfaction. Journal of Organizational Behavior 25
(4), 527–545.
Laschinger H.K.S., Leiter M., Day A. & Gilin D. (2009a)
Workplace empowerment, incivility, and burnout: impact on
staff nurse recruitment and retention outcomes. Journal of
Nursing Management 17 (3), 302–311.
Laschinger H.K.S., Wilk P., Cho J. & Greco P. (2009b)
Empowerment, engagement and perceived effectiveness in
nursing work environments: does experience matter? Journal
of Nursing Management 17 (5), 636–646.
Laschinger H.K.S., Finegan J. & Wilk P. (2011) Situational and
dispositional influences on nurses’ workplace well-being The
role of empowering unit leadership. Nursing Research 60 (2),
124–131.
Laschinger H.K.S., Gilbert S., Smith L.M. & Leslie K. (2010)
Towards a comprehensive theory of nurse/patient empower-
ment: applying Kanter’s empowerment theory to patient care.
Journal of Nursing Management 18 (1), 4–16.
Lautizi M., Laschinger H.K.S. & Ravazzolo S. (2009) Work-
place empowerment, job satisfaction and job stress among
Italian mental health nurses: an exploratory study. Journal of
Nursing Management 17 (4), 446–452.
Lee H. & Cummings G.G. (2008) Factors influencing job satis-
faction of front line nurse managers: a systematic review.
Journal of Nursing Management 16 (7), 768–783.
Leiter M.P. & Laschinger H.K.S. (2006) Relationships of work
and practice environment to professional burnout: testing a
causal model. Nursing Research 55 (2), 137–147.
LoBiondo-Wood G. & Haber J. (1998) Nursing Research:
Methods, Critical Appraisal, and Utilization, 4th edn. Mosby
Inc, St Louis, MO.
Lu H., While A.E. & Barriball K.L. (2005) Job satisfaction
among nurses: a literature review. International Journal of
Nursing Studies 42 (2), 211–227.
Manojlovich M. & Laschinger H.K.S. (2002) The relationship
of empowerment and selected personality characteristics to
nursing job satisfaction. Journal of Nursing Administration
32 (11), 586–595.
Manojlovich M. & Laschinger H.K.S. (2007) The Nursing
Worklife Model: extending and refining a new theory. Journal
of Nursing Management 15 (3), 256–263.
ª 2013 John Wiley & Sons Ltd G. Cicolini et al. McDermott K., Laschinger H.K.S. & Shamian J. (1996) Work
empowerment and organizational commitment. Nursing Man-
agement 27 (5), 44–48.
Meyer J.P. & Allen N.J. (1991) A three-component conceptuali-
zation of organizational commitment. Human Resource Man-
agement Review 1 (1), 61–89.
Miller P.A., Goddard P. & Laschinger H.K.S. (2000) Evaluating
physical therapists’ perception of empowerment using Kan-
ter’s theory of structural power in organizations. Physical
Therapy 81 (12), 1880–1888.
Nedd N. (2006) Perceptions of empowerment and intent to
stay. Nursing Economics 24 (1), 13–18.
Ning S., Zhong H., Libo W. & Qiujie L. (2009) The impact of
nurse empowerment on job satisfaction. Journal of Advanced
Nursing 65 (12), 2642–2648.
Purdy N., Laschinger H.K.S., Finegan J., Kerr M. & Olivera F.
(2010) Effects of work environments on nurse and patient
outcomes. Journal of Nursing Management 18 (8), 901–913.
Regan L.C. & Rodriguez L. (2011) Nurse empowerment from a
middle-management perspective: nurse managers’ and assis-
tant nurse managers’ workplace empowerment views. The
Permanente Journal 15 (1), e101–107.
Spreitzer G.M. (1995) Psychological empowerment in the work-
place: dimensions, measurements, and validation. Academy of
Management Journal 38 (5), 1442–1465.
Spreitzer G.M. (1996) Social structural characteristics of psy-
chological empowerment. Academy of Management Journal
39 (2), 483–504.
Spreitzer G. (2007) Taking stock: A review of more than twenty
years of research on empowerment at work. In The Hand-
book of Organizational Behavior (C. Cooper & J. Barling
eds). Sage Publications, Thousand Oaks, CA.
Stamps P.L. (1997) Nurses and work satisfaction: an index for
measurement. American Journal of Nursing 98 (3), 16KK–
16LL.
Stewart J.G., McNulty R., Griffin M.T. & Fitzpatrick J.J. (2010)
Psychological empowerment and structural empowerment
among nurse practitioners. Journal of American Academy
Nurse Practitioners 22 (1), 27–34.
Thomas K.W. & Velthouse B.A. (1990) Cognitive elements of
empowerment: an interpretive model of intrinsic task motiva-
tion. Academy of Management Review 15 (4), 666–681.
Upenieks V. (2003) Nurse leaders’ perception of what com-
promises successful leadership in today’s acute inpatient
environment. Nursing Administration Quarterly 27 (2), 140
–152.
Utriainen K. & Kyngas H. (2009) Hospital nurses’ job satisfac-
tion: a literature review. Journal of Nursing Management 17
(8), 1002–1010.
Wagner J.I.J., Cummings G., Smith D.L., Olson J., Anderson L.
& Warren S. (2010) The relationship between structural
empowerment and psychological empowerment for nurses: a
systematic review. Journal of Nursing Management 18 (4),
448–462.
Whittemore R. & Knalf K. (2005) The integrative review:
update methodology. Journal of Advanced Nursing 52 (5),
546–553.
Wilson B. & Laschinger H.K.S. (1994) Staff nurse perception of
job empowerment and organizational commitment. Journal of
Nursing Administration 24 (4), 39–47.
Wong C.A. & Cummings G.G. (2007) The relationship between
nursing leadership and patient outcomes: a systematic review.
Journal of Nursing Management 15 (5), 508–521.
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Home ANA Periodicals OJIN Vol.12 – 2007 No3:Sept’07 Nursing Quality Indicators
The National Database of Nursing Quality Indicators® ( NDNQI ®)
^ m d
Isis Montalvo, MS, MBA, RN
Abstract
The National Database of Nursing Quality IndicatorsTM (NDNQI®) is the only national nursing database that provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level. Linkages between nurse staffing levels and patient outcomes have already been demonstrated through the use of this database. Currently over 1100 facilities in the United States contribute to this growing database which can now be used to show the economic implications of various levels of nurse staffing. The purpose of this article is to describe the work and accomplishments related to the NDNQI as researchers utilize its nursing-sensitive outcomes measures to demonstrate the value of nurses in promoting quality patient care. After reviewing the history of evaluating nursing care quality, this article will explain the purpose of the NDNQI and describe how the database has been operationalized. Accomplishments and future plans of the NDNQI will also be discussed.
Citation: Montalvo, I., (September 30, 2007) “The National Database of Nursing Quality IndicatorsTM (NDNQI®)” OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 3, Manuscript 2.
DOI: 10.3912/OJIN.Vol12No03Man02
Key Words: nursing-sensitive indicators, quality, nurse staffing, patient outcomes, nursing outcomes, performance measurement Quality is a broad term that encompasses various aspects of nursing care. Various health care measures have been identified over the years as indicators of health care quality ( American Nurses Association, 1995 ; Institute of Medicine, 1999 , 2001 , 2005 ; Joint Commission, 2007 ). In 2004 , the National Quality Forum (NQF), via its voluntary consensus standards process, end orsed 15 national standards to be used in evaluating nursing-sensitive care. These standards are now known as the NQF 15 ( Kurtzman & Corrigan, 2007 ). The purpose of this article is to describe the work and accomplishments related to the National Database of Nursing Quality IndicatorsTM (NDNQI®) as researchers utilize its nursing-sensitive outcomes measures to demonstrate the value of nurses in promoting quality patient care. After reviewing the history of evaluating nursing care quality, this article will explain the purpose of the NDNQI and describe how the database has been operationalized. Accomplishments and future plans of the NDNQI will also be discussed.
History of Evaluating Nursing Care Quality
Evaluating the quality of nursing practice began when Florence Nightingale identified nursing’s role in health care quality and began to measure patient outcomes. She used statistical methods to generate reports correlating patient outcomes to environmental conditions ( Dossey, 2005 ; Nightingale, 1859/1946 ). Over the years, quality measurement in health care has evolved. The work done in the 1970s by the American Nurses Association (ANA), the wide dissemination of the Quality Assurance (QA) model ( Rantz, 1995 ), and the introduction of Donabedian’s structure, process, and outcomes model ( Donabedian, 1988, 1992 ) have offered a comprehensive method for evaluating health care quality. The workforce restructuring and redesign prevalent in the early 1990s demonstrated the need for the ANA to evaluate nurse staffing and identify linkages between nurse staffing and patient outcomes.The workforce restructuring and redesign prevalent in the early 1990s demonstrated the need for the ANA to evaluate nurse staffing and identify linkages between nurse staffing and patient outcomes. In 1994 the ANA Board of Directors asked ANA staff to investigate the impact of these changes on the safety and quality of patient care. In 1994, ANA launched the Patient Safety and Quality Initiative ( ANA, 1995 ). A series of pilot studies across the United States were funded by ANA to evaluate linkages between nurse staffing and quality of care ( ANA, 1996a , 1997 , 2000a , 2000b , 2000c ). Multiple quality indicators were identified initially. Evidence of the effectiveness of these indicators was used to adopt a final set of 10 nursing-sensitive indicators to use in evaluating patient care quality ( Gallagher & Rowell, 2003 ). Implementation guidelines were subsequently published ( ANA, 1996b , 1999). Nursing-sensitive indicators identify structures of care and care processes, both of which in turn influence care outcomes. Nursing-sensitive indicators are distinct and specific to nursing, and differ from medical indicators of care quality. For example, one structural nursing indicator is nursing care hours provided per patient day. Nursing outcome indicators are those outcomes most influenced by nursing care. Purpose of the NDNQI® In 1998, the National Database of Nursing Quality Indicators was established by ANA so that ANA could continue to collect and build on data obtained from earlier studies and further develop nursing’s body of knowledge related to factors which influence the quality of nursing care. Linkages between nurse staffing and patient outcomes had already been identified, but continued data collection and reporting was necessary to evaluate nursing care quality at the unit level and thus fulfill nursing’s commitment to evaluating and improving patient care. Nursing’s foundational principles and guidelines identify that as a profession, nursing has a responsibility to measure, evaluate, and improve practice. This is stated in two of nursing’s guiding documents: The Code of Ethics for Nurses with Interpretative Statements states: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient ( ANA, 2001, p.12 ).
Nursing: Scope & Standards of Practice, Standard 7 states: The registered nurse systematically enhances the quality and effectiveness of nursing practice ( ANA, 2004. p. 33 ). The Utilization Guide for the ANA Principles for Nurse Staffing recognizes that in order to measure sufficiency of staffing on an ongoing basis, at a minimum, unit level nursing-sensitive structure, process, and outcome indicators need to be collected ( ANA, 2005 ). NDNQI’s mission is to aid the nurse in patient safety and quality improvement efforts… NDNQI’s mission is to aid the nurse in patient safety and quality improvement efforts by providing research-based, national, comparative data on nursing care and the relationship of this care to patient outcomes.
Operationalization of the National Database
The NDNQI® database is managed at the University of Kansas Medical Center (KUMC) School of Nursing under contract to ANA with fiscal and legal support provided by KUMC Research Institute (KUMCRI). A health care facility that is interested in joining the NDNQI submits a signed contract and fee, based on hospital size, to KUMCRI, along with information on the person who will be the facility’s NDNQI® primary point of contact. This person is then identified as the NDNQI Site Coordinator. The NDNQI Site Coordinator serves as the interface between the participating facility and the NDNQI liaisons working at the University of Kansas. The NDNQI® liaisons provide ongoing assistance and support to health care facilities at multiple levels. For example they provide help in identifying nursing units appropriately for data entry; offer web-based, data-entry tutorials; conduct pilot testing; and answer questions about definitions and the reading of reports. NDNQI® researchers are also available to answer questions related to the database or the nursing measures. Education on NDNQI and nursing-sensitive indicators has been ongoing for participating facilities since 1999. Facilities have quarterly conference calls with NDNQI® staff to review any changes or updates to the indicators or database. They also have the opportunity to participate in pilot studies performed when an indicator is being evaluated for implementation. Once access to the database has been provided, the facility NDNQI® Site Coordinator will work with NDNQI staff from the University of Kansas to correctly classify the nursing units. This is an important step to ensure nursing units are classified appropriately prior to data entry. The facility NDNQI Site Coordinator and other authorized hospital staff also complete web-based tutorials to learn about each indicator prior to initial data submission.The facility NDNQI Site Coordinator has continuous access to the indicator definitions and is responsible for aligning the hospital data collected to NDNQI definitions. The facility NDNQI Site Coordinator has continuous access to the indicator definitions and is responsible for aligning the hospital data collected to NDNQI definitions. On average, it takes three months to join the database and start data submission. The NDNQI is then dependent on hospitals correctly submitting the data on a quarterly basis. All data is submitted electronically via the intranet in a secure website or by X ML submission. Data checks and error reports are conducted on an ongoing basis by participating facilities and by NDNQI staff to ensure data integrity. As of the writing of this article, the NDNQI has implemented six of the ten original ANA-endorsed NDNQI indicators (See Table 1 ). The initial set of indicators used in establishing the database was selected based on feasibility testing. These indicators included: Falls, Falls with Injury, Nursing Care Hours per Patient Day, Skill Mix, Pressure Ulcer Prevalence, and Hospital-Acquired Pressure Ulcer Prevalence. The RN job satisfaction indicator was pilot tested in 2001 and subsequently implemented in 2002. The RN satisfaction survey is an important indicator to assist nursing leaders and staff in evaluating the work environment so as to facilitate nursing retention and recruiting efforts. Table 1. NDNQI Indicators
Indicator
Sub-indicator
Measure(s)
1. Nursing Hours per Patient Day1,2 a. Registered Nurses (RN) b. Licensed Practical/Vocational Nurses (LPN/LVN) c. Unlicensed Assistive Personnel (UAP) Structure 2. Patient Falls1,2 Process & Outcome 3. Patient Falls with Injury1,2 a. Injury Level Process & Outcome 4. Pediatric Pain Assessment, Intervention, Reassessment (AIR) Cycle 5. Pediatric Peripheral Intravenous Infiltration Rate 6. Pressure Ulcer Prevalence1 a. Community Acquired b. Hospital Acquired c. Unit Acquired Process & Outcome 7. Psychiatric Physical/Sexual Assault Rate Outcome 8. Restraint Prevalence2 Outcome 9. RN Education /Certification Structure 10. RN Satisfaction Survey Options1,3
a. Job Satisfaction Scales b. Job Satisfaction Scales – Short Form c. Practice Environment Scale (PES)2 Process & Outcome 11. Skill Mix: Percent of total nursing hours supplied by1,2 <=""> a. RN’s b. LPN/LVN’s c. UAP d. % of total nursing hours supplied by Agency Staff Structure 12. Voluntary Nurse Turnover2 Structure 13. Nurse Vacancy Rate Structure 14. Nosocomial Infections(Pending for 2007) a. Urinary catheter-associated urinary tract infection (UTI)2 b. Central line catheter associated blood stream infection (CABSI)1,2 c. Ventilator-associated pneumonia (VAP)2 Outcome 1 Original ANA Nursing-Sensitive Indicator Pediatric and psychiatric indicators have been added more recently because participating hospitals requested indicators for these areas. Additional NQF endorsed measures (Table 1) were then added to the database because these represented additional nursing measures available that had already gone through a consensus measure approval process. ANA supported the addition of these measures to the database because they were of interest nationally to the nursing profession and were in concert with ANA’s seminal work and ongoing support of nursing measures. Implementing an indicator is a multi-step process ( Table 2 ) that includes evaluating the evidence that a specified indicator is nurse sensitive and then pilot testing ( Table 3 ) of the indicator by participating facilities. In addition, …there is ongoing monitoring and testing for validity and reliability per NDNQI standard operating procedure. there is ongoing monitoring and testing for validity and reliability per NDNQI standard operating procedure. An outcome indicator is deemed to be nursing sensitive if there is a correlation or multivariate association between some aspect of the nursing workforce or a nursing process and the outcome. The NDNQI utilizes state-of-the-science methods, such as the hierarchical mixed model, to assess the strength of correlation between nursing workforce characteristics and outcomes ( Gajewski et al., 2007 ; Hart, et al., 2006 ).
Table 2. Indicator Development Process
1. Review scientific literature for: (a) evidence that some aspect of nursing case has an effect on a patient outcome; (b) specific definitions of the indicators; and (c) evidence that the indicators can be validly and reliably measured 2. Collect information from researchers in the field on threats to reliability and validity 3. Conduct expert review of draft indicator definitions, data collection guidelines, and data collection forms 4. Distribute revised definitions, guidelines, and forms to clinical experts for comments on face validity and feasibility of reliable data collection 5. Incorporate clinical expert feedback and develop revised versions of definitions, guidelines, and forms 6. Conduct a pilot study ( 7. Finalize definitions, data collection guidelines, and forms 8. Train database participants in standardized data collection practices
Table 3. Pilot Testing Process
1. Develop the indicator with draft guidelines and data collection instruments 2. Recruit pilot testers via e-mail and phone 3. Select pilot sites from those interested. Sites are selected for hospital/unit diversity 4. Guide pilot sites in collecting data according to the draft guidelines 5. Analyze data submitted by pilot sites 6. Collect written and telephone evaluations to assess for clarity, feasibility, and assessment of threats to validity and reliability 7. Analyze pilot data for indicator refinement 8. Finalize guidelines and instruments for dissemination Quarterly Reports are downloaded electronically from the web by participating facilities. Reports can be downloaded in Adobe PDF, or Microsoft Excel format to facilitate data sharing and dissemination within a given institution. Figure 1 provides a sample of two tables from the report. The reports range from 25-200+ pages based on the number of nursing units and indicators for which hospitals submit data. The reports provide the most current eight quarters worth of data and a rolling average of those eight quarters with national comparisons at the unit level based on patient type, unit type, hospital bed size, and statistical significance of unit performance. For example, patient falls with injury could be reported for each adult medical unit of a 100-199 bed facility. The means for all medical units in a given-size facility can be compared with national standards for a given, nursing-sensitive indicator. The process measures associated with falls are collected and reported as well as the outcome measure of a patient fall.
Figure 1 – Sample Tables from NDNQI Reports The significance of offering the reports at the unit level is that such reports provide data regarding the specific site where the care occurs and provides a better comparison among like units. The significance of offering the reports at the unit level is that such reports provide data regarding the specific site where the care occurs and provides a better comparison among like units. Nursing leaders at participating facilities have used the information to advocate for more staff or a different mix of staff based on their comparisons of units in comparable facilities nation wide. Staff are also able to identify whether their performance improved after they intervened in an area needing improvement, e.g., a decrease in the fall rate due to implementation of a new protocol. Some facilities join NDNQI as part of their MagnetTM Journey to report nursing-sensitive indicators. The Magnet facilities represent about 20% of the database. The remaining 80% of NDNQI-participating facilities join because they believe in the value of evaluating the quality of nursing care and improving outcomes, activities which are both basic responsibilities of the profession. NDNQI is also used to aid in the recruitment and retention of nurses by hospitals that use the annual RN Survey data and quarterly data to improve work environments, to staff based on patient outcomes, and to meet regulatory or state reporting requirements.
Broad Accomplishments
NDNQI accomplishments include development of nationally accepted measures to assess the quality of nursing care, improvements in training procedures for data submission, identification of nursing workforce structures and processes that influence outcomes, and sharing best practices for improving outcomes. Each will be discussed in turn. Nursing leaders at participating facilities have used the information to advocate for more staff…
To date the NDNQI has already developed a number of standards. Four of the 15 standard nursing measures endorsed by the NQF have been NDNQI measures. Thirteen indicators already have been implemented in NDNQI, and at the time of this writing three additional measures, which are also NQF-endorsed measures, are scheduled for implementation. Of the 13 implemented indicators, eight are NQF consensus measures. NQF uses a consensus process to endorse measures. This process includes (a) consensus standard development, (b) widespread review, (c) member voting and member council approval, (d) board of directors action, and (e) evaluation. The importance of the NQF-endorsed indicators is that they provide a standard measure for evaluating nursing care and are the only nursing measures that have been endorsed for public reporting. Data training procedures and submissions have advanced from a telephone call for 1:1 training and submission using a CD, to use of comprehensive, web-based tutorials training participants to submit data using electronic means. Data submission now involves specification of unit types and various patient types, such as adult, pediatric, neonatal, psychiatric, and rehabilitation patient populations. Research on the database has yielded meaningful information on both workforce characteristics which influence quality outcomes and the importance of evaluating the data based on unit type. Identification of important correlations between structures and processes and observed nursing outcomes can help facilities improve their nursing care outcomes.Dunton et al. (2004) evaluated nurse staffing and patient falls and noted important correlations. They observed that lower fall rates were associated with higher staffing on certain types of units, and noted a strong relationship between fall rates, nursing hours, and skill mix. Hart, et al.(2006) studied the incidence of pressure ulcers among NDNQI hospitals, and reported a difference in quality outcomes based on the nursing workforce element of certification. As a result of the Hart et al. study an additional, web-based tutorial on pressure ulcers was created by NDNQI to educate the staff nurse on wound assessment. It is available publicly on the NDNQI web-site for any nurse to complete. Both of these studies demonstrated the value of reporting nursing-sensitive indicator data at the unit level, recognizing that variability of outcomes occurs at the unit level based on patient type, nurse staffing, and the nursing workforce characteristics. The NDNQI database enables researchers to identify various nursing workforce elements that can impact patient outcome, such as nurse staffing, skill mix, and specific nursing processes. It also enables researchers to identify process elements that can influence patient outcomes. Identification of important correlations between structures and processes and observed nursing outcomes can help facilities improve their nursing care outcomes. The database provides the end user with a powerful tool to aid in decision making related to improving the nursing work environment and patient outcomes.
…80% of NDNQI-participating facilities join because they believe in the value of evaluating the quality of nursing care and improving outcomes, activities which are both basic responsibilities of the profession. NDNQI staff have also helped facilities improve patient care by sharing best practices. In 2006 NDNQI staff identified facilities that had sustained an improvement in a given nursing-sensitive indicator. These facilities were asked to share what they had done to bring about this improvement. Fourteen facilities were profiled in a monograph identifying their experience with the database, their use of the data, and improvement strategies they had implemented to improve nursing performance in a given measure ( Montalvo & Dunton, 2007 ). For example, in one facility the hospital-acquired pressure ulcer (HAPU) rate dropped from 6.31 to 3.04 after implementing a quality improvement process that included assigning wound/ostomy/ continence specialists to specific nursing units to help all staff improve their surveillance for HAPUs and adopt a zero tolerance for HAPU. The opportunity for varying-size facilities to share these best practices adds to nursing’s knowledge base and helps nurses nation wide to improve nursing practice and patient outcome. The First Annual NDNQI Data Use Conference was held in January 2007 and was highly successful with 900 attendees being able to walk away with practical tools and tips in utilizing NDNQI data and to improve nursing-sensitive indicator outcomes. The monograph by Montalvo and Dunton, along with the annual national conference, have aided in disseminating such helpful information to all interested parties. The current consumer-driven health care environment requires accountability for the health care decisions made and the impact of these decisions on patients. Although direct financial cost/benefits have not been fully calculated with NDNQI globally, the staff nurses and nurse leaders now have a valuable nursing tool to aid them in decision making about staffing, skill mix, patient care processes, and workforce characteristics that affect patient outcomes, thus influencing directly and indirectly the cost of patient care. The facility now has the data necessary to calculate their cost/benefit ratio based on their improvements and outcomes.
Future Plans and Goals for NDNQI® The NDNQI database continues to grow in the number of facilities participating and in methodological sophistication. The database has grown from the original 30 facilities to over 1100 facilities in 2007, and ongoing investment and database enhancements continue. Two key developments are slated to begin in 2007. One is to develop methods for measuring unit-level acuity. This will provide mixed acuity units (units having more than 10% of patients representing a different patient population, such as rehabilitation patients on medical units [NDNQI operational definition, 2007]) and universal bed units (those having patient rooms equipped to care for any patient regardless of acuity [ Brown, 2007 ]) with the ability to receive comparisons from NDNQI. The second enhancement is to improve reporting features of NDNQI, so that more finite or granular comparisons of a very specific type of unit can be made. An example of a more finite comparison for particular facilities would be comparing coronary critical care units in the 100-bed to 199-bed hospitals. More enhanced reporting will provide more specific comparisons, the ability to download and post different sections of the report, new color graphics, single report cards, and hospital-level summaries. These value-added enhancements will provide the end user with a more powerful tool to evaluate nursing care, improve quality, and influence outcomes for both the patient and the nursing staff alike. New indicators are added to the database on an annual basis. Additionally, over the next 18 months, existing indicators in the database will become available for all appropriate nursing units. For example, the current psychiatric assault indicator could be pertinent in the Emergency Department (ED) because the ED is a point of entry for these patients. As the demand for data increases, expanding existing indicators to relevant areas will facilitate the ability of facilities to respond to patient and staff needs. Researchers will also continue to benefit from these enhancements. These developments will enable researchers to fine-tune their research questions and identify additional associations between nursing workforce characteristics and processes and the observed patient outcomes.
Conclusion
The NDNQI has made considerable progress since the ANA Board of Directors asked ANA staff to investigate the impact of workforce restructuring and redesign on patient care and to quantify the relationship between nurse staffing and patient outcomes. Today’s national spotlights on patient safety and public reporting have increased the need for nursing to collect and monitor data related to patient outcomes. It is also critical to continue these efforts to ensure nursing has the appropriate workforce to render the care necessary to optimize patient outcomes at the unit level. NDNQI studies have demonstrated the value of nursing care and the significance of nursing’s contribution to positive patient outcomes. NDNQI data now has the validity and reliability to be used to evaluate nursing care, improve patient outcomes, and identify the linkages between nurse staffing and patient outcomes at the unit level. NDNQI has indeed become the seminal nursing database that is used to influence nursing policy and improve nursing care.
Author
Isis Montalvo, MS, MBA, RN Isis.Montalvo@ana.org Isis Montalvo is Manager, Nursing Practice & Policy at the American Nurses Association (ANA). She is primarily responsible for providing oversight to the National Database of Nursing Quality Indicators™ (NDNQI®) in which over 1100 hospitals currently participate ( www.nursingquality.org ). Ms. Montalvo has over 20 years experience in multiple areas of clinical and administrative practice with a focus in critical care and performance improvement. As a former NDNQI Site Coordinator, Quality Specialist, and Nursing Research Chair at a large urban facility she brings expertise in data analysis, performance improvement, and nursing care evaluation. In 1996, she received her Master’s in Business Administration from the University of Baltimore in Maryland and her Master’s of Science in Nursing Administration from the University of Maryland . She is a Critical Care Registered Nurse (CCRN) Alumnus and a member of the American Association of Critical Care Nurses, the American Society of Association Executives/The Center for Association Leadership, the National Association for Healthcare Quality, and Phi Kappa Phi and Sigma Theta Tau honor societies.
References
American Nurses Association. (1995). Nursings report card for acute care. Washington, DC: American Nurses Publishing. American Nurses Association. (1996a).
Nursing quality indicators: Definitions and implications
Washington, DC: American Nurses Publishing. Available: www.nursingworld.org/books/pdescr.cfm?cnum=11#NP-108 American Nurses Association. (1996b).
Nursing quality indicators: Guide for implementation.
Washington, DC: American Nurses Publishing. American Nurses Association. (1997). Implementing nursings report card: A study of RN staffing, length of stay and patient outcomes. Washington, DC: American Nurses Publishing. American Nurses Association. (1999). Nursing quality indicators: Guide for implementation (2nd Ed.) Washington, DC: American Nurses Publishing. Available: www.nursingworld.org/books/pdescr.cfm?cnum=11#9906GI American Nurses Association. (2000a).
Nursing quality indicators beyond acute care: Literature review
. Washington, DC: American Nurses Publishing American Nurses Association. (2000b).
Nursing quality indicators beyond acute care: Measurement instruments
. Washington, DC: American Nurses Publishing American Nurses Association. (2000c).
Nurse staffing and patient outcomes
. Washington, DC: American Nurses Publishing American Nurses Association. (2001).
Code of ethics for nurses with interpretative statements.
Washington, DC: American Nurses Publishing, pg 12. American Nurse Association. (2004).
Nursing: Scope & standards of practice
. Silver Spring, MD: nursesbooks.org. American Nurses Association. (2005).
Utilization guide for the ANA principles for nurse staffing.
Silver Spring, MD: nursesbooks.org. Brown, K.K. (2007, March/April) The universal bed care delivery model. Patient Safety and Quality Health Care. Retrieved, August 19, 2007 from www.psqh.com/marapr07/caredelivery.html Dossey, B.M., Selanders, L.C., Beck D.M., & Attewell, A. (2005). Florence Nightingale today: Healing, leadership, global action. Silver Spring, MD: Nursesbooks.org. Available: www.nursingworld.org/books/pdescr.cfm?cnum=29#04FNT Donabedian A. (1988). The quality of care: How can it be assessed? JAMA, 260,1743-1748. Donabedian, A. (1992). The role of outcomes in quality assessment and assurance. Quality Review Bulletin, 11, 356-60. Dunton, N., Gajewski, B., Taunton, R.L., & Moore, J. (2004). Nurse staffing and patient falls on acute care hospital units. Nurse Outlook, 52, 53-9. Gajewski, B., Hart, S., Bergquist-Beringer, S., & Dunton, N. (2007). Inter-rater reliability of pressure ulcer staging: Ordinal probit Bayesian hierarchical model that allows for uncertain rater response. Statistics in Medicine (in press). Gallagher, R.M. & Rowell, P.A. (2003). Claiming the future of nursing through nursing-sensitive quality indicators. Nursing Administration Quarterly 24(4), 273-284. Hart, S., Berquist, S., Gajewski, B., & Dunton, N. (2006). Reliability testing of the National Database of Nursing Quality Indicators pressure ulcer indicator. Journal of Nursing Care Quality 21(3), 256-265. Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press. Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academies Press. Institute of Medicine. (2005). Performance measurement: Accelerating improvement. Washington, DC: National Academies Press. Kurtzman, E.T., & Corrigan, J.M. (2007). Measuring the contribution of nursing to quality, patient safety, and health care outcomes. Policy, Politics & Nursing Practice, 8(1), 20-36. Montalvo, I., & Dunton, N. (2007).
Transforming nursing data into quality care: Profiles of quality improvement in U.S. healthcare facilities
. Silver Spring, MD: Nursesbooks.org. Nightingale, F. (1859; reprinted 1946). Notes on nursing: What it is, and what it is not. Philadelphia: Edward Stern & Company. Rantz, M. (1995). Nursing quality measurement: A review of nursing studies. Washington, DC: American Nurses Publishing. Available: www.nursingworld.org/books/pdescr.cfm?cnum=11#NQM22 Robert Wood Johnson Foundation. (2007, May 30). Interdisciplinary nursing quality research initiative. (INQRI). Robert Wood Johnson Foundation. Retrieved, May 31, 2007 from www.inqri.org/ProgramOverview.html The Joint Commission. (2007, May 27).. Performance measurement initiatives. The Joint Commission. Retrieved May 27, 2007, from www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/ © 2007 OJIN: The Online Journal of Issues in Nursing
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The Growing Role of Patient A pate in discussions, watch interviews, or
read articles about our changing health
care system that do not concern patient engage-
ment. The Center for Advancing Health defines
patient engagement as
Actions individuals must take to obtain the
greatest benefit from the health care services
available to them. . . . Engagement is not syn-
onymous with compliance. . . . [Engagement]
signifies that a person is involved in a process in
which he [or she] harmonizes robust information
and professional advice with his [or her] own
needs, preferences, and abilities in order to
prevent, manage, and cure disease. Patient engagement strategies have been shown
to improve care delivery and translate into better
outcomes related to patient satisfaction and re-
covery. One author captured the importance of
patient engagement with this statement: “If pa-
tient engagement were a [medication], it would
be the blockbuster [medication] of the century
Patient engagement begins with relationship-based care. (Nurse’s warm-up jacket http://dx.doi.org/10.1016/j.aorn.2014.02.007
� AORN, Inc, 2014 April 2014 Vol 99 No 4 � AORN Journal j 517 http://dx.doi.org/10.1016/j.aorn.2014.02.007 and malpractice not to use it.” consensus among health care providers about how
to engage patients is still being determined.
The nursing profession’s role in patient engage-
ment and advocacy is key to the care that we de-
liver and continues to evolve to meet the needs of
patients. For example, before the 1970s, there was
not a high demand for patient’s rights. AORN published a position statement on creating
an environment of safety, which set the ground-
work for patient-centered care as an important
element in defining the perioperative culture. number of ethical, philosophical, and professional
considerations related to the rights of patients
have led to the nurse’s role as patient advocate.
According to one author, the three components of
this role are
1. informing patients of their rights,
2. providing patients with information necessary
to making informed decisions, and
3. supporting patients in their decisions.5
Regarding the patient’s role in engagement, one
author, who is also a perioperative RN, shared his
experiences as a surgical patient. In his article,
McGowan suggested that almost every patient en-
ters the surgical suite with anxiety and looks to
the perioperative team for reassurances. He be-
lieves that inaccurate portrayals of surgery in the
media “contribute to patients’ perceptions of sur-
gery and not always in a positive way.” Critical to the health care provider’s ability to
establish trust is communicating in a manner that
informs and empowers the patient. For example,
he stated that, as a patient, he felt hurried in saying
goodbye to his partner before the procedure began,
which suggests that he perceived a lack of sup-
port from those providing his care. According to
McGowan, nurses must provide reassurances to
patients in their care and “remember the leap of
faith that [undergoing care] requires of patients
and never [to] take the trust that they place in
us lightly.” By bringing together this panel of contributors,
my hope is that we come to a better understanding
of how we elicit our patients’ perspective and
involve them in improving satisfaction and health
outcomes. We would be remiss if this commentary
did not include the patient’s perspective. To that end,
a patient is one of the contributors. As you read these
commentaries, the clear themes among each disci-
pline and the engagement of key stakeholders can
be taken as a sign of the broader inclusion necessary
to achieving our desired outcomes. The panel of
contributors responded to the following statement:
Patient engagement and patient satisfaction
are playing critical roles in a changing health
care system and the emerging compensation
models. This directly impacts both the inpatient
environment and the ambulatory care setting.
From your perspective, please comment on what
you believe is the link between patient engage-
ment and improved outcomes for periopera-
tive patients.
CHARLOTTE L. GUGLIELMI PERIOPERATIVE NURSE SPECIALIST BOSTON, MA
Nurse’s perspective
Our goal as health care providers is to meet the
physical, social, and emotional needs of patients
and their family members. This cannot be accom-
plished without fully engaging patients in their own
care or without fully engaging their families. According to a white paper on patient and family
engagement from the Nursing Alliance for Quality
Care, “active engagement of patients, families,
and others is essential to improving quality and
reducing medical errors and harm to patients.” As perioperative nurses, it is sometimes difficult
to see our role in this process because of the limited
518 j AORN Journal
April 2014 Vol 99 No 4 TABLE TALK time for interaction and the drive for increasing
efficiencies. Perioperative leaders should promote
a culture that carefully balances efficiency, patient
safety, and patient participation by establishing
processes to support this philosophy. Strategies that
are developed to create this balance should estab-
lish a model for engaging patients and should en-
sure that perioperative nurses receive education on
communication techniques or methods that they
will use when interacting with those in their care.
At AnMed Health, Anderson, South Carolina,
perioperative leaders have adopted strategies that
offer a framework for successful engagement. Two
techniques that we use to guide personnel in their
interactions with patients and families are teach-
back (http://www.teachbacktraining.org) and Ask
Me 3 (http://www.npsf.org/for-healthcare-profe
ssionals/programs/ask-me-3).
Teach-back is a research-based health literacy
intervention that improves patient-provider com-
munication and health outcomes. active communication, the nurse prompts the
patient to explain, in his or her own words, the
information that the nurse has provided. This
method allows the patient to process health infor-
mation in a context that is meaningful to him or
her, and it demonstrates the patient’s understanding
to the health care provider. “Asking that patients
recall and restate what they have been told is one
of the 11 top patient safety practices based on the
strength of scientific evidence.” Teach-back is a
particularly powerful tool to use when providing
postoperative discharge instructions. By using this
technique, nurses can be reasonably sure that the
patient and his or her family members understand
the postoperative care that will be needed at home.
This can help reduce the risk of complications re-
lated to miscommunication or misunderstanding
of instructions.
Ask Me 3 is a teaching methodology that is based
on health literacy principles and often is used in
combination with the teach-back approach. Part-
nership for Clear Health Communication developed
this technique with the intent of helping all patients
comprehend their particular health condition and
what they should do about it. There are three
questions that patients are encouraged to ask
any health care provider:
n What is my main problem?
n What do I need to do?
n Why is it important for me to do this?
The use of these techniques adds structure to
patients’ interactions with their health care pro-
viders, thereby increasing patients’ engagement in
their own health. AnMed Health introduced these
methods in 2010, first in the surgical services and
pediatric departments, as part of an overall health
literacy and patient education initiative. Before
implementation, perioperative nurses received in-
depth training from the facility’s training and
organizational development department on both
techniques. Although these methods may seem
simplistic, both have proven effective in our facility
for allowing patients the opportunity to be part of
the conversation rather than passive receivers of
their medical information. The nurses in surgical
services directly teach patients to ask questions and
recall information. Nurses also use other commu-
nication methods, such as handouts and pamphlets,
to reinforce the delivery of information regarding
care. These methods of patient engagement start
when the patient arrives for surgical assessment
several days before surgery and continue through
postoperative discharge.
Although strategies provide a foundation for
patient engagement, it is nurses who establish re-
lationships with patients to make them partners in
their care. Nurses, in their role as committed patient
advocates, are uniquely positioned to embrace the
concept of active patient engagement. Therefore, it
is vitally important that perioperative leaders not
only provide the education and support necessary
for nurses to gain competency in patient engage-
ment practices but also actively participate in those
processes themselves. At AnMed Health, it is an
expectation that nurse managers and directors visit
with patients on a daily basis. Patient rounding by
AORN Journal j 519
TABLE TALK www.aornjournal.org http://www.teachbacktraining.org http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3 http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3 http://www.aornjournal.org leaders sets an example for personnel but also
provides one more step in cementing the patient-
provider relationship that is so important to pa-
tient outcomes.
Helping personnel embrace “hardwire processes”
that are related to patient engagement is not sim-
ple, but perioperative leaders should be persistent
and supportive because these efforts are known
to be effective in improving postoperative patient
health. Here are some key tips for nurses who are
getting started on this journey or who are renewing
their focus of patient engagement.
n Set aside a predetermined time each day to
round on patients. You can do this by putting
an appointment on your calendar. Allow enough
time to make the visits meaningful.
n Determine ahead of time the major points you
want to convey to the patient so that you can
work these into the conversation. Use teach-
back and Ask Me 3 whenever possible.
n Take a surgery schedule with you so that you
know the patient’s name, the scheduled surgical
procedure, and the name of the surgeon.
n If you are a director, ask a manager to ac-
company you for a few days. If you are a
manager, ask staff nurses to join you from
time to time.
n Manage up your team! Make sure you relay
to the patient what a wonderful team will be
providing his or her care.
MARTHA STRATTON DIRECTOR OF NURSING, SURGICAL SERVICES Surgeon’s perspective
The Institute of Medicine report To Err is Human:
Building a Safer Health System documented sig-
nificant breaches in safe patient care. Many of the
breaches involved poor communication, a lack of
professionalism, and an inability to work as a team.
These deficiencies are major impediments to es-
tablishing good physician-patient relationships and
must be addressed by the profession. Doing so is
especially critical as the health care industry fo-
cuses on both increased patient engagement and
measured outcomes.
As surgeons, we have always been cognizant of
results (ie, outcomes). We have now been served
notice that we shall be rated and paid by the out-
comes we achieve. In many ways, however, we are
very reliant on others to achieve the best results
possible in any given patient encounter, perhaps
on none more so than the patient. Thus, educat-
ing and empowering the patient through effective
communication is now more important than ever.
By engaging with the patient in his or her own
care and providing education, health care providers
can show their dedication to safe patient care and
provide the patient with the feeling of not only
being cared for but cared about.
The surgeon must recognize his or her role as a
critical member of the preoperative, intraoperative,
and postoperative teams. A major component of
this role is serving as an educator to both the patient
and team members to explain the purpose, plan,
and expected outcome of the surgical procedure.
Each member of the team (eg, surgeon, anesthesia
professional, perioperative RN) must work together
to ready and empower the patient for the surgical
encounter. Silos are no longer effective or appro-
priate. As part of their engagement, patients and
their family members must be made aware that they
also have a responsibility to act as their own or as a
relative’s advocate and become part of the surgical
team. Thus, their goals and expectations must be
verbalized and understood by other members of the
team. I believe that having well-informed patients
and family members will lead to greater satisfac-
tion and will improve outcomes dramatically.
Yet, the world of health care becomes more
frenzied by the day, which has led to perioperative
520 j AORN Journal
April 2014 Vol 99 No 4 TABLE TALK personnel experiencing increased workloads and
greater stress. A sad fallout as a result of these
conditions is increased unprofessional behavior
on the part of members of the perioperative team.
When team members behave unprofessionally or
give the impression that they do not care about the
patient, it does not go unnoticed by patients and
serves only to sour their perception of the surgical
team, or at least some of its members. This weak-
ens their sense of engagement and increases the
possibility of a poor outcome. between stress levels and professional behaviors is
critical for physicians and nurses if we are to suc-
cessfully engage with our patients.
I believe that patients simply want to be part
of their own solution. A happy and relaxed patient
and surgical team are more successful than are an
unhappy and a stressed patient and surgical team in
achieving the desired positive outcome. Patients
want to understand what is happening to them and
to be informed about their care in a language that
they can understand. This means that they want to
be cared for in a safe environment by competent
professionals whose goal is a quality, cost-effective
outcome. In the end, we must not forget that pa-
tients do not care how much we know until they
know how much we care.
GERALD B. HEALY PAST PRESIDENT, AMERICAN COLLEGE OF HARVARD MEDICAL SCHOOL Anesthesiologist’s perspective
There can be very little argument that there is
indeed a link between patient engagement and
outcomes in the perioperative setting. This link
prevails across all settings of care, from hospitals
to ambulatory surgery centers to office surgery
suites. As a physician who has practiced almost
exclusively in the ambulatory surgery center set-
ting, I have no doubt that the patient plays a pivotal
role throughout the perioperative continuum in
the outpatient environment. Perhaps because of
the nature of the types of procedures we perform
(ie, those that are largely elective) and the relatively
short duration of the care provided (ie, usually less
than 24 hours), the extent to which personnel can
engage the patient and provide personalized, patient-
centered care is amplified in the ambulatory surgery
center setting.
Consequently, it is critical for the physician to
carefully assess the degree of patient, as well as
family member, engagement when considering the
most suitable location for the surgery to be per-
formed, regardless of the particular surgery and
anesthetic planned. A patient who is either unable
or unwilling to actively participate in his or her
own perioperative care, regardless of the reason,
is at an increased risk for poor outcomes. Further-
more, such a patient may be an unsuitable candi-
date for outpatient surgery.
As an example, a patient who is not motivated
to thoroughly administer his or her prescribed in-
testinal prep before a colonoscopy can adversely
affect the likelihood of an optimal procedure and is
at significant risk for cancellation entirely, there-
by defeating the opportunity for critical diagnosis
and treatment. Similarly, because patients are sent
home relatively quickly after outpatient procedures,
adherence to discharge instructions and attention to
possible signs and symptoms of surgical compli-
cations are crucial to a safe and timely recovery.
Although the relationship that perioperative
team members have with the patient is intuitive-
ly important, relationship-based care can place a
considerable burden both on the provider and on
the recipient of heath care in the outpatient setting.
For health care providers, it can be very difficult for
personnel to proactively ascertain the commitment
and ability of a patient to monitor and participate in
his or her own care, thereby making it difficult for
AORN Journal j 521
TABLE TALK www.aornjournal.org http://www.aornjournal.org health care providers to help facilitate patient
compliance with the requisite postoperative self-
care regimens. For the recipient of health care (ie,
the patient), it can be very difficult to process and
attend to all the information communicated during
what is often a physically challenging and emo-
tionally charged time. Despite these difficulties, the
extent to which patient engagement can be lever-
aged during any given episode of care will almost
certainly enhance the outcome.
As definitive as I believe the relationship be-
tween patient engagement and outcomes is, the
relationship between patient engagement and pa-
tient satisfaction appears to be a bit less well es-
tablished or understood. The two are inexorably
intertwined, but the precise nature of the interaction
is considerably less clear. Are engagement and
satisfaction a cause or result of outcomes, or are
there other factors at play? I believe that, by clar-
ifying the factors that affect clinical outcomes, both
patient engagement and satisfaction will begin to
be better understood.
Although the very topical concept of patient
satisfaction recently has become the focus of an
inordinate amount of attention by the media and by
payers, I believe that much more research is needed
to determine the precise role that patient satisfac-
tion, or the patient experience, plays in health care
delivery and outcomes. At this time, however, the
precise nature of the patient-provider relationship
remains not only complicated but also largely un-
charted. Clearly, this is a fertile area of exploration
because patients, especially those undergoing sur-
gical or other invasive procedures, will most defi-
nitely play an increasingly important role in the
responsibility for their own perioperative care.
Only through further exploration and evidence-
based research will the precise nature of the link
between patient engagement and outcomes be
more clearly elucidated. As a result of this fo-
cus of endeavor, I anticipate that the concept of
relationship-based care will become more clearly
established as an important determinant of patient
satisfaction.
One important concept that surely will emerge
as an important area of continuing endeavor is to
arrive at clear, consistent, and universally accepted
definitions of terms such as engagement, satisfac-
tion, and outcome. Only after these definitions
have been refined and promulgated can we begin
the subsequent task of accurately quantifying, or
measuring, all the variables therein. Patient en-
gagement and patient satisfaction, therefore, are
an evolving and positive focus of health care, es-
pecially as we strive to improve the quality of
the perioperative services that we provide to our
patients. Surely, any efforts directed toward im-
provement on behalf of our patients are mission
critical for us as health care providers in the inpa-
tient and in the rapidly growing outpatient settings.
DAVID SHAPIRO ANESTHESIOLOGIST Chief nursing officer’s perspective
I could not be happier with the growing focus on
patient satisfaction as a measure of quality. Mea-
suring patients’ perceptions of their care helps us,
their care providers, to understand their emotional
and spiritual health during all phases of periopera-
tive care. By referring to spiritual health in this
context, I am not discussing patients’ religious state
of mind but rather the health of the human spirit
that is inside all of us. Human beings are complex
creations who need to feel safe while also being
safe to thrive. Maslow’s hierarchy of needs de-
monstrated that, after an individual’s physical needs
are met, the individual ascends to more complex
needs to achieve self-actualization. Understand-
ing the needs of our patients to thrive both physi-
cally and spiritually is critical to helping them
face whatever risks they encounter from disease
or injury.
522 j AORN Journal
April 2014 Vol 99 No 4 TABLE TALK As a nurse I have always viewed my practices as
providing a combination roles, that of scientist and
care provider. The scientist role allows me to focus
on assessing the physical needs, signs, and symp-
toms of those patients in my care so that I can
develop and implement suitable interventions. The
care provider role allows me to focus on enhancing
the spiritual health of my patients. I believe that we
are unable to be expert caregivers if we do not care
for all the needs of our patients, both physical and
spiritual. Unfortunately, over the years, as the
cost of providing care has grown, our health care
systems have continually shifted the focus of care
delivery to developing processes and systems that
deliver physical care in as efficient a manner as
possible. In the surgical environment, we all have
experienced the ongoing push for efficiency and the
multiple meetings to discuss reducing turnover time
and cost per procedure. It was not until the Institute
of Medicine published its report, To Err is Human:
Building a Safer Health System, which estimated
that 100,000 lives are lost each year because of
medical errors, that society demanded a response
to patient outcomes in the form of safer care de-
livery models that respect health care efficiency but
not at the expense of safety. I believe the response to the Institute of Medicine
report aligns with Maslow’s theory. Nurses and
other members of the health care team have looked
to improve structures and processes to meet the
physical needs of the patient first. For example,
in the OR, perioperative personnel embrace safety
initiatives such as the time out and the Surgical Care
Improvement Project. We have looked to reduce
variations to decrease human error from inexperi-
ence with a certain supply or piece of equipment.
Additionally, both the “captain of the ship” doctrine
and bullying behavior that were tolerated for so
many years have been replaced with huddles and
debriefings about the plan of care, so that all team
members can be equal partners in providing care.
Despite these efforts, we still face challenges
with outcomes. I believe that the realization must
be that problems related to mediocre outcomes
cannot be solved if we do not involve the patients in
their care. As McGowan stated in his article, a pa-
tient who is made to feel valued and part of the care
process is a patient who has a better chance to ex-
perience an optimal outcome. strengthens the health of their spirit. A healthy spirit
is critical to patients’ successdyet, up to this point,
everything the health care industry has been focused
on has been to address patients’ physical needs and
not their spiritual needs. It is only now that we are
responding to that oversight by enhancing physical
care with relationship-based care.
Let’s face it, receiving health care can be one
of the most dehumanizing experiences in a person’s
life. We strip patients of their clothes, their valu-
ables, and their family and friendsdand we may
even paralyze them with anesthesiadso that a
group of strangers whom they have never, or only
briefly, met can perform a surgical or other invasive
procedure on their body. I have had surgery only
as a child, but still I have wondered many times
as I put the safety strap on my patients about the
leap of faith that is required of those who undergo
surgery. The stress of a surgical procedure must
be enormous, and that stress can hinder a patient’s
ability to thrive throughout the perioperative course.
To me, this is why it is so important to engage our
patients and make them feel valued during the
perioperative process.
I believe that patients enter a hospital believing
that we know how to provide physical care, but
what they hope for, and are concerned about, is
whether we will value them as human beings.
When an individual feels valued, he or she feels
stronger; and the stronger the patient is, the better
the chances are for a great outcome. I frequently
see evidence of how important spiritual care is to
patients. In my 30 years as a nurse leader, almost
every letter I receive from patients discusses how
my nurse team members either did or did not make
them feel valued. Except for incidents of a clear-cut
error, patients rarely discuss the physical aspects of
care or their outcomes. It is clear to me that they
want to share their perception of the quality of the
AORN Journal j 523
TABLE TALK www.aornjournal.org http://www.aornjournal.org spiritual care they received. For someone to stop
and take the time to write a message of thanks or
concern means that their spiritual care is something
they value very much; and, if this is important to
them, then it should be equally important to us as
their care providers.
WILLIAM J. DUFFY REGIONAL VICE PRESIDENT, CHIEF NURSE LAKE SHORE REGION CHICAGO, IL
Patient’s perspective
My perspective as a surgical patient in an ambu-
latory setting is a bit unique because of my pro-
fessional background. For the past 42 years, I have
worked for a major surgical organization and have
witnessed the development of statements, guide-
lines, and protocols to meet the organization’s
mission to improve quality in surgery, trauma,
and cancer care and to have fewer complications,
better outcomes, and greater access for patientsd
all at lower costs. In my view, this laudable mis-
sion should include cooperative efforts from both
patients and perioperative team members. For
example, soon I will begin my term as the first
patient to serve on the Board of Directors of the
Council on Surgical and Perioperative Safety
(http://www.cspsteam.org), a coalition that previ-
ously comprised only representatives from profes-
sional societies.
I have been a surgical outpatient on three occa-
sions: for a torn meniscus repair, a cystoscopy, and
a colonoscopy. All three interventions had excellent
outcomes, and my recovery was within the normal,
prescribed time frames for each. Although I have
had additional surgical experiences as an inpatient
at a large Midwestern teaching hospital, all three
of the outpatient procedures were performed in
either a mid-size suburban hospital or in the sur-
geon’s office. In all three instances, I was impressed
with the level of preoperative and postoperative
care that personnel provided. During these experi-
ences, I was encouraged to ask questions about the
surgical procedure and was given written informa-
tion as well. I felt a part of the process and was
treated as a unique individual and not as an anon-
ymous patient or just another procedure.
I believe that patients must be their own advo-
cates or, if required, have someone with them to
serve in that role. No matter how routine a procedure
is for the perioperative team, it is perhaps the first
time for the patient. Not to be flippant, but I liken the
surgical experience to attending a Broadway play.
The cast and crew may have multiple performances
under their belts, but most members of the audience
are there for the first time and expect the best. Un-
like anticipating a delightful evening at the theater,
however, the patient may be fearful or anxious about
the procedure and outcome. These emotions usually
are linked to not knowing or understanding how the
perioperative phases of care will go. In my experi-
ence, patient education is instrumental to preoper-
ative planning and postoperative recovery. As stated
earlier, the written and verbal explanations were
very helpful and spoken in terms that were under-
standable to me as the patient. My questions were
encouraged and willingly answered, and I felt val-
ued as a human being.
In an outpatient setting, the nursing team does not
have much time with patients; therefore, effective
educational tools are far more focused and time
sensitive before and after the procedure compared
with the inpatient setting. In particular, I found the
postoperative follow-up telephone call after dis-
charge very helpful. The nursing team made sure
that I understood and was following the postoper-
ative instructions. At-home care regimens can in-
clude, but are not limited to, caring for the surgical
wound and pain management. In addition, the
postdischarge call provides a great deal of comfort,
as it did for me. The subsequent follow-up visit with
the surgeon is critical to postoperative care. It is
524 j AORN Journal
April 2014 Vol 99 No 4 TABLE TALK http://www.cspsteam.org during this visit that more extensive questions may
be addressed. Good follow-up leads to peace of
mind for the patient. For me, this appointment
provided great follow-up and peace of mind.
An engaged patient is usually a satisfied patient.
As the health care system in this country changes
and new compensation models are developed,
patients will probably have more concerns and
questions, and health care professionals, particu-
larly the perioperative team, should be prepared
and ready to guide and understand the patient’s
perspective. Health care providers also should be
aware that any of us may become a patient on any
given day; that alone should dictate a desire to
promote and provide optimal patient education.
BARBARA L. DEAN AMERICAN COLLEGE OF SURGEONS COUNCIL ON SURGICAL AND PERIOPERATIVE CHICAGO, IL AORN perspective
The contributors to this “Table Talk” all have pro-
vided clear support of the link between patient and
family member engagement and clinical outcomes.
The growing importance of patient engagement to
the health care system role is recognized in section
3021 20,21 Centers for Medicare & Medicaid Services Inno-
vation Center operationalized in 2011 through its
Partnership for Patients. As a public-private
endeavor, the Partnership comprises a broad and
inclusive network of members (eg, physicians,
nurses, hospitals, associations, federal and state
governments, patients) who have joined together
to improve the quality, safety, and affordability of
health care for all Americans. AORN was one of the first associations to
join the Partnership and pledge its support to
achieving outcomes that are consistent with the
mission and vision of AORN. Members of the
Partnership are committed to reaching two goals:
making care safer and improving care transitions.
The desired outcomes of these initiatives are a
40% reduction of preventable hospital-acquired
conditions and a 20% reduction of 30-day read-
missions, both by the end of 2013 as compared
with 2010 data. As a major vehicle for improving patient care,
the Partnership leverages three key elements:
1. Hospital engagement networksdto identify
solutions for reducing hospital-acquired con-
ditions as well as share and spread successful
practices to other hospitals and health care
providers. (See “Resources: Partnership for
Patient Affinity Groups.”)
2. Community-based care transition programsd
to test models of improving care transitions
from the hospital to another setting, and to aid
in reducing the readmissions rate for high-risk
Medicare beneficiaries.
3. Patient and family engagementdto focus
on the importance of the relationship among
health care professionals and patients and their
family members in preventing health caree
associated illness as well as to help patients
heal without complications through improved
transitions across health care settings and re-
duced readmissions. Regarding the Partnership’s third key element,
the importance of patient engagement is consistent
with AORN’s Perioperative Patient Focused Model
(Figure 1), which is a framework grounded around
the principle that the patient is the focus of all
nursing interventions to achieve optimal patient
outcomes. This model clearly illustrates the patient-
centered goal of perioperative nursing practice,
which is to assist patients and their family members
AORN Journal j 525
TABLE TALK www.aornjournal.org http://www.aornjournal.org with achieving a level of wellness equal to or
greater than the level of wellness that the pa-
tients have before undergoing their operative
or other invasive procedure.
AORN provides resources for improving patient
and family engagement, such as Perioperative
Standards and Recommended Practices. This publication includes references to involving the
patient and family members during patient assess-
ment, developing expected outcomes of care, in-
cluding the patient in the implementation of the
care plan, verifying that interventions reflect the
rights and desires of the patient, and involving
the patient and family members in the postpro-
cedure evaluation process. The perioperative RN
coordinates patient care continually throughout
the patient’s perioperative experience and assists
the patient and family members with identifying
options for care. The Perioperative Standards
and Recommended Practices also indicates that
the perioperative RN uses ethical principles to
determine decisions and actions, such as by act-
ing as a patient advocate and encouraging patient
self-advocacy.
Additional AORN resources include AORN
position statements and tool kits. AORN position
statements serve to articulate the Association’s
official position or belief about specific periop-
erative nursingerelated topics. In particular,
several position statements convey and support
the importance of the
relationship among peri-
operative nurses, patients,
and their family members during the perioperative
period. A number of AORN
tool kits also provide re-
sources for engaging pa-
tients and their family
members. These resources
include the following:
n AORN Position
Statements
n Care of the Older Pa-
tient in Perioperative
Settings (https://
www.aorn.org/Wo
rk Area/DownloadAsse
t.aspx?id¼21926) Environment of Safety
(http://www.aorn.org/
WorkArea/Download
Asset.aspx?id¼21919) www.aorn.org/Work
Area/DownloadAsse t.aspx?id¼21930)
Resources: Partnership for Patient Affinity Groups
Information shared via the Partnership for Patients hospital
engagement networks often comes from Affinity Groups with
clinical focuses, such as health careeassociated infections, medi-
cation safety and pharmacist engagement, patient and family
member engagement, and product safety and resource manage-
ment. AORN, the American College of Surgeons, the American
Society of Anesthesiologists, and the American Association of
Nurse Anesthetists collaborated with the Partnership to create the
Procedural Harm Affinity Group, practices related to surgical safety, such as use of the World Health
Organization’s Surgical Safety Checklist. nership and the Affinity Group make information available to the
Partnership’s hospital engagement networks (eg, through web
events, conference calls, shared tools), so that health care pro-
fessionals have direct access to resources that can be used in
providing optimal preoperative, intraoperative, and postoperative
care to the surgical patient.
1. Procedural Harm Affinity Group. Healthcare Communities. http://www.health
carecommunities.org [membership required]. Accessed February 12, 2014.
2. AANA, ACS, AORN, ASA and the Council on Surgical and Perioperative
Safety (CSPS) endorses the use of the World Health Organization’s Safe
Surgery Checklist and the implementation of The Joint Commission’s
Universal Protocol [news release]. Denver, CO: AORN, Inc; 2012. http://
www.aorn.org/uploadedFiles/Main_Navigation/Advocacy/Supporting_
Documents/Issues/PfP%20Affinity%20Group%20Joint%20Statement .
Accessed February 6, 2014.
526 j AORN Journal
April 2014 Vol 99 No 4 TABLE TALK https://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21926 https://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21926 https://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21926 https://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21926 https://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21926 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21919 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21919 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21919 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21919 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21930 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21930 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21930 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21930 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21930 http://www.aorn.org/uploadedFiles/Main_Navigation/Advocacy/Supporting_Documents/Issues/PfP%20Affinity%20Group%20Joint%20Statement http://www.aorn.org/uploadedFiles/Main_Navigation/Advocacy/Supporting_Documents/Issues/PfP%20Affinity%20Group%20Joint%20Statement http://www.aorn.org/uploadedFiles/Main_Navigation/Advocacy/Supporting_Documents/Issues/PfP%20Affinity%20Group%20Joint%20Statement n Perioperative Care of Patients with Do Not
Resuscitate Orders (http://www.aorn.org/
WorkArea/DownloadAsset.aspx?id¼21917) n Correct Site Surgery Tool Kit (http://www
.aorn.org/Secondary.aspx?id¼20846) .org/Clinical_Practice/ToolKits/Workplace_
Safety/Workplace_Safety_Tool_Kit.aspx)
n Just Culture Tool Kit (http://www.aorn.org/
Secondary.aspx?id¼20848) .org/Secondary.aspx?id¼20849) Nursing Alliance for Quality Care (http://www
.naqc.org), of which AORN is a member. This
alliance comprises 22 national organizations and
consumer advocacy groups that are committed to
improving the quality and safety of health care
for all Americans. Goals of the alliance include
the active engagement of patients, family members,
and others to improve quality and to reduce
medical errors and harm to patients; a second
goal is that nurses at all levels of education and
across all health care settings must play a central
role in fostering successful patient and family
member engagement. To meet these goals, the
Nursing Alliance for Quality Care created
the following: n guiding principles to support nurses’ efforts
in fostering patient engagement and
n the Fostering Successful Patient and Family
Engagement white paper plan that both encourages nurses’ support of
patient engagement and identifies how organi-
zations and individual nurses can be active in
implementing the plan.
AORN believes that patients and their family
members are essential partners in the care that
health care professionals provide to perioperative
patients. In addition, involving patients in aspects
of their care is necessary to developing a safe
perioperative culture. AORN president Victoria
M. Steelman, PhD, RN, CNOR, FAAN, has em-
braced the concept of patient engagement by ap-
pointing a task force to make recommendations
for infusing the principles of relationship-based
care into new and existing resources to aid in
the care of the perioperative patient. Members
of the Patient Engagement Task Force will share
their results at the AORN Surgical Conference &
Expo 2015.
LINDA K. GROAH EXECUTIVE DIRECTOR AND CHIEF EXECUTIVE AORN, INC Editor’s note: Ask Me 3 is a registered trade- Boston, MA.
References Engagement Important? Washington, DC: Center for
Advancing Health; 2010. http://www.cfah.org/pdfs/
CFAH_Engagement_Behavior_Framework_current .
Accessed January 13, 2014.
Figure 1. AORN Perioperative Patient Focused AORN Journal j 527
TABLE TALK www.aornjournal.org http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21917 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21917 http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21917 http://www.aorn.org/Secondary.aspx?id=20846 http://www.aorn.org/Secondary.aspx?id=20846 http://www.aorn.org/Secondary.aspx?id=20846 http://www.aorn.org/Clinical_Practice/ToolKits/Workplace_Safety/Workplace_Safety_Tool_Kit.aspx http://www.aorn.org/Clinical_Practice/ToolKits/Workplace_Safety/Workplace_Safety_Tool_Kit.aspx http://www.aorn.org/Clinical_Practice/ToolKits/Workplace_Safety/Workplace_Safety_Tool_Kit.aspx http://www.aorn.org/Secondary.aspx?id=20848 http://www.aorn.org/Secondary.aspx?id=20848 http://www.aorn.org/Secondary.aspx?id=20848 http://www.aorn.org/Secondary.aspx?id=20849 http://www.aorn.org/Secondary.aspx?id=20849 http://www.aorn.org/Secondary.aspx?id=20849 http://www.naqc.org http://www.naqc.org http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current http://aorn.org http://www.aornjournal.org 2. Kish L. The blockbuster drug of the year: an engaged
patient. HL7Standards.com e-newsletter. 2012. http://
www.hl7standards.com/blog/2012/08/28/drug-of-the
-century/. Accessed January 13, 2014.
3. Malik M. Advocacy in nursingda review of the litera- 4. AORN position statements. AORN J. 2011;93(5):545-549.
5. Schroeter K. Advocacy in perioperative nursing practice.
AORN J. 2000;71(6):1207-1222.
6. McGowan R. A surgical patient’s perception of trust.
AORN J. 2011;93(4):493-497.
7. A Leadership Resource for Patient and Family Engage-
ment Strategies. Chicago, IL: Health Research & Educa-
tional Trust; 2013. http://www.hpoe.org/Reports-HPOE/
Patient_Family_Engagement_2013 . Accessed
January 13, 2014. 8. Shoshanna S, Schumann MJ. Fostering Successful Pa-
tient and Family Engagement: Nursing’s Critical Role
[white paper]. Silver Spring, MD: Nursing Alliance for
Quality Care; 2013. http://www.naqc.org/Main/Resources/
Publications/March2013-FosteringSuccessfulPatientFami
lyEngage ment . Accessed February 10, 2014.
9. Schillinger D, Piette J, Grumback K, et al. Closing the
loop: physician communication with diabetic patients
who have low health literacy. Arch Intern Med. 2003;
163(1):83-90.
10. Shojania KG, Duncan BW, McDonald KM, Wachter RM,
eds. Making Health Care Safer: A Critical Analysis of
Patient Safety Practices. Rockville, MD: Agency for
Healthcare Research and Quality; 2001. http://psnet
.ahrq.gov/resource.aspx?resourceID¼1599. Accessed 11. Ask Me 3. National Patient Safety Foundation. http://
www.npsf.org/for-healthcare-professionals/programs/
ask-me-3/. Accessed January 13, 2014.
12. Pelletier LR, Stichler JF. Action brief: patient engage-
ment and activation: a health reform imperative and
improvement opportunity for nursing. Nurs Outlook.
2013;61(1):51-54.
13. Institute of Medicine. Kohn LT, Corrigan JM,
Donaldson MS, eds. To Err Is Human: Building
a Safer Health System. Washington, DC: National
Academy Press; 2000.
14. Coulter A. Patient engagementdwhat works? J Ambul 15. McLeod S. Maslow’s hierarchy of needs. Simple-
Psychology. 2007. http://www.simplypsychology.org/
maslow.html. Accessed January 13, 2014.
16. Duffy WJ. The value of our practice. AORN J. 2004;
79(6):1125-1127.
17. Brendle TA. Surgical care improvement project and the
perioperative nurse’s role. AORN J. 2007;86(1):94-101.
18. Costa MJ. The lived perioperative experience of ambu-
latory surgery patients. AORN J. 2001;74(6):874-881.
19. Establishment of Center for Medicare and Medicaid
Innovation within CMS. Patient Protection and Afford-
able Care Act (Pub. L. 111e148) x 3021(2010). http:// -111publ148 . Accessed February 6, 2014.
20. ANA Policy & Provisions of Health Reform Law. Silver
Spring, MD: American Nurses Association; 2010. http://
www.nursingworld.org/MainMenuCategories/Policy-
Advocacy/HealthSystemReform/Policy-and-Health-Reform-
Law . Accessed February 6, 2014.
21. Health care transformation: the Affordable Care Act and
more. American Nurses Association. http://nursingworld
.org/MainMenuCategories/Policy-Advocacy/HealthSystem
Reform/AffordableCareAct . Published March 23,
2012. Accessed February 6, 2014.
22. The CMS Innovation Center. Centers for Medicare &
Medicaid Services. http://innovations.cms.gov/. Accessed
February 6, 2014. 23. About the Partnership for Patients. CMS.gov. http://partner
shipforpatients.cms.gov/about-the-partnership/aboutthe
partnershipforpatients.html. Accessed February 6, 2014.
24. Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2014.
25. Guiding principles for patient engagement. In: The
Nursing Alliance for Quality Care National Consensus
Conference program. Nursing Alliance for Quality Care.
http://www.naqc.org/Main/Resources/Publications/2012
-NursesContributionsFosteringSuccessfulPatientEngage
ment . Accessed February 10, 2014. The authors of this article have no declared
affiliations that could be perceived as posing
potential conflicts of interest in the publication
of this article.
The AORN Journal is seeking contributors for the Table Talk column. Interested authors can contact
Charlotte Guglielmi, column coordinator, by sending topic ideas to journalcolumns@aorn.org.
528 j AORN Journal
April 2014 Vol 99 No 4 TABLE TALK http://www.hl7standards.com/blog/2012/08/28/drug-of-the-century/ http://www.hl7standards.com/blog/2012/08/28/drug-of-the-century/ http://www.hl7standards.com/blog/2012/08/28/drug-of-the-century/ http://refhub.elsevier.com/S0001-2092(14)00166-5/sref2 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref2 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref2 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref3 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref4 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref4 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref5 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref5 http://www.hpoe.org/Reports-HPOE/Patient_Family_Engagement_2013 http://www.hpoe.org/Reports-HPOE/Patient_Family_Engagement_2013 http://www.naqc.org/Main/Resources/Publications/March2013-FosteringSuccessfulPatientFamilyEngagement http://www.naqc.org/Main/Resources/Publications/March2013-FosteringSuccessfulPatientFamilyEngagement http://www.naqc.org/Main/Resources/Publications/March2013-FosteringSuccessfulPatientFamilyEngagement http://refhub.elsevier.com/S0001-2092(14)00166-5/sref8 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref8 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref8 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref8 http://psnet.ahrq.gov/resource.aspx?resourceID=1599 http://psnet.ahrq.gov/resource.aspx?resourceID=1599 http://psnet.ahrq.gov/resource.aspx?resourceID=1599 http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/ http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/ http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/ http://refhub.elsevier.com/S0001-2092(14)00166-5/sref10 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref10 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref10 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref10 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref11 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref11 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref11 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref11 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref12 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref12 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref12 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref14 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref14 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref15 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref15 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref16 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref16 http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148 http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148 http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148 http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Policy-and-Health-Reform-Law http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Policy-and-Health-Reform-Law http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Policy-and-Health-Reform-Law http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Policy-and-Health-Reform-Law http://nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/AffordableCareAct http://nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/AffordableCareAct http://nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/AffordableCareAct http://innovations.cms.gov/ http://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html http://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html http://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html http://refhub.elsevier.com/S0001-2092(14)00166-5/sref17 http://refhub.elsevier.com/S0001-2092(14)00166-5/sref17 http://www.naqc.org/Main/Resources/Publications/2012-NursesContributionsFosteringSuccessfulPatientEngagement http://www.naqc.org/Main/Resources/Publications/2012-NursesContributionsFosteringSuccessfulPatientEngagement http://www.naqc.org/Main/Resources/Publications/2012-NursesContributionsFosteringSuccessfulPatientEngagement mailto:journalcolumns@aorn.org Copyright of AORN Journal is the property of Elsevier Inc. and its content may not be copied
2
1
Nurse-Sensitive Quality Indicator Dashboard – Adams 5 (Inpatient Rehab Unit)
Time Period
Q
3
0
Q4FY05
Q1FY06
Q2FY06
Q3FY06
Q4FY06
Q1FY07
Q2FY09
Q3 FY09
Q4 FY09
Q1 FY10
Description
Mean
Target
Actual
Var
Target^
NDNQI Data
NHPPD^^
7.65
8.52
6.39
-2.13
7.82
8.78
7.06
-1
8.08
9.10
6.41
-2.69
8.13
9.07
6.54
-2.53
7.97
6.51
6.31
–
0.20
8.09
7.03
0.52
8.15
6.69
7.07
0.38
6.56
0.13
7.95
6.59
0.10
8.18
6.23
0.46
8.27
7.19
7.23
-0.04
RN Care Hrs
53.3
6
1.4
59.46
-2.01
61.09
5
6.96
-4.13
53.48
60.56
59.20
–
1.3
53.84
60.89
56.87
-4.02
54.82
62.09
5
6.01
-6.08
54.05
6
1.08
59.47
–
1.6
54.48
62.42
58.42
–
4.00
54.86
6
1.8
58.71
3.15
55.49
55.90
5.96
54.93
56.59
5.27
54.81
54.07
7.79
%AGNCYHR
1.76
0.00
0.31
0.06
1.83
3.05
1.85
6.89
6.58
1.
92
1.99
0.84
-0.84
2.32
2.12
0.08
-0.08
2.8
%PRSSULC
15.28
3.70
23.81
20.11
1
5.18
5.26
15.00
1
2.85
3.23
17.39
14.16
14.39
4.17
44.44
40.27
16.11
4.35
22.22
17.87
15.41
-4.17
14.65
23.53
16.47
2.84
20.00
-17.16
14.15
10.53
-7.69
13.37
12.41
8.70
-5.86
%AQPRULC
7.46
4.76
6.68
5.01
6.07
33.33
6.65
5.56
5.84
5.64
17.65
7.73
-5.26
6.15
-4.35
%PRSRSKA
54.74
100.00
59.02
95.00
-5.00
56.68
78.26
-21.74
63.46
94.44
-5.56
63.9
61.48
65.72
67.77
65.2
68.51
68.79
60.87
-39.13
TOTFALLS
7.35
3.00
5.71
2.71
7.71
3.45
10.11
6.66
2.93
24.37
21.44
7.32
2.86
8.84
5.98
7.56
3.22
8.64
5.42
3.17
4.28
1.1
3.03
2.40
-0.63
3.14
-3.82
7.68
7.31
5.97
-2.83
7.38
9.19
-6.05
%RSK&PROT
91.11
90.35
90.00
-10.00
90.12
66.67
-33.33
92.27
81.82
–
18.18
80.00
-20.00
90.91
92.01
88.18
78.86
81.58
91.09
%BSN
31.44
42.86
3
1.2
-11.61
32.98
21.43
-23.01
32.97
2
3.08
-21.36
34.03
44.64
36.36
–
8.28
33.42
46.41
50.00
3.59
32.31
45.45
57.14
11.69
32.11
43.75
53.33
9.58
45.20
46.67
32.07
47.00
1.80
33.36
33.19
62.50
17.30
% CERT
12.72
1.25
11.25
14.34
22.73
-22.73
15.3
24.00
15.38
-8.62
16.02
25.00
-6.82
14.92
14.29
-10.71
15.78
-2.10
15.05
-3.08
23.87
-3.87
1
4.88
14.86
Nurse-Sensitive Serviceline/Unit -Specific Indicators
FIM: Bowel
1.00
1.30
0.30
1.20
1.40
0.40
1.50
0.50
0.60
FIM: Bladder
-0.10
1.60
-0.30
-0.20
Nurse-Sensitive General Indicators
LOS*
3.79
-0.21
11.80
8.67
-3.13
3.02
9.00
2.80
8.99
2.81
9.80
1.52
Mislabeled Sp
Nurse-Sensitive Patient Satisfaction Survey Indicators
RN Courtesy
87.52
93.80
6.28
92.70
93.10
5.58
95.10
7.58
91.80
83.90
89.30
5.40
94.00
88.85
3.85
91.4
2.55
94.6
5.75
91.2
2.35
Promptness
86.10
-1.42
84.00
-3.52
90.6
85.70
-1.82
83.60
-3.92
84.50
79.50
87.00
-2.50
85.75
84.40
-1.35
84.1
–
1.65
88.2
2.45
81.6
-4.15
Attn Spc Needs
-0.52
89.2
1.68
91.70
4.18
89.60
2.08
88.00
0.48
85.30
80.60
-4.70
90.20
87.50
-2.70
87.75
84.70
-3.05
86.20
-1.55
90.7
2.95
-3.65
Response Pain
89.50
1.98
90.30
2.78
92.50
4.98
92.40
88.60
86.00
88.15
-8.15
-1.95
89.8
85.5
-2.65
Instruct Home
-3.12
87.20
-0.32
88.80
1.28
85.20
-2.32
87.80
81.50
-6.30
88.55
89.70
1.15
-0.75
86.4
-2.15
Care Well Coord
-2.82
-0.02
87.90
2.68
88.90
-0.90
89.80
90.10
89.35
88.30
-1.05
86.50
-2.85
-0.15
* Estimated
Unfavorarble
%PRSSULC = % Patients with pressure ulcers
Favorable
%AQPRULC = % Patients with acquired pressure ulcers
%PUPRSRSKA = % Patients who were assessed for pressure ulcers within 24 hours of point-prevalence assessment
TOTFALLS = Total falls/1,000 days
%RSK&PROT = % At risk and on fall protocol
^ With the exception of NHPPD, the target reflects the best quartile performers per NDNQI
^^ NHPPD mean is the NDNQI mean and the target is the Sinai budgeted NHPPD
FIM = Functional Independence Measure
LOS = Length of Stay
NHPPD = Nursing Hours Per Patient Day
Sheet2
Sheet3
2016, Vol. 38(1) 111 –128
Reprints and permissions:
DOI: 10.1177/019394591454285
the NDNQI® Injury Falls
Measure
Nancy Dunton1, and Byron Gajewski1,2
Although remarkable efforts have been made to improve patient fall reporting
through the utilization of standardized definitions, injury falls reporting has
rarely been examined. This study used an overall intra-class correlation
coefficient (ICC) estimate and factor analysis to assess the reliability and
validity of the National Database of Nursing Quality Indicators® (NDNQI®)
falls with injury measure. Data were collected from an online Fall Injury Level
Survey that was administered to 1,159 NDNQI site coordinators (39.7%
response rate; 91% registered nurses [RNs]). Estimated overall ICC was .85.
Exploratory factor analysis (EFA) with a Promax rotation (root mean square
error of approximation [RMSEA] = 0.053) identified three latent factors:
No Injury, Minor Injury, and Moderate/Major Injuries. Final confirmatory
factor analysis (CFA) assessment (comparative fit index [CFI] = 0.914,
Tucker Lewis Index [TLI] = 0.910, RMSEA = 0.048) confirmed an acceptable
model fit. Results provided strong evidence that the NDNQI falls with injury
measure is reliable and valid in supporting hospitals’ fall prevention efforts
and future injurious falls research.
3University of Wyoming Fay W. Whitney School of Nursing, Laramie, USA
4University of Basel, Switzerland
5Inselspital Bern University Hospital, Switzerland
Lili Garrard, University of Kansas School of Nursing, 3901 Rainbow Blvd., MS 3060, Kansas
City, KS 66160, USA.
Email: lgarrard@kumc.edu
research-article2014
injury falls, fall injury levels, reliability, NDNQI
continue to pose challenges to health care quality. Fall reduction is identified
as a patient safety priority in the United States (National Priorities
Partnership, 2011). Approximately 30% of falls result in injury, particularly
among older adults (Shorr et al., 2008). Injuries from falls burden hospitals
and patients with increased costs due to longer lengths of stay and additional
patient care costs (Currie, 2008). For older adults, the direct and indirect cost
of injuries associated with falls is projected to reach US$54.9 billion (in year
2007 dollars) annually by 2020 (Centers for Disease Control and Prevention,
2013; Englander, Hodson, & Terregrossa, 1996). In an effort to promote
patient safety, the National Quality Forum (NQF; 2011) named “patient
death or serious injury associated with a fall while being cared for in a
healthcare setting” (p. 9) as one of the health care Serious Reportable Events
(SREs). Similarly, the Centers for Medicare & Medicaid Services (CMS)
identified hospital falls and resulting trauma as one of the preventable
Hospital-Acquired Conditions (HAC). Additional costs associated with
HAC are no longer covered by Medicare for hospitals participating in the
Inpatient Prospective Payment System (IPPS; CMS, 2012; Inouye, Brown,
& Tinetti, 2009).
(NDNQI®) Fall and Falls With Injury Measures
surement and reporting. NQF’s goals are to increase public awareness in
quality performance, establish incentives for performance improvement, and
provide national benchmarks (NQF, 2002; Simon, Klaus, Gajewski, &
Dunton, 2013). Both patient fall and falls with injury have been endorsed by
the NQF as national consensus measures since 2004 (NQF, 2004). The
American Nurses Association (ANA), serving as the NQF steward for both
measures, commissioned the NDNQI to conduct separate studies to assess
the reliability of each fall measure in part to support their successful NQF
re-endorsement in 2013 (NQF, 2013a, 2013b). NDNQI was established in
1998 by ANA to monitor nurse-sensitive quality indicators that are essential
for patient safety and quality improvements in hospitals (Montalvo, 2007).
NDNQI is a quality database that collects and evaluates unit-specific nurse-
sensitive data from over 2,000 U.S. and international hospitals. Member hos-
pitals of NDNQI benefit from regular reporting of nursing quality measures
improvement.
colleagues (2013) to examine the agreement of fall classifications among
staff in U.S. hospitals (sensitivity = 0.90, specificity = 0.88, mean probabil-
ity for classifying a fall = 0.60). Based on the results of Simon’s study, the
NQF-endorsed NDNQI patient fall definition was revised to provide more
standardized reporting of falls. Although remarkable efforts have been
made to improve fall reporting, previous research has indicated a lack of
standardized definition and methods of measuring and reporting falls-
related injuries (Schwenk et al., 2012). As previously mentioned, injuries
associated with falls increase the cost of health care substantially. Without
standardized clinical guidelines for reporting injury falls, hospitals lack the
ability to properly compare themselves with reliable national comparison
data and to develop and implement cost-effective fall prevention plans.
Given the financial impact on both hospitals and patients, correct classifi-
cation of fall-related injuries is imperative, particularly being able to distin-
guish no injury and minor injuries from serious injuries. Correct
classification will allow hospital fall prevention efforts to better target edu-
cation, risk assessment, and prevention protocols. Thus, the need to evalu-
ate standardized reporting of injury levels, the key to a reliable and valid
injury falls measure, is apparent.
the NDNQI falls with injury measure by utilizing the NQF and NDNQI
injury level definitions (NDNQI, 2010). The specific aims were to assess
(a) the consistency of injury level assignment among raters of the fall
injury scenarios and (b) the accuracy of correct injury level assignment.
The information on the fall scenarios emulated those commonly found in
adverse event or incident reports. Before the study began, approval was
obtained from the University of Kansas Medical Center Human Subjects
Committee.
to regular falls reporting to NDNQI by member hospitals. When a patient fall
filed, including the hospital location of the fall; whether the fall was wit-
nessed, self-reported, or assisted; medication administered to the patient; and
any injuries observed at the time of the fall or during post-assessment. Based
on the information collected on the incident reports, the fall prevention team
would review the incident and determine whether it constituted a unit fall or
not, and assign the proper injury level according to NDNQI definitions,
which are described in a later section. A unit fall indicates that the event was
a fall that occurred on a unit declared eligible by NDNQI for falls reporting.
Once the incident had been thoroughly reviewed, it would be reported to
NDNQI along with any other fall incidents on the same unit for the calcula-
tion of a unit fall rate.
responsibility is being a point of contact for all NDNQI-related activities. The
NDNQI site coordinator serves a vital role in ensuring that all data collection
and reporting adhere to NDNQI guidelines. Thus, the targeted survey popula-
tion consisted of a convenience sample of site coordinators.
responded, resulting in a 39.7% response rate. Among all respondents, 411
provided responses for all fall scenarios, which were considered as “com-
plete” responses. Specific instructions for the site coordinators were provided
in an email invitation. Because fall prevention programs in hospitals are often
viewed as an inter-professional team effort, other hospital staff who serve as
final decision makers about injury levels were also asked to be consulted
while completing the survey. The most important aspect of the survey was
that respondents must assign each scenario to a fall injury level using the
NDNQI definitions. A typical respondent was a registered nurse (RN; 91%),
held a masters or higher degree (60%), and worked in nursing management
(40%) or quality improvement (31%).
identified incident reports from NDNQI hospitals and NDNQI guidelines on
injury levels. Each scenario went through rigorous revisions after being
reviewed by hospital and NDNQI staff members who were involved in
patient fall–related activities. This process was critical to ensure the content
as candidates for the final survey.
the correct classification of injury levels in the 20 fall scenarios. Both experts
were masters prepared RNs with over 30 years of clinical experience and
who provided daily guidance for NDNQI hospitals on classifying actual falls.
The experts scored the fall scenarios independently and reached 100% agree-
ment on classification after discussions. Five scenarios were excluded from
this study as they were identified by the experts as not a fall or not a unit fall
according to the NDNQI fall definition. Thus, the NDNQI experts’ judgment
was considered the correct injury level classification and deemed to be the
“gold” standard. The final Injury Fall Level Survey consisted of 15 fall sce-
narios, and the distributions of the scenarios were as follows: 6 non-injurious
falls, 3 minor injury falls, 3 moderate injury falls, 3 major injury falls, and 0
death resulting from a fall (Table 1). Having the experts’ gold standard was a
crucial first step for subsequent statistical analysis. Table 1 shows an abbrevi-
ated description and the expert classification for each of the scenarios.
injury level of each scenario according to the NDNQI definitions. Also, ques-
tions were included in the survey about the respondents’ characteristics such
as professional background, highest education level, and current work depart-
ment within the hospital. The Fall Injury Level Survey was conducted online
using the survey tool Zoomerang (http://www.zoom-erang.com).
survey to assist respondents with injury level classifications for the fall sce-
narios (NDNQI, 2010). A fall was defined as
other equipment) with or without injury to the patient, and occurs on an eligible
reporting nursing unit. All types of falls are to be included whether they result
from physiological reasons (fainting) or environmental reasons (slippery floor).
Include assisted falls—when a staff member attempts to minimize the impact
of the fall. Exclude falls by visitors, students, and staff members; falls on other
units not eligible for reporting; falls of patients from eligible reporting units,
however patient was not on unit at time of the fall (e.g., patient falls in radiology
department). (p. 13)
guidelines:
Expert
Mean Scale Score
to lacerations on elbow.
back pain. MD ordered Dilaudid and heat packs
applied. X-rays negative for fracture or displacement.
sound heard from room. No signs/symptoms of injury
at that time and at 24 hr post event.
when walking to BR. No signs of injury and had full
ROM. Tylenol administered.
No pain or other injury at the time of the fall or 24
hr post fall.
reaching for a book on bedside table. Her NG tube
was pulled out, but no other pain or signs of injury 24
hr post fall. MD said to leave NG tube out.
injury noted at the time. The next day (15 hr later)
pt. complained of R knee pain. X-ray negative, ice, and
ACE bandage applied.
head, R elbow, and knees. Pt. states he is dizzy, neuro
checks found reduced R hand grasp. Small subdural
hematoma found on CT scan and pt. transferred to
ICU.
fell. Pt. denies pain or other symptoms. Chest X-rays
prior to fall indicated a recent rib fracture. Pain meds
given 4 hr prior to deep breathing exercises.
laceration on forehead and bandaid applied. Also
complained of low back pain, CT of head and lumbar
back negative for fracture or hematomas. Pt. given
acetaminophen.
heard from room. Large amount of blood on BR floor,
sink, and R side of head. Does not respond to painful
stimuli, pupils dilated, no B/P, weak and thready pulse.
Code blue activated and CPR performed for 15 min
without success.
dizzy. While trying to lower pt. to the toilet, he
became limp and was lowered to the floor. He
arm struck the handrail and started swelling. X-ray
revealed closed fracture of ulna and a cast was
applied.
if an x-ray, CT scan or other post fall evaluation results in a finding of no injury
elevation, topical medication, pain, bruise or abrasion
or muscle/joint strain
neurological (basilar skull fracture, small subdural hematoma) or internal
injury (rib fracture, small liver laceration) or patients with coagulopathy who
receive blood products as a result of a fall
physiologic events causing the fall). (pp. 14-15)
Expert
Classification
Mean Scale Score
(95% CI)
from EGD. Pt. states he fell to floor after trying to get
back in bed. He complained of pain in R ankle. X-ray
revealed distal fracture and a cast was applied. After
3 days, pt. complained of numbness and tingling in
foot and toes appear blue/purple with swelling. Cast
removed 17 hr later by MD and no pedal pulses. Pt.
taken to OR for immediate amputation.
commode to bed. Six staff helped lift pt. with bath
blankets to bed and blankets ripped and pt. fell against
side rails. Pt. treated for 5 inch abrasion to lumbar
area. X-ray of lumbar revealed small compression
fracture and treated with back brace.
Nurse assisted patient to the floor. Pt. sustained 4
inch skin tear on R forearm during the decent. Steri-
strips and Kerlix bandage applied.
= patient; MD = medical doctor; BR = bathroom; ROM = range of motion; IV = intravenous therapy; NG
= nasogastric; R= right; ACE = all cotton elastic (a bandage brand name); CT = computerized tomography;
ICU = intensive care unit; B/P = blood pressure; CPR = cardiopulmonary resuscitation;
EGD = esophagogastroduodenoscopy; OR = operating room; CFA = confirmatory factor analysis.
a. Final scenario selected by CFA.
b. Complex scenario.
according to NDNQI definitions for each of the 15 fall scenarios described in
the survey. The response options were coded as 1 “none,” 2 “minor,” 3 “mod-
erate,” 4 “major,” and 5 “death.” The correct injury level for each scenario
was the gold standard set by the experts’ classification as described above.
Based on the gold standard, all participant responses were further classified
as 1 “correct” and 0 “incorrect,” for all 15 fall scenarios. The data file con-
taining the recoded dichotomous data for the 15 fall scenarios served as the
main analysis file for all statistical analyses used in this study.
produce similar results when repeated measurements are made under iden-
tical conditions” (Bordens & Abbott, 2011, p. 130). One common practice
to assess the reliability of a target, under the influence of judgments made
by a group of respondents is to calculate the intra-class correlation coeffi-
cient (ICC). ICC is calculated as the proportion of the total variance that is
due to the true variance from raters (Skrondal & Rabe-Hesketh, 2004). For
this study, the fall scenarios were treated as targets and the survey partici-
pants as raters. An overall ICC could be used to describe the between-
scenario variation of injury level assignment. A high ICC would indicate
that the majority of the variance was due to differences among the scenar-
ios, which implied that the difference within each scenario, influenced by
raters, was small. Thus, the raters had a high consistency of injury fall clas-
sification for each scenario. In this study, the overall ICC estimate was
interpreted as excellent (around .90), very good (around .80), and adequate
(around .70), following general guidelines provided by Kline (2011). The
overall reliability estimate computation was performed using SPSS soft-
ware version 20.
The validity of a measure is defined as “the extent to which it measures what
you intend it to measure” (Bordens & Abbott, 2011, p. 133). For the 15 fall
scenarios, it was important to assess the construct validity of the scenarios. In
other words, the goal was to determine if the fall scenarios could appropri-
ately predict the severity of injury falls by assessing the accuracy of correct
injury level assignment. A decision needed to be made after examining the
proportion of respondents selecting the exactly correct injury level and select-
ing the correct injury level within one response option, both with a 95% con-
fidence interval. Two scenarios (S11 and S14) were very complex, which
might have caused a large proportion of the respondents to choose the wrong
made to eliminate these two scenarios from the construct validity analysis.
which was approached with a two-stage factor analysis using only complete
responses. An exploratory factor analysis (EFA) was the logical first step to
explore the possible latent factor structure of the injury levels among the fall
scenarios. Once the latent factor structure was identified from EFA, it was
necessary to verify the factor structure by using a confirmatory factor analy-
sis (CFA) with structural equation modeling. Factor analysis is a correlation-
oriented approach that aims to reproduce the inter-correlation among the
variables. Several types of correlations exist; however, due to the nature of
dichotomous data in this study, tetrachoric correlation was the most appropri-
ate correlational method to serve as the basis of the factor analysis. Unlike
Pearson’s correlation for continuous data, using tetrachoric correlation
allowed us to estimate correlations among dichotomously measured variables
as if the variables were made on a continuous scale.
software version 5.21 (Muthén & Muthén, 1998-2009). Mplus is an
Correct Within One Injury Level.
S2 [69.97, 78.04] [98.59, 100.08]
S3 [82.47, 88.95] [98.94, 100.17]
S4 [36.52, 45.63] [98.94, 100.17]
S5 [93.62, 97.45] [99.34, 100.21]
S6 [88.66, 93.89] [98.23, 99.98]
S7 [84.09, 90.30] [100.00, 100.00]
S8 [90.11, 95.00] [97.89, 99.86]
S9 [69.56, 77.81] [78.56, 85.74]
S10 [84.27, 90.50] [98.91, 100.18]
S11b [0.00, 0.68] [3.39, 7.70]
S12 [73.30, 81.18] [96.90, 99.42]
S13 [94.53, 98.08] [100.00, 100.00]
S14b [0.43, 2.82] [1.75, 5.21]
S15 [61.83, 70.73] [98.90, 100.18]
b. Complex scenario.
ous latent variable models. Following recommendations by MacCallum,
Roznowski, and Necowitz (1992), the main analysis file with 411 complete
responses were randomly split into comparable training (196 responses,
47.7%) and validation (215 responses, 52.3%) data sets to avoid capitaliza-
tion on chance concerns. An EFA with categorical factor indicators was
conducted using the training data set in Mplus, which conveniently incor-
porated tetrachoric correlation into the analysis. Traditional factor extrac-
tion, such as Kaiser’s criterion, has been widely accepted for suggesting
factors with an eigenvalue greater than 1 as common factors. Eigenvalues
are often interpreted as the variances extracted by the common factors.
However, eigenvalues based Kaiser’s criterion should not be used solely to
determine the number of factors due to over-extraction concerns. Another
requirement for including items in a specific factor was that the individual
items must meet a criterion of at least 0.30 in absolute value for factor load-
ing to be retained. Additional model fit can be evaluated by using the root
mean square error of approximation (RMSEA), and a RMSEA value around
0.05 or less usually indicates an acceptable model fit. As latent factors were
identified, a CFA with categorical factor indicators using structural equa-
tion modeling was performed on the validation data set to confirm the fac-
tor structure demonstrated in the EFA step. Several statistical indices such
as the comparative fit index (CFI; around 0.9 or higher), Tucker Lewis
Index (TLI; around 0.9 or higher), and RMSEA (around 0.05 or less) were
used to assess the final model fit.
cept of the proportion of variance explained by a factor is complex and less
intuitive. Factor solutions provided by a Varimax rotation (uncorrelated fac-
tors) are often very similar to the Promax solutions. Thus, the Varimax factor
solutions can be used as a proxy to compute the variability explained by a
given factor under the Promax setting. The proportion of variance explained
by a factor can be calculated as the sum of squared factor loadings on the
assigned factor divided by the number of fall scenarios assigned to that par-
ticular factor. In addition, Mplus also provides estimates for the proportion
of variance in each fall scenario, explained by their assigned factor.
fall scenarios was 1.479, resulting in an overall ICC (1, 1) of .85, which was
between “very good” and “excellent” according to the general guidelines
the fall scenarios and a high consistency of injury level assignment among
the respondents for each scenario. The mean scale scores with 95% confi-
dence intervals for all 15 fall scenarios are summarized in Table 1. The vari-
ance between the scenarios was much larger than the variance within each
scenario, which echoed the results of the overall ICC estimate and indicated
a high reliability.
were excluded from further analysis. After exclusion, the overall ICC (1, 1)
for the remaining 13 scenarios was re-calculated to be .82, which still main-
tained a very good reliability and was suitable for the validity analysis.
eigenvalues greater than 1 were suggested based on Kaiser’s criterion (eigen-
values: 3.556, 2.807, 1.582, 1.195, 1.171, 1.079, 0.692, 0.654, 0.353, 0.284,
0.094, −0.163, −0.305), but only three factors could be extracted success-
fully, indicating an over-extraction based on Kaiser’s criterion. Factor load-
ings of the three-factor model were further clarified after applying a Promax
rotation for correlated factors, resulting in a RMSEA of 0.053, which indi-
cated an acceptable model fit. All scenarios loaded over 0.30 on the assigned
factors. The aim of the EFA was to identify underlying factor structure that
could be used to predict the severity of injury falls. The results indicated three
latent factors: ability associated with classifying non-injurious falls (No
Injury), ability associated with classifying minor injury falls (Minor Injury),
and ability associated with classifying moderate or major injury falls
(Moderate/Major Injuries; Table 3).
factors measured by the 13 scenarios, with each scenario assigned to the rel-
evant factor. The goal was to identify and retain scenarios that contributed
most to respondents’ ability associated with injury fall classifications.
Estimates of the pattern coefficients representing the direct effects of the fac-
tors on the scenarios ranged from −0.021 to 0.950 (Figure 1a). Several statis-
tical indices were used to determine the adequacy of model fit to the data.
Results from the initial CFA assessment did not indicate a good model fit
(CFI = 0.868, TLI = 0.863, RMSEA = 0.055). Pattern coefficient estimates
for all scenarios were statistically significant (p value < .05) with the excep-
tion of Scenario 4 (−0.021, p value = .851) and Scenario 13 (0.395, p value =
.051). The pattern coefficient estimate for Scenario 13 can be considered as
marginally significant and we decided to keep this scenario in the model. The
ture remained the same (Figure 1b). The final CFA assessment confirmed an
acceptable model fit and supported the hypothesis that a relationship exists
between the 12 final fall scenarios (Table 1) and the three underlying latent
factors (CFI = 0.914, TLI = 0.910, RMSEA = 0.048).
calculate the variability explained by the three correlated latent factors.
Results from the Varimax rotation are not reported here due to the high degree
of similarity with the Promax rotation solutions. The proportion of variance
explained by the No Injury, Minor Injury, and Moderate/Major Injuries fac-
tors were 52.3%, 31.9%, and 46.7%, respectively. In addition, the ability
associated with classifying non-injurious falls accounted for 53.6%, 34.8%,
31.8%, 15.6%, and 49.3% of the proportion of variance in Scenarios 1, 8, 12,
13, and 15, respectively. The variability in Scenarios 2, 7, and 10, explained
by the ability associated with classifying minor injury falls, were 33.7%,
36.0%, and 56.1%, respectively. Finally, the ability associated with classify-
ing moderate or major injury falls accounted for 57.8%, 90.5%, 66.9%, and
11.7% of the variability in Scenarios 3, 5, 6, and 9, respectively.
narios from the survey resulted in appropriate latent structures for predicting
Injury Levels.
S8 −0.173 −0.014 0.535 Major
S12 0.104 −0.005 0.643 Major
S13 0.005 −0.144 0.883 Major
S15 0.094 0.028 0.715 Moderate
S2 −0.019 0.778 0.033
S10 0.197 0.312 −0.274 Minor
S3 0.448 0.444 0.233
S5 0.873 0.64 −0.023 None
S6 0.684 0.393 −0.064 None
S9 0.311 0.03 0.082 None
Note. Highest factor loading for each fall scenario is in bold.
injury level classifications made by survey respondents for all 12 final fall
scenarios.
excellent, indicating high consistency of injury level classifications among
Major
1
Moderate/
Major
.098 .143 .113 .202 .095
1
S9
Minor
Note. CFA = confirmatory factor analysis.
reliability of the NDNQI falls with injury measure. Construct validity was
also confirmed, resulting in 12 final fall scenarios with 4 non-injurious falls,
3 minor injury falls, 2 moderate injury falls, and 3 major injury falls. The 12
final fall scenarios represented a reliable and valid approach to evaluate
respondent fall injury level classification ability.
scenarios clustered very well into the three distinct categories. However, the
correlations among the three latent factors exhibited a very interesting pat-
tern, which could be presented as poor (Minor vs. Moderate/Major = .024, p
value = .810), average (None vs. Moderate/Major = .538, p value < .05), and
good (None vs. Minor = .734, p value < .05). The pattern in the factor correla-
tion estimates merited further investigation. The poor correlation (.024)
between Minor Injury and Moderate/Major Injuries could be interpreted,
such that the respondents’ ability to correctly classify minor injuries did not
imply that they would also have the same ability to correctly classify moder-
ate or major injuries, and vice versa. This finding is rather concerning and can
indicate several potential issues, such as confusion over the definitions,
ambiguity of the incident reports, or bias introduced from both the patient and
fall evaluator’s perspectives. On the contrary, it is certainly encouraging to
see that the respondents had average ability to correctly distinguish no injury
from moderate or major injuries, and vice versa. Moreover, the respondents
had a good ability to correctly classify no injury from minor injuries, and vice
versa. The overall results can be viewed as an indication that more education
or training is needed for correctly identifying all injury levels, particularly the
moderate or major injury falls, as these types of fall scenarios are rare. The
clarity of the injury level definitions also needs to be further reviewed to
minimize potential classification challenges. In addition, although the con-
struct validity assessed respondents’ ability to distinguish among No Injury,
Minor Injury, and Moderate/Major Injuries, the ability to distinguish injury
levels within the global category of Moderate/Major Injuries remains
unknown and requires further investigation.
selecting the exactly correct injury level with the exception of three scenarios
(S4, S11, and S14). Specifically S11 and S14 had close to 0% of the respon-
dents being exactly correct (Table 2). When the requirement was relaxed to
allow within one injury level, S11 and S14 still remained very low with less
than 10% of the respondents being correct (Table 2). The sequence of events
in Scenario 11 made it unclear whether the fall caused the patient death or the
death caused the fall. In Scenario 14, the patient fell and then was dropped by
the staff as they attempted to assist the patient back to bed, leading
considered to be very complex, which resulted in a wide variance of injury
level assignment among the respondents. Thus, both fall scenarios were
excluded from the construct validity analysis for psychometric difficulties.
The complex fall scenarios (e.g., S11 and S14) need to be examined carefully
and debriefed by the fall prevention team, and when necessary, expert consul-
tations should be considered to help prevent bias by the fall evaluator. In
addition, concerns can arise with patient self-reported falls (e.g., S4) because
this type of fall is often not observed and hard to validate without evidence;
thus, potential bias could be introduced from both the patient and fall evalu-
ator’s perspectives.
help design the online survey. Previous research by Shorr and colleagues
(2008) pointed out that using incident reports alone contributes to the under-
reporting of both injurious and non-injurious falls in hospitals. Potential bias
could be introduced by using a convenience sample of de-identified incident
reports, which are not representative for all fall scenarios that patients experi-
ence daily in hospitals. Although all fall scenarios went through rigorous
revisions to ensure their clinical reality, it remains unclear how frequent these
scenarios occur. Perhaps more scenarios need to be developed to cover the
full spectrum of NDNQI injury classifications.
primary audience for the survey was a convenience sample of NDNQI site
coordinators. Comparing with the general population of U.S. hospitals,
NDNQI consists of more Magnet® designated, not-for-profit, larger, and
higher case-mix index (CMI) hospitals (Lake, Shang, Klaus, & Dunton,
2010). The general profile of NDNQI hospitals may include more hospital
resources, which play an important role in establishing training for staff and
fall prevention programs. Being the primary respondent of the survey (68%),
NDNQI site coordinators are constantly informed on new updates to NDNQI
guidelines and definitions. They are most familiar with NDNQI frameworks
and thus may represent a more “trained” group of hospital staff in regard to
standardized data collection and reporting. The ability of correct injury level
classification across other hospital staff involved in fall-related activities still
remains unclear and needs to be further evaluated.
measure was evaluated and findings supported the successful re-endorsement
by NQF. The NDNQI site coordinators demonstrated high consistency in
classifying injury levels for specific fall scenarios, according to NDNQI defi-
nitions. The Falls Injury Level Survey with the final 12 fall scenarios was
shown to be valid in assessing respondents’ abilities to predict the severity of
moderate or major injury falls. Hospital site coordinators are encouraged to
continue contacting NDNQI for assistance with the classification of complex
fall scenarios and patient self-reported fall scenarios. Findings of this study
also supported rationales for revising the standardized NDNQI falls and
injury level definitions to include additional types of falls and provide more
clarification on injuries.
utilized in the future as a training tool for hospital staff that serve as final
decision makers on injury levels. Researchers at NDNQI launched a well-
known and comprehensive Pressure Ulcer Identification and Staging Training
Program in 2009, which can be used to guide the development of a falls with
injury training tool (Bergquist-Beringer et al., 2009; Bergquist-Beringer,
Gajewski, Dunton, & Klaus, 2011; Gajewski, Hart, Bergquist-Beringer, &
Dunton, 2007; Hart, Bergquist, Gajewski, & Dunton, 2006). In addition,
because the NDNQI injury falls measure is NQF-endorsed, standardized
injury level definitions are available to the public domain. A recent article
published by Mion and colleagues (2012) utilized NDNQI injury level defi-
nitions as part of their retrospective study for determining potential predic-
tors and outcomes of injurious falls among a cohort of hospital patients. The
NDNQI injury falls measure provides a reliable and valid tool for non-
NDNQI hospitals and external researchers to support future quality improve-
ment efforts and injurious falls research.
article. Jan Davidson provided clinical consultation with summarizing the fall
scenarios.
authorship, and/or publication of this article.
authorship, and/or publication of this article: This study was conducted under a con-
tract with American Nurses Associations.
& Christopher, A. (2009). Evaluation of the National Database of Nursing Quality
Education in Nursing, 40, 252-258; quiz 259-260, 279.
of the National Database of Nursing Quality Indicators pressure ulcer indica-
tor: A triangulation approach. Journal of Nursing Care Quality, 26, 292-301.
doi:10.1097/NCQ.0b013e3182169452
approach (8th ed.). New York, NY: McGraw-Hill Higher Education.
Retrieved from http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.
html
(HAC) in acute inpatient prospective payment system (IPPS) hospitals. Retrieved
from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HospitalAcq-Cond/Downloads/HACFactsheet
and quality: An evidence-based handbook for nurses. Rockville, MD: Agency
for Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/
professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/
nurseshdbk
slip and fall injuries. Journal of Forensic Sciences, 41, 733-746.
reliability of pressure ulcer staging: Ordinal probit Bayesian hierarchical model
that allows for uncertain rater response. Statistics in Medicine, 26, 4602-4618.
doi:10.1002/Sim.2877
National Database of Nursing Quality Indicators pressure ulcer indicator. Journal
of Nursing Care Quality, 21, 256-265.
tal falls, and unintended consequences. New England Journal of Medicine, 360,
2390-2393. doi:10.1056/NEJMp0900963
New York, NY: Guilford Press.
with hospital Magnet status and nursing unit staffing. Research in Nursing &
Health, 33, 413-425. doi:10.1002/nur.20399
tions in covariance structure analysis: The problem of capitalization on chance.
Psychological Bulletin, 111, 490-504.
S. T., & Shorr, R. I. (2012). Is it possible to identify risks for injurious falls in
hospitalized patients? Joint Commission Journal on Quality and Patient Safety,
38, 408-413.
(NDNQI®). The Online Journal of Issues in Nursing, 12(3). Retrieved from
A N A P e r i o d i c a l s / O J I N / T a b l e o f C o n t e n t s / V o l u m e 1 2 2 0 0 7 / N o 3 S e p t 0 7 /
NursingQualityIndicators.aspx?%3E
Angeles, CA: Author.
tion on the American Nurses Association’s National Quality Forum endorsed
measures. Kansas City: University of Kansas Medical Center.
Services on priorities for the national quality strategy. Washington, DC: National
Quality Forum. Retrieved from http://www.qualityforum.org/WorkArea/linkit.
aspx?ItemID=68238
ity measurement and reporting: A consensus report. Retrieved from http://
www.qualityforum.org/Publications/2002/07/A_National_Framework_for_
Healthcare_Quality_Measurement_and_Reporting.aspx
ing-sensitive care: An initial performance measure set. Retrieved from http://
www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_
Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_
Set.aspx
update: A consensus report. Retrieved from http://www.qualityforum.org/
Publications/2011/12/Serious_Reportable_Events_in_Healthcare_2011.aspx
forum.org/QPS/0202
forum.org/QPS/0141
Hauer, K. (2012). Definitions and methods of measuring and reporting on injuri-
ous falls in randomised controlled fall prevention trials: A systematic review.
BMC Medical Research Methodology, 12, Article 50. doi:10.1186/1471-2288-
12-50
L. A. (2008). Improving the capture of fall events in hospitals: Combining a ser-
vice for evaluating inpatient falls with an incident report system. Journal of the
American Geriatrics Society, 56, 701-704.
sifications among staff in US hospitals. Nursing Research, 62, 74-81.
Multilevel, longitudinal, and structural equation models. Boca Raton, FL: CRC
Press.
Issues M a r y J. R ock R o b e r ta H o e b e k e
W hose D u ty to Inform ?
however, they may be unaware of w hat is involved in
obtaining truly informed consent. Nurses are n o t con
sistent in their roles in obtaining consent. They assume
differing am ounts of responsibility in obtaining consent
from their patients, thus exposing themselves to liabili
ty claims and placing their nursing licenses at risk
(Guido, 2010). The history of consent, different types of
consent, the duties of the physician and the nurse with
regard to informed consent, and ways in which nurses
can decrease the risk of liability related to their role in
obtaining informed consent will be discussed.
An essential and fundamental patient right is the right
autonom y protects this fundamental right. This principle
provides the foundation for the belief that patients are
given the authority to evaluate medical treatm ent choic
es. Based on the patient’s beliefs and values, treatment
alternatives can be rejected or embraced (Fry, Veatch, &
Taylor, 2011).
through common law decisions. These early court deci
sions gave some guidance to health care providers about
how to comply with the requirements of consent. A sig
nificant comm on law case that established the right of
consent and self-determination was the landmark case
Schloendorff v. Society o f New York Hospitals (
Cardoza, a highly respected and well-known judge who
presided in this case, often is quoted:
has a right to determine what will be done with his
own body; and a surgeon who performs an operation
without his patient’s consent commits an assault, for
which he is liable in damages. This is true, except in
cases of emergency where the patient is unconscious,
and where it is necessary to operate before consent
can be obtained, (p. 93)
the concept of self-determination as included in Anglo-
American law. Each patient is considered to be the master
of his or her own body. A patient of sound m ind may pro-
University of Southern Indiana, Evansville, IN.
Southern Indiana, Evansville, IN.
Even if the physician believes the medical treatm ent is
desirable or lifesaving, American law does not permit him
or her to substitute personal judgment for that of the
patient.
and expanded by requiring health care providers to fulfill
their duty by providing clear, necessary information vital
to the understanding of the procedure to their patients
before obtaining consent. A seminal informed consent
case, Salgo v. Leland Stanford Jr. University Board o f Trustees
(1957), held that a physician had a duty to relate “any
facts necessary to form the basis of an intelligent consent
by the patient to proposed treatment” (p. 181).
to the public’s attention during the Nuremberg war
crimes trials. The experiments and torture performed by
Nazi physicians led to development of the Nuremberg
Code, which absolutely required patient consent prior to
medical research (National Com m ission for the
Protection of Hum an Subjects of Biomedical and
Behavioral Research, 1979; Nuremberg Military Tribunals,
1949). Since then, the requirement of consent prior to
research has been extended to clinical procedures.
rights statutes. These laws prohibit treating a patient
without first providing necessary information to obtain
informed consent. They also are based on common law
principles and the premise that patients have the right to
make decisions about their own medical care and treat
m ent (Backlund v. University o f Washington, 1999).
sized the importance of the com m itm ent to patient self-
determination.
of specific patient rights, particularly, the right of self-
determination. Self-determination, also known as
autonomy, is the philosophical basis for informed
consent in health care. Patients have the moral and
legal right to determine what will be done with their
own person; to be given accurate, complete, and
understandable information in a m anner that facili
tates an informed judgment; to be assisted with
weighing the benefits, burdens, and available options
in their treatment, including the choice of no treat
ment; to accept, refuse, or terminate treatm ent with
out deceit, undue influence, duress, coercion, or
penalty; and to be given necessary support through
out the decision-making and treatm ent process. Such
support would include the opportunity to make deci
sions with family and significant others and the pro
vision of advice and support from knowledgeable
should be involved in planning their own health care
to the extent they are able and choose to participate,
(p. 148)
patients’ legal and moral rights to self-determination. In
the role of advocates, nurses are positioned uniquely to
assess the patient’s understanding of the information pre
sented by physicians regarding procedures and the impli
cations of decisions.
Consent generally is expressed or implied. Express con
vided by printed words in a written consent form (usual
ly called informed consent). General consent forms are
signed upon admission to a health care facility. Implied
consent can be provided by patient conduct rather than
verbally or in writing. W hen a nurse asks a patient to
extend an arm for blood pressure measurement, the nurse
infers the patient has given consent. Implied consent fre
quently is given for routine care and minor procedures. In
addition, implied consent is inferred in emergency situa
tions. If a patient is not able to communicate consent
prior to an emergency treatm ent and the delay will result
in loss of life or threatened well-being, the health care
provider may proceed with care (Guido, 2010).
by the patient in a formal, written consent form.
Informed consent is a person’s agreement to allow some
thing to happen, such as surgery or other invasive proce
dure, based on a full disclosure of risks, benefits, alterna
tives, and consequences of refusal. Unless a patient knows
the risks and dangers of a medical procedure before con
sent, the decision to have the procedure performed does
not represent truly informed consent and is ineffectual
(State v. Presidential Women’s Center, 2006).
based on the fiduciary quality of the physician-patient
relationship. A fiduciary relationship is a unique relation
ship in which the law imposes specific liabilities and
duties. A fiduciary duty includes a duty to act for some
one else’s benefit, while subordinating personal interests
to the interests of the other person. It is the highest stan
dard of duty implied by law (Garner, 2009). In the case of
health care relationships, the patient is untrained in med
ical science and consequently depends completely on the
education, training, skill, and experience of the physician
to provide information the patient can use to make an
informed decision (Johnson v. Sears, Roebuck & Co., 1992).
Patients trust in their physicians’ knowledge, skill, and
clinical experience when making choices about treatment
options.
may recover damages in an action against the physician
under different theories of recovery. The performance of
surgery or treatm ent by a physician without first obtain
ing informed consent may constitute the intentional tort
of assault and battery. This claim is completely separate
the surgery or medical treatm ent (Blanchard v. Kellum,
1998). Likewise, battery may be established if a physician
obtains consent to perform one type of treatm ent and
then performs a substantially different treatment (Cline v.
Lund, 1973).
is negligent failure to disclose. The doctrine of informed
consent focuses on the reasonableness of the physician’s
disclosures to the patient (Johnson by Adler v. Kokemoor,
1996). It is based on the information communicated by
the physician to the patient before the surgery or treat
ment. A final theory for recovery used in some jurisdic
tions to recover for inadequate consent would be a claim
for professional m isconduct or malpractice (Hill v.
Women’s Medical Center o f Nebraska, 1998).
The physician has an ethical duty to ensure the patient
physician who gives the treatm ent or performs surgery
has the duty to inform the patient about the procedure
and obtain the consent (Bryant v. HCA Health Services o f
Tenn., 2000). The process of securing informed consent
involves patient education by the physician. The physi
cian explains the procedure, possible risks, and alterna
tive therapies in words the patient can understand. The
physician then should evaluate the patient’s understand
ing, if the patient accepts the risk of the treatment, and if
the patient has given consent to proceed with the proce
dure or treatm ent with full knowledge. The patient then
is required to sign the consent form. A physician may
appoint another member of the health care team to
obtain the patient’s signature on the consent form with
the reassurance the physician has explained the proce
dure fully. A physician may be liable for lack of informed
consent if he or she abandons the patient by improperly
delegating to others the professional task and responsibil
ity of securing informed consent ( Veith v. O’Brien, 2007).
the physician to explain the nature and probable conse
quences of a recommended surgery, the material risks
associated with the surgery, and the alternatives to the rec
ommended procedure. Common law and statutes require
slightly different disclosures depending upon the law in
each state. For instance, the state of Indiana requires infor
mation regarding informed consent to include the follow
ing (Indiana Code 34-18-12-3; Lasley v. Moss, 2007):
1. The general nature of the patient’s condition.
2. The proposed treatment, procedure, examination, or
3. The expected outcome of the treatment, procedure,
4. The material risks of the treatment, procedure, exam
5. The reasonable alternatives to the treatment, proce
In some jurisdictions, a physician’s duty to disclose
from the physician’s point of view. Still other jurisdictions
require both the physician’s and the patient’s perspective.
If the patient’s viewpoint is used to determine what infor
m ation should be disclosed prior to informed consent, the
standard is based on the data or information required by
a reasonable patient to make an intelligent decision con
cerning performance of a particular procedure (Brown v.
Dibbell, 1999). As measured by the physician standard, the
duty to disclose information before informed consent is
obtained reflects a professional medical standard. Courts
would identify what a reasonable, pm dent physician
would disclose under the same or similar circumstances, or
what the customary disclosure practices of physicians are
in a similar community (Weber v. McCoy, 1997).
Although a physician may appoint a nurse to obtain
may not delegate the professional task of educating the
patient about the risks and benefits of the proposed sur
gery, available alternatives to surgery, and the expected
outcome. A physician or other independent practitioner
performing the surgery alone has the legal duty to obtain
informed consent (Davis v. Hoffman, 1997). After review
ing court cases across the United States, the Supreme
Court of Nebraska concluded a hospital and nursing staff
do not have the legal responsibility to inform the patient
about the risks of surgery. Liability for not getting appro
priate informed consent lies with the physician (Giese v.
Stice, 1997).
of a surgery or procedure is clearly in the realm of the
physician’s education and expertise. Even though sea
soned perioperative nurses may know the requisite risks
and benefits of a particular surgery, relaying the details of
surgery could result in conflicting information and, at the
very least, interfere with the physician-patient relation
ship (Giese v. Stice, 1997). Nurses can create accountabili
ty for informed consent through their actions (Guido,
2010; Rogers v. T.f. Samson Community Hospital, 2002). A
nurse who decides to explain the minutiae of a particular
surgery, complications, and available alternatives to the
surgery, exposes himself or herself and the hospital to
potential liability. A nurse can be held liable for profes
sional negligence if a patient is harmed because a nurse’s
explanation to a patient falls short of properly informing
the patient of the risks and benefits of the contemplated
procedure or the nurse’s conduct invades the physician-
patient relationship (Davis v. Hoffman, 1997).
consent to a nurse, he or she does so at the risk of liabili
ty. The nurse needs to understand his or her role in
obtaining informed consent is limited to the patient
advocate role and a witness to the patient’s signature.
After the details of the surgery are explained adequately
to the patient and the patient signs the informed consent
form, the nurse simply witnesses that (a) the patient is
giving consent voluntarily, (b) the patients appear lucid
nature is authentic (Guido, 2010).
not lucid or is not informed appropriately about the pro
cedure, the nurse should never proceed with witnessing
the patient’s signature. The patient’s concerns should be
documented in the medical record, and the physician
(and perhaps the immediate supervisor) notified that
informed consent may be deficient. The nurse has a legal
duty to investigate the situation and notify the primary
provider of concerns about informed consent prior to sur
gery (Guido, 2010).
In the past, the process of obtaining informed consent
physician handed the nurse the form and told the nurse
to get it signed prior to the procedure. Patients sponta
neously signed forms, all too often without asking vital
questions. Fortunately, this procedure has changed.
Patients often ask critical questions about proposed treat
m ent or procedure options. Furthermore, nurses must be
knowledgeable about the legal and moral rights of their
patients to self-determination. Nurses are patient advo
cates who should protect and preserve their patient’s
interests by assessing the patient’s understanding of pre
sented information and the implications of treatment
decisions (ANA, 2010). ESEH
American Nurses Association (ANA). (2010). Guide to the code of
Backlund v. University of Washington, 975 P.2d 950 (Wash. 1999).
Blanchard v. Kellum, 975 S.W.2d 522 (Tenn. 1998).
Brown v. Dibbell, 595 N.W.2d 358 (Wis. 1999).
Bryant v. HCA Health Services of Tenn., 15 S.W.3d 804 (Tenn. 2000).
Cline v. Lund, 31 Cal.App.3d 755, 107 Cal.Rptr. 629 (1st Dist. 1973).
Davis v. Hoffman, 972 F.Supp. 308 (E.D. Pa. 1997).
Fry, S., Veatch, R., & Taylor, C. (2011). Case studies in nursing ethics
Garner, B.A. (Ed.). (2009). Black’s law dictionary (9th ed.). St. Paul,
Giese v. Stice, 567 N.W.2d 156 (Neb. 1997).
Guido, G. (2010). Legal & ethical issues in nursing (5th ed.). Upper
Hill v. Women’s Medical Center of Nebraska, 580 N.W.2d 102
Indiana Code § 34-18-12-3 (West).
Johnson v. Sears, Roebuck & Co., 832 P.2d 797 (N.M. App. 1992).
Johnson by Adler v. Kokemoor, 545 N.W.2d 495 (Wis. 1996).
Lasley v. Moss, 500 F.3d. 586 (7th Cir. 2007).
Natanson v. Kline, 350 P.2d 1093 (Kan. 1960).
National Commission for the Protection of Human Subjects of
Ethical principles and guidelines for the protection o f human
subjects o f research. Retrieved from http://www.fda.gov/
ohrm s/dockets/ac/05/briefing/20054178b_09_02_Belm ont%
20Report
of war criminals before the Nuremberg military tribunals under
control council law no. 10 (vol. 2, pp. 181-182). Washington, DC:
U.S. Government Printing Office. Retrieved from http://www.
hhs.gov/ohrp/archive/nurember.html
m§§MB98%
key issues and trends in health care
> A ccess original research b y >-
in h e a lth care m an ag em en t.
care services w h ile ^
co n tain in g or re d u c in g
costs.
> Earn valu ab le co n tin u in g
co n tact h o u rs at a great rate.
peer-reviewed
o f b e s t p ra c tic e s in h e a lth care
m a n a g e m e n t, e c o n o m ic s, a n d
p o lic y m a k in g .
a rtic le s w r itte n b y a n d for
n u rs e lead ers.
• Leadership
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• Health Policy and Politics
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• Impacts and Innovations
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3 N T U R SS I UNTO.
Official Journal of the Academy of Medical-Surgical Nurses
MEDSURG Nursing, The journal of Adult Health, the official
journal of the Academy of Medical-Surgical Nurses, is a
scholarly journal dedicated to advancing adult health nurs
ing practice, clinical research, and professional development.
The journal’s goal is to enhance the knowledge and skills of
adult health and advanced practice nurses to prevent and
manage disease, and to work with patients and their families
to improve the health status of the nation’s adults.
continued from page 191
2002).
170 (Calif. Ct. App. 1957).
92 (1914).
Veith v. O’Brien, 739 N.W.2d 15 (S.D. 2007).
Weber v. McCoy, 950 P.2d 548 (Wyo. 1997).
Seeks Manuscript Reviewers
MEDSURG Nursing, the Official Journal of the
health/medical-surgical nurses in private practice,
acute, general, long-term, and outpatient health
care settings, and other professionals with expertise
in adult health/medical-surgical nursing to join its
Manuscript Review Panel.
accuracy and relevancy of
information in submitted
manuscripts. W hen possi
ble, reviewers evaluate the
research designs of submit
ted studies. The review
panel position has no m on
etary reimbursement but,
perhaps, some glory.
please visit the journal’s
web site www.medsurgnursing.net and complete
the Manuscript Reviewer application.
N U KS I NO
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individual use.
Data Sets into Performance Improvemen
Diane Storer Brown, Carolyn E. Aydin, Nancy Donaldso
lenges of transforming data into meaningful information for
understand an individual facility, service, or patient care unit’s
tization and focused data presentation are needed.This article
sets into dashboards for setting performance improvement
available and easily used by support staff.This methodology is
illustrated with examples from a large nursing quality data set,
benchmarking
prioritization
healthcare professionals and senior leaders
iiionitor organizational perfonnance and pri-
oritize the design of improvement interven-
lions (Donaldson, Brown, Aydin, Bolton, 8c
RLiilcdgc, 2005; Rosow, Adam, Coulombe, Race,
8c Anderson, 2003). Dashboards provide data
on structure, process, and outcome variables;
report cards provide final leporLs on (jutcomes
and are often intended for external audiences
(Gregg, 2002). Recent public reporting initia-
tives and tJie pay-for-perforinance demonstra-
tion project funded by tbe Centers for Medicare
and Medicaid Semces represent tbe report card
strategy in whicb liospital performance isjudged
by external constituents incoiporating incentives
for performance improvement {Lindenauer,
Remus, 8c Roman, 2007). In order to improve
performance on public report cards, hospitals
construct internal dashboards to review perfor-
mance and identify areas in need oí change.
Benchmarking with similar hospitals in a confi-
dential context is an important clement in this
proce.ss (Brown, Donaldson, Aydin, Sc C^aiison,
2001; Gregg, 2002).
Traditionally, large quality data sets have been
placed in tables, bar graphs, or line graphs to
track key metrics over time. Those operationally
accountable to improve patient care quality and
saiety depend on quality professionals to trans-
late data into usable information, which is then
used to determine performance thresholds foi’
(Irilkiown analyses oi” benchmarks and perfor-
mance goals to understand relative comparative
performance. This article uses common defini-
tions for perlbrmance metrics as follows from
Merriam Webster Online Dictionary (2007): Goal is
the end toward which effort is directed (where
you want your perfonnance to be) and is synony-
mous with target, a goal to be acbieved; threshoùl
is a level, point, or value above which something
will take place, and below which it will not (the
point where performance has declined and you
need to drill down further to understand why); a
benchmark is something that sei’ves as a standard
by which others may be measured or judged (a
best practice that you strive to meet or exceed).
must learn how to translate data for benchmark-
ing endeavors based on the data set undei
review. Raw data reported out as frequencies
(the count or number of occurrences) has liitk-
use in performance monitoring, with the excep-
tion of monitoring rare events. When monitoi-
ing patient safety indicators that occur rarely,
monitoring days between occurrences may be
an important metric for frontline st;iff watcli-
ing zenKolerance indicators such as falls witli
major injury. Tbe mean or average, calculated as
tbe sum of all occurrences divided by tbe lumi-
ber of occurrences, is a statistic likely reported
in all numerical data sets. However, the mean
is known to be sensitive to extreme values or
outliers, especially when sample sizes are small
(Dawson 8c Trapp, 2004). This means that one
patient with an extreme value can pull the mean
for tlie datii set and leave the wrong impies-
sion about performance for all patients, which
could lead to unnecessary improvement efforts.
The median or middle value may be a bettei’
extreme values. The median reflects the middle
point of all observations—half the observations
are larger than the median, and half are smaller.
The median is also more appropriate to use for
ordinal data—data where there is an inherent
order to the values, but the values themselves
may not have meaning. An example of ordinal
tiata consists of the numeric response choices
on a satisfaction survey where I may represent
dissatisfaction and 5 may represent complete
satisfaction. The average of these data (response
choices of 1-5) may be distorted or skewed by
sui’vey respondents selecting complete satisfac-
tion (5), and those interpreting the results may
not clearly see the distribtition of the patients or
statï responses.
spread out is important for determining per-
formance goals and benchmarks from data
sets. Traditionally, the average may have been
used as a goal. However, in today’s competitive
heallhtiue industi”y, sttiving to be average may
not be the benchmark that senior leaders wish
to target. Quality professionals have the task
of interpreting the spread of the data to help
establish ti.seful benchmarks from the daui set
so that leaders can establish realistic targets.
Healthcare qtiality data are often sknoed data—
dat;i that are not symmetrically distributed (bell-
shaped or normally distributed) in such a way
that hail* the data are above the mean and half
are belo\v. hi symrnelmal data, the mean and the
median are numerically equal. This is important
information to confirm when using a mean for
a target—when the mean is pulled by extreme
values, it may not be represen ta uve. The range
may be included In reports to show where the
mean sits in the data set. The range describes
the data spread from the highest to the lowest
luimbeis and is calculated by subtracting the
minimimi value from the maximum (Dawson Sc
Trapp, 2004). The same infonnation is available
il d a t a sets provide the minimum and maximum
\alues.
when means are reported. The standard dnnaiion
mathematically descrihes how the data spread
(lut around the mean by representing the aver-
age distance of obsei”vations from the mean
(Dawson & Trapp, 2004). You might recall
from statistics cla.sses that if the observations
are symmetrical or normally distributed (in a
hell-shaped ciii-ve). then 67% are between the
mean and plus or minus I standard deviation;
standard deviations; and 99.7%, between the
mean and plus or minus 3 standard deviations.
By taking the mean and adding or suhtracting 1,
2, and 3 standard deviation values from it, you
will see the distribution of the data and will bet-
ter understimd the usefulness of the mean to set
performance metrics.
lics with semce times (minutes of waiting)
follows. When meastiring mintites of waiting,
negative values would not be possible (mintites
below zero), and if the mean minus 1 standard
deviation produces negative ntimbers, consider
whether ihere were patients with extremely
long wait times that ptiUed tlie group average
up (resulting in a large standard deviation).
The average tor this data set may not be use-
ful for performance metrics. Consider pulling
the outliers otit of the data set after re\1ewing
the individual datii points. A scattergram is an
easy way to see tlie outliers. By looking at the
actual data and pulling otit extreme values (e.g.,
more than 3 standard deviations), the average
for these data would be lower and would better
reflect actual patient experiences.
sopbisticated, reporting percentiles is emerg-
ing as another way tí) understand the spread
of the data and to pro\ide more specificity for
estahlishing performance metrics.
use the data, and it is easier to set benchmarks
or targets with percentiles. A percentile is the per-
centage of a distribution (responses or \~alues)
that are equal to or below that number (Dawson
&: Trapp, 2004). Percentiles are commonly
repoited in healthcare with growth charts for
children and in academia wilh test scores. For
example, in a growth chart, if 60 pounds is the
90th percentile, that ntimber tells us that 90% of
the children at that age weigh (30 pounds or less,
and 10% of the children weigh more. It is easy to
understiuid that this child is heavier than 89% of
the other children the same age.
and interquartile ranges describe how the data
spread out and tluis are extremely valuable
for establishing performance metrics.
25th percenlile as the firet or lower quartile;
the 50th percentile as the median or middle,
which separates the second and third qnartiles;
and the 75th percentile as the upper quartile
(Figure 1). The interquartile range is the spread
/
range
mediar
Î
Quartiles
• Above Median 1 Upper Quartile
the middle values llial represeiu 50% of” ilie
data set. Quartiles demonsti’ate performance
relative to oihers in the data set and are used to
set uieauiugful metrics. For example, if senice
satisfaction scores are being compared, and
your unit or lio.spital falls in the hiwer quartile,
this means that 75% of those conipaied have
higher satisfaction. A meaningiul goal might be
to reacli the 50th pereentile for performance.
Setting tlie 75tli percendle or upper quartile as
the goal may be a stretch goal and diñicult to
achieve, creating frustration for those account-
able to implement improvements. The 50th
percendle, or median, could be a short-term
goal; and the 75th pereentile, a long-term goal.
Another hospital might already be in the upper
quartile at the 85th percendle; quality profes-
sionals at tliat hospital may wish to set the 75th
pereentile as the tlneshold indicating that their
performance has declined (or indicating that
the competition has gotten better).
marking expands the toolbox for qnality profes-
sionals for data display beyond traditional pie
charts, bar graphs, and trend or line graphs.
Today, qualit)’ prt)fe.ssionals can nse the follow-
ing guidelines in deciding which measure of
data set (Daw.son &• Trapp, 2004):
when Ihe mean is tised and the data are
synnnetrical numerical data.
are appropriate when the median is used
for ordinal data or the nutnerical data are
skewed.
describe the middle 50% of the data dis-
trihiuion regardless of its shape.
when the purpose is to understand
extreme valttes.
to translate data sets into dashboards and set
performance t;irgets, thresholds, and bench-
marks? Armed with a basic understanding of
the statistics described earlier, quartiles may
provide a more sophisticated mcthodolog)’ to
establish e\idence-based performance metrics.
Quartiles or percendles can be .selected as goals
for performance, ÍLS thresholds for drilUiown
analyses if perfonnance is already at the desired
level, or as benchmarks for best practices from
high perfomiers.
100 «I ku ecu
HfliHtjb
31
31
31
31
31
31
33
93
93
93
93
93
%
%
99
99
99
000
uia
ooc
ooo
S9
000
UiiUibasi’s pro\’idc iiilbrinaüoii to users in a
variety of formats. Selecting which format to iise
may he ovei’whelniiiig for new quality profession-
als. Keeping tlic purpose of ihe dala review in
mind will help make the selection easier. Typical
reports include suiniiuiries of multiple indicators
at a point in time, compiuison of peifonnance
against outside henchmarks, comparison of per-
formance on an individual or multiple indicators
with a pictuie, and uiouiLoiing performance
on individual indicators over time. To illustrale
reports that arc commonly availahlc, examples
from the (California Nursing Oulcouics Coalition
(CalNOC) data set are described, with discussion
on hi)w to iLse the reports to meet the reviewer’s
iutcuded ptupose.
surement database, is a collaborative effort of
the American Nursing Association-California
(.AJVA/C) and the Association of Clalifornia
Nui^c Leaders lo advance improvements in
patient care by sustaining a valid and reliable
statewide outcomes databa.se. Voluntaiy tnem-
beiship is available to all acute care hospitals
in the state of California, as well as selected
hospital groups in other states in the western
180 of CJalifornia’s H60 acute care hospitals par-
ticipated in CalNOC, with additiotiai hospitals
from Nevada, Arizona, (Oregon, and Hawaii.
Nuim’-seusitive qtiality indicators are collected
at tlie patient care utiit level and clustered into
categories of variables related lo muse staffing
(houi-s of care, skill tnix, tise of contiacl stalf,
staff tutuover, and bed turnover); registered
nurse (RN) education level, certification, and
years of experience; ¡jatienl falls; pressure ulcer
(FU) prevalence; restraint prevalence; central
line-associated bloodstream infections; and
medication administration accuracy. Hospitals
access Web-ha-sed customized reports generated
directiy fri)m the data set to compare their own
performance with thai of like hospitals, CalNOC
hospitals develop their own facility dashboards,
combining reports from the Web site with those
from other dala sources to display indicators
on a single document (Don;üdson et al., 2005).
The CalNOC prí)ject has been described in
de-tail elsewhere (Aydin et al,, 2004; Brown et
al., 2001).
etence for aggregaled data at a given point in
time (e.g., the curieut quarter) to populate
These reports often provide columns ol’ aggre-
gated numeric data without graphs, and they
usually include averages and mea.sures of data
spread such a.s standard deviations or mini-
mum and maximum values and may provide
quaitiles. CalNOC summar)’ statistics reports
provide member hospitals with aggregated sta-
tistics for all CalNOC hospitals on all variahles.
Figure 2 shows an example of summaiy statistics
for stafTing and falls bv’ unit type and hospital
average daily census.
performance on select indicators at a point in
time (e.g., the current quarter). Graphs provide
a visual representation of comparative hospital
performance, which may quickly provide perfor-
mance information. Graphs should not be used
to summarize «/idata, only those prioritized for
performance monitoring. Wiien reports iiii hide
pages and pages of graphs, the key messages
and analyses from the data set are lost on those
reviewing the teports. Figure 3 shows a sample
comparison graph for falls per 1,000 patient
days for all medical/surgical units in hospitals
with an average daily census under 100 patients.
This graph gives hospitals a visual reprcscntit-
tion of the variation amotig hospitals, followed
by a report that lists the actual performance for
each hospital (not included).
prioritized indicators over time. These reports
often include graphs as well as a data table for
monitoiing. Using trend charts can heip hospi-
tals understand their ongoing performance over
time by watching tbe slope of the line or bars
to uuderstand vvbcther performance is improv-
ing, declining, or stable compared to the same
hospital (your hospital) each month or quarter.
Figure 4 provides an example f)f a hospital trend
teport for falls per 1,000 patient days for one
ho.spital. Both the facilit)’ average and CalNOC
average for tbe .selected time period are shown
by Unes across the gi-aph. The report includes
the graph sbown, followed by a table listing the
actual numeric fall rates ibr each montb (not
included).
reports. Even if perfonnance remains stable
(i.e., flat slope), comparison to others is still
important to see whetlier the bar rises. As the
group prioritizes improvement over time, the
group average may raise the bar or benchmark.
Even if individual performance is stable, relative
performance may decline—for example, from
sitTipl} because tlie rest of the group in the data
set improved. It would be a mistake to monitor
only individtial performance over time.
indicators is very importiint in determining
whether gains are held. Wiien data are being
viewed over time, it is usually better to use line
graphs to better visualize trends. Figure 5 pro-
vides an example of the same data using verti-
cal bai graphs and line graphs. Although both
graphs clearly demonstrate die spike in restraint
use in 2005, the trend of decrease over time is
much clearer in the line graph.
mary of performance, together with the per-
formance of like groups. These teports may
be helpful to setiior leaders such as the chief
officers or the board of directors when data are
at the facility level, and ihey may be helpful to
individual unit managers when data are at the
unit level of analysis. These reports are usually
nimieric data in columns and provide compari-
sous for Uic individual perlbrmance with other
groups such as state or national averages, or
averages of other like facilities based on criteiia
from the given database. Data may be similar
to summary statistics with averages and data
spread infonnation and may include percentiles
or quartile itiformatioti. GalNOC’s facilitv-level
benchmarking leports show stunmary data for
tbe total facility and by unit type (i.e., critical
care, step-down, and medical/surgical ttnits).
Figure 6 shows a facility-level benchmarking
report for prevalence studies. Unit-level data
allow managers to compare their performance
within the facility as well as externally. Unit man-
agers can examine imit perfonnance in detail,
including botb PU prevention process variables
and patient oiUcomes. These statistics track the
actttal number of patients with ulcers in addi-
tion to tbe percent. Actual ntimbei’s may be
meaningful to fiontlinc unit suilf wbcu tracking
rare events by days between occurrences. Also
included arc statistics useful for performance
metrics such as the facility’ mean by unit type,
like ho.spital mean by unit type, and CalNOC
mean by unit type. Taken togetlier, the statistics
on this uuit-Ievel report provide a valuable drill-
down into both patient outcomes and the PU
prevention process.
A six-step process has been developed to guide
quality professionals through the translation
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and using the definition lor dashboards present-
ed earlier, prioritized indicators representiiif»
stnictnre, process, and ontcomes were selected
(¡nartile information troni siiiiiniar}- reports
using readily availahle tools in software prochiets
sitch as Microsoft Excel or PowerPoint.
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After reviewing all the reports available to qual-
ity professionals in databases, tbe next cbal-
Icnge is one of syntbesizing tbe information to
narrow the focus to indicators that are impor-
tant to tnonitor compared to benchmarks.
Prioritization should come from tbe key stake-
bolders wbo manage operations associated with
the data set. Indicators should be limited to the
“vital few” and should represent structure, pro-
cess, and outcomes. Tbe prioritized indicator
list will need to be placed into a .spreadsbeet to
create tbe dasbboard.
Performance on tlie prioiitizt-d indicators
will next need to be translated into quartiles.
Gather the reports tbat provide bencbmark
quartile values witb facility performance. For
eacb indicator, identify tbe numeric value
tbat defines tbe range of values for eacb
i|uartile in tbe data set. Next, identify tbe
facility’s individual performance and wbere
tbat value falls witbin tbe identified quartile
range (this can be done concurrently or as
individual steps). Transfer this information
summary reports can be completed by support
staff after training on tbe specific reports tbat
will be used atid the ftmdamentals of quartile
metrics. Figure 7 sbows a very simple worksheet
for capluring performance by indicating wbich
quartile the hospital fell into for each indicator.
Pereentile numbers (25, 50, 75) were assigned
in the last colmTin of the worksheet, which will
be used to generate dashboard grapbs.
infonnation, refer back to Figure 2, Summary
Statistics, as a reference. Tolal hours per patient
day in medical/surgical units bas tbe following
quartiles: the lower quartile is 7.44 {1st to 25tb
percentiles), the median value is 8.56 (50th
pereentile), and tbe upper quartile begins at
9.75 (75th to lOOtb pereentile). Next, identify
the individual hospital’s performance on tbe
same indicator. If the value is 7.44 or less, it is
in tbe lower quartile; if it is 7.45 to 8.56 (tbe
median value), it is below the median but
above tbe lower quartile; if it is 8.57 to 9.74,
it is above tbe median btit below tbe tipper
quartile; and if it is 9.75, it is in the upper
quartile.
Performance from Summary
Statistics Quarter 1 2008
Lower Upper Performance
25 Median 50 Median 75 100 column to left)
%LVNHour^ofCare
X
X
X
X
X
X
X
X
X
X
X
100
100
25
100
100
25
100
% PL) Risk Assess in 24 hours
% At Risk for PU
% At Risk PL) Prevention
% Restrained
% Restrained Vest or Limb
X
X
X
X
25
25
100
100
Palls
Falls with Iniury
%Hosp Acquired Ulcer
% Stage II+ HAPU
% Stage III+ HAPU
25
100
100
75
! = hospital-acquired tilcer.
The next step in Úiv translation process is to
use Uie quartile data to create a picture that will
show perfomiance priorities tisitig the data in
the la.st column of the worksheet and a readily
available software application, Microsoft Excel or
PowerPoint. Again, support staff will he ahle to
accomplish this translation once the indicators
have heen selected and the worksheet has been
set up.
these data using horizontal bar graphs. The
percentiles tiiat define them. A more poweritil
picture may be available for quartiles using radar
or spider diagrams. Rgure 9 provides the same
information, but the picture is more powerful
\isvially. Similar to the bar graph, the quartiles
are demarcated numerically by the percentiles
that define them. Ttie center of the diagram
represents the lower quartile, with each quartile
moving away from the center progressively,
so that the upper qnartile is the ()Uter ring of
the diagram, which resembles a spider web.
(liagrani—^wilb more color Indicaling perfor-
mance reacbing out from the center and lower
quartile.
Dashboard
Clusici ibc i^iaplis on a one-page document
so tbal all infonnation is readily a\ailable at a
glance. Two examples are provided in Figure 10
and Figure 11. sbowing the boiizontal bar gia[)h.s
and (hi- radai” fliagrams, respeclively, using stiiic-
ture, process, and outcome indicators from ihe
worksheet. Because all the data are on one page,
(be end user can quickly visualize comparative
performance on prioritized indicators.
Creation of an appendix or stipporting docti-
menl for tbe dasbboaril is based on die end
user’s need for additional information. A t;ible
<»f indicator definitions may be inchided, whicb
also could provide data sources and time frames
for tbe data set. Wben quartiles arc used ;LS
bencbmarks, it is also belplul to identily tbe
desired direction for perfonnance. For example.
using the indicator data in these d;\shboaids for
risk or prevention inteiTention perfonnance
in tbe uftfjn quartiles would be desirable, and
outcome perfonnance related lo acquiring PUs
in the toiCíT quartiles would be desirable. AITOWS
indicating tlie desired direction can be placed
on tbe dasbboard as one helpful tool, as shown
in Figure 10. Anolber option, one tequiring
liu tber explanation to the users, is to rescale tbe
dasbboard so that low performance is always in
the Icjwer quartile and desired performance is
always in the upper quartile. For ihe infonnation
on PUs, this would require transposing actual
quartile perfonnance data for acquiring ulcers—
in this case, being in the lower {|uarlile is good—
and representing that as the upper quartile on
the da.shboard. Tbe dasbboard must be clearly
labeled witb ibotnotes so Íl is clear to those
using the dashboard tbat good perfonnance is
always bigh, even though intuiiively you wisb it
to achieve low pre\alence.
Tbe final step in the translation process involves
analysis or interpretation of comparative perfor-
mance to otbers in the data set. The key opera-
tional stakeholders wbo prioritized tlie itidicator
LVN Voluntary Turnover
Licensed Hours PPD
# Patients Per RN
% Other Hours of Care
Caie
0
of Care
of Care
Hours ot Care
25
Per Palieni
75
RN
50
Hours PPD
Sitter Hours
25
75
Bed Turnover
Turnover
Turnover
100
Turnover
Quartiles
Total Hours Per Patient Day
sions must be summarized ioi senior leadersbip.
following interpretation might be drawn by
tbosi- with operational accountability. {Note
diat this dashboard was not rescaled for desired
perfonnance placement in tbe upper quartile.)
Looking at tbe structure data, one sees ibat tbis
bospital bas more licensed vocational nurse
(LVN) boms tban tbe median and has little L\TS’
tumover olthcstaíí (lower quai lile). Unlicensed
support stafFuse is low (lower quartile) although
RN lumrs of care are at the median, but the
number of patients lor each RN is bigb (upper
quartile). Tbe ntimber of patients in a bed
(bed turnover) on a given day is bigh (indicat-
ing many adtnissions, discbarges. or transfers),
whicb would require a lot of RN time. RN ttirn-
over on tbe workforce is also bigb (perbaps the
unit is too bu.sy), and staüing is accomplished
with contract or registry staff (upper quartile).
Tbis luiit likely would examine its sUiffing pat-
terns because the siiuation appeals to be a dif-
ficult one for the RN workforce.
data wilbin die context of ibese structure data,
one might make tbe following interpretation.
usf t)f sittfis to prevent resuaint or falls is
in tbe lower quardle. Patients at risk for PUs
are not getting prevention intei-ventions (lower
quarlile), and tbe risk assessments ibr PU devel-
opment are only at the median. Ri.sk assessments
and detennination ()f appropriate intci-veniions
may not be gelling accomplisbed, given die RN
patterns just identified. Although tbe percent
of patients at risk for hijspital-acqiiired PUs
(FL’VPL’s) is low (lower quartile), this bospital
is in the upper quartile for HAPU develoi>
ment. This b(xs]>ital will want to invesiigiue tbese
outcomes further by drilling down inlo tbe dala
to better understand performance. This hospital
may be doing well wilb fall prevention, however:
falls with injtir)’ are in the lower quarlile. Note
thai “all falls” are higb (upper quartile), whicb
could be inter¡5reied as good reporting or as a
bigb rate tbat needs fut ther investigadon. If this
bospital bas been working on a culture of saiety
and respi)nsible reporting, a high fall rate may
indicate success in tbis area (good reporting).
sionals at tbis bospital would likely prioritize
perfonnance improvement around PU develop-
ment and use of resti’aint; tbey may wisb to set
starling P t r t B t m i R U In Q m r l l l a i
F i l l i • I d P n u H r a Ulcsr Q i i r l l i a Psrlotmanc» Analytic
percentile as a short-term goal, and below the
50th percentile or median as a long-tenn goal.
Given that they are doing well with injuiy falls,
they may wish to set the median as a thresh-
old for further analyses should the hospital’s
performance decline to that level. They would
also likely investigate fnrther staffing patterns
to support the higli volume of patients that are
admitted, discharged, or translerred Into this
uiiii dailv. Given the high RN staff turnover,
they may also wish to coudnct a survey or focus
grotip to better undeistand the stafFs perspec-
ti\e on the work cn\iroument. They may wish
to set a performance target to be below the
median for total voluntary stafT tumover.
This article provides tools for the quality pro-
fessional to translate data sets into dashboards
and (o .set performance tingets, thresholds, atid
benchtnarks. Armed widi a basic understatiding
of the statistics described, quartiles may provide
a more sophisticated mt’thodolog)’ lor bench-
maiking. Depending on how data are reported,
quartiles or petcentiles can be selected as goals
for performance, as thresholds for drill-down
analyses if performance is already at the desired
level, or as the benchmarks for best practices
from high performers. Graphs cati be used to
create powerful \isual UJOIS to quickly inlbrm
froiuline staff, operational leaders, and gcnern-
ing bodies on piioritized metiics.
Aydiii, (1. V… Hiiim-s, IV 1,,, Dodaldson. N.. Brown, L). S.,
itiK a slatcwide mirsiiig qiialil)’ measurement database.
foumnl ofNiiruufySchotar.^hip. 36(4), S71-378.
(2(101). Hdspiial minsiiig iM-ncliinaik.s: The Oalif’nrnia
Niiisiiig Outcome (loiililicut jnojeel experience, founxd
ftir Uealthrarp Qiiality. 23(4). 22-27.
listits. I.an|Te Medical Books.
Riitledgf, I). N. {2O0.’i). Leveraging imrse-relatt-d dash-
board benchmarks in expedite perlbrmance improve-
ineni and d«»< umeiit excellence. Joimtal of Nursing
Adminislratum, 35(4), l()3-172.
tems lor nursing service Kiv^AnVráúowf,. foanial t)f Nursing
Admiimtratioii, 32(‘¿), 71-7S.
ing and |7ay for perlbmiance in hospital qiuüity inipit)veineiit.
Neil’F.n^and Jmmmlof Mfilkive. 556(5), 486—4%.
1.”), 2007, from w’ii’w.merriain-wí-hstercDm/diciionaiy.
R, (2()(t.’î). N’irtual iiislrnnifnlatjon and real-time cxeeii-
tivf dashboards. Sohnioiis for Iieallh care systems.
Nursing Administration (¿uarlerly, 2 7 ( 1 ) , .^i8-7(i.
Diane Stotrr Jhowii. PhD fîN FNA¡Í(¿, is the California
Nursing (hitcomrs Coalition (CalNOC) ayfniniipal iiix’es-
tigatM’ and has heen part tif the CalNOC research learn for
more than 10 years. She is nirrmtly the dinical practice lead-
er for hospital accreditation pmgranis at Kaiser P/rmanente
Ntirlherri California Region in Oablan/l. CA.
Coalition. {CalNOC} coinvestiga tor and has been tlie
CalNOC {fata manager for the f)a.st ¡O^ears. Shf is currently
a research scientist nt Ceilitr.s-Sinai Health System. Bums antl
Allen Research Institute in. ¡.os Angeles, (A.
Nursitig Outcomes Coalition (CalNOC) cof/rincifial inves-
tigattrr and has aLw hem part of tlw CalNOl. research
team for imiif than 10 years. She is the .Ameritan Nurses
Associâtiini-Catif(/rnia (ANA/(^) CJIINOC pmje/t direclrrr
and coprinrifuil investigator as well as the dim tor far the
Cinder for Research and ¡nnoi’ation in Patient (Jam al
University of Cakfomia-San Frandvo Stnnfi/rd Health
(jitv through the University of California—.San Francisco
SchiM>l tif Nursing.
Bwuni at Diane..linnvn@k.p.org.
the opportunity to earn continuing edticatioii
(CE) credit to those who read this article
and take tlie online posttest at www.nahq.
org/Journal/ce. This contitiuing edtication
offering, J H Q 209, will prinidi’ I contact liDtn
to those who toiuplete it ap|}ropriately.
111. Perlorinaiicf ltnpro\ctuciil
systematic
1
, DANIA COMPARCINI R N , M S N
‘G.d’Annunzio’ University, Chieti Scalo,
22, 855–871.
examined the relationship between nurse empowerment and job satisfaction in
cause of nursing turnover. Job satisfaction has been linked to a high level of
Evaluation We reviewed 596 articles, written in English, that examined the
relationship between struc
nurses’ job satisfaction. Struc
Conclusion A satisfying work environment for nurses is related to structural and
psychological empowerment in the workplace. Structural empowerment is an
positive retention outcomes such as job
leaders’ strategies to develop and maintain an empowering work environment
that enhances job satisfaction. This could lead to nurse retention and positive
empowerment, workplace
856 Journal of Nursing Management, 2014, 22, 855–871
● What is the relationship between psychological
structural empowerment, psychological empowerment,
Journal of Nursing Management, 2014, 22, 855–871 857
met) or 1 (=met) and the items related to outcomes
measurement were scored out of two. Based on
:lanruoJ
noiretirchcaerofoNroseY.1
.)7/6/5/3/2/1(
Design: Sample:
CWEQII? YES NO
2. Does the study measure psychological empowerment (Using
Psychological Empowerment measuring tool)? YES NO
3. Is the relationship between empowerment and job satisfaction in
nursing staff evaluated? YES NO
4. Is the relationship between workplace empowerment and other
outcomes evaluated? YES NO
Statistical analysis
ONSEY?deifitnedicitsitatsaerehtsI.6
ONSEY?edutingamfonoitacidninaerehtsI.7
858 Journal of Nursing Management, 2014, 22, 855–871
Publication date: Journal:
1. Was the study prospective? 0 1
1. Was probability sampling used? 0 1
2. Was sample size justified? 0 1
3. Was sample drawn for more than one site? 0 1
4. Was anonymity protected? 0 1
5. Response rate was more than 60%? 0 1
Empowerment (IV) [assess for IV correlated with DVs only]
1. Was the outcome measured reliably? 0 1
2. Was the outcome measured using a valid instrument? 0 1
1. Was the dependent variable measured using a valid
instrument? 0 1
the internal consistency ≥ .70?
1. If multiple outcomes were studied, are correlation analyzed? 0 1
2. Were outliers managed? 0 1
(0-4 = LO; 5-9 = MED; 10-14 = HI) LO MED HI
database searching
through manual and website search
Abstract screened for inclusion/exclusion
Full-text articles included in
Full-text article
Studies retained
Full text screened for inclusion
Journal of Nursing Management, 2014, 22, 855–871 859
Measurement
Theoretical framework used 5 7
860 Journal of Nursing Management, 2014, 22, 855–871
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a
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4
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=
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5
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P
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862 Journal of Nursing Management, 2014, 22, 855–871
job satisfaction
a
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(C
o
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A
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Journal of Nursing Management, 2014, 22, 855–871 863
a
b
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3
e
la
ti
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s
h
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t
a
P
-v
a
lu
e
=
0
.0
0
1
in
o
s
p
it
a
l
M
,
x
c
e
p
t
fo
r
S
E
in
o
s
p
it
a
l
S
(s
ig
n
ifi
c
a
n
t
re
la
ti
o
n
s
h
ip
t
a
P
-v
a
lu
e
=
0
.0
5
).
C
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
S
E
a
n
d
J
S
(r
0
.5
0
6
,
P
c
c
e
s
s
to
u
p
p
o
rt
a
n
d
J
S
(r
0
.5
1
,
P
p
p
o
rt
u
n
it
y
to
a
rn
=
0
.5
1
,
P
fo
rm
a
ti
o
n
(r
=
0
.3
0
,
P
l
p
o
w
e
r
=
0
1
,
P
E
w
a
s
s
ig
n
ifi
c
a
n
t
p
re
d
ic
to
r
o
f
S
=
0
.3
0
,
F
=
1
5
.0
6
,
P
tr
e
s
s
.
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
S
E
a
n
d
n
u
rs
e
’s
o
rk
tr
e
s
s
(r
�0
8
,
P
tr
e
s
s
w
a
s
s
ig
n
ifi
c
a
n
t
p
re
d
ic
to
r
o
f
S
(R
=
0
.3
0
,
F
=
1
5
.0
6
,
P
<
0
.0
0
1
).
C
o
rr
e
la
ti
o
n
b
e
tw
e
e
n
S
E
a
n
d
J
S
(r
0
.5
4
7
,
P
1
.5
%
f
v
a
ri
a
n
c
e
in
E
w
a
s
e
x
p
la
in
e
d
b
y
a
o
m
b
in
a
ti
o
n
o
f
a
g
e
a
n
d
w
o
rk
b
je
c
ti
v
e
.
H
ig
h
le
v
e
ls
f
E
w
h
e
n
n
u
rs
e
s
w
e
re
o
u
n
g
a
n
d
lo
v
e
d
th
e
p
ro
fe
s
s
io
n
.
–
S
E
e
x
p
la
in
e
d
2
2
.8
%
<
0
.0
0
1
)
f
th
e
v
a
ri
a
n
c
e
in
S
h
e
n
e
n
te
re
d
fi
rs
t
(i
n
m
u
lt
ip
le
e
a
r
re
g
re
s
s
io
n
a
n
a
ly
s
is
).
E
w
a
s
a
s
tr
o
n
g
e
r
p
re
d
ic
to
r
(b
0
.2
8
)
o
f
S
.
rg
a
n
iz
a
ti
o
n
a
l
c
o
m
m
it
m
e
n
t,
rn
o
v
e
r
in
te
n
ti
o
n
.
h
e
p
re
d
ic
to
r
v
a
ri
a
b
le
s
(S
E
,
In
c
iv
ili
ty
n
d
B
u
rn
o
u
t)
a
c
c
o
u
n
te
d
fo
r
6
%
f
th
e
v
a
ri
a
n
c
e
in
b
s
a
ti
s
fa
c
ti
o
n
a
n
d
fo
r
2
9
%
f
th
e
v
a
ri
a
n
c
e
in
rg
a
n
iz
a
ti
o
n
a
l
c
o
m
m
it
m
e
n
t.
T
h
e
s
tr
o
n
g
e
s
t
p
re
d
ic
to
rs
f
tu
rn
o
v
e
r
te
n
ti
o
n
s
w
e
re
y
n
ic
is
m
=
0
7
,
P
=
0
.1
9
,
P
=
0
.1
6
,
P
n
t
e
x
p
la
in
e
d
1
9
.2
%
<
0
.0
0
1
)
o
f
th
e
v
a
ri
a
n
c
e
in
rg
a
n
iz
a
ti
o
n
a
l
c
o
m
m
it
m
e
n
t.
S
E
w
a
s
s
tr
o
n
g
e
s
t
p
re
d
ic
to
r
(b
0
.3
1
)
o
f
rg
a
n
iz
a
ti
o
n
a
l
c
o
m
m
it
m
e
n
t.
S
E
w
a
s
s
ig
n
ifi
c
a
n
t
p
re
d
ic
to
r
o
f
tu
rn
o
v
e
r
te
n
ti
o
n
s
(b
�0
8
,
P
e
p
re
v
io
u
s
o
d
e
ls
.
O
v
e
ra
ll
e
m
p
o
w
e
rm
n
t
(S
E
)
w
a
s
p
o
s
it
iv
e
ly
la
te
d
to
S
=
0
.5
6
,
P
0
.0
1
).
p
p
o
rt
u
n
it
y
(r
0
.2
2
,
P
0
.0
1
)
a
n
d
re
s
o
u
rc
e
s
=
0
.3
0
,
P
0
.0
1
)
w
e
re
o
s
it
iv
e
re
la
te
d
to
S
.
u
rn
o
v
e
r
in
te
n
ti
o
n
u
rn
o
v
e
r
in
te
n
ti
o
n
w
a
s
s
ig
n
ifi
c
a
n
tl
y
n
e
g
a
ti
v
e
ly
o
rr
e
la
te
d
w
it
h
p
e
rc
e
iv
e
d
rm
l
p
o
w
e
r
(r
�0
.2
7
,
P
0
.0
5
),
o
v
e
ra
ll
e
m
p
o
w
e
rm
n
t
=
�0
1
,
P
0
.0
1
)
a
n
d
jo
b
s
a
ti
s
fa
c
ti
o
n
(r
�0
9
,
P
0
.0
1
).
S
E
in
fl
u
e
n
c
e
d
le
v
e
l
o
f
J
S
:
m
a
g
n
it
u
d
e
o
f
th
e
re
la
ti
o
n
s
h
ip
5
).
ro
fe
s
s
io
n
a
l
e
n
v
ir
o
n
m
e
n
t,
q
u
a
lit
y
f
n
u
rs
in
g
c
a
re
.
ta
ffi
n
g
a
d
e
q
u
a
c
y
in
fl
u
e
n
c
e
d
le
v
e
l
o
f
jo
b
s
a
ti
s
fa
c
ti
o
n
:
m
a
g
n
it
u
d
e
o
f
th
e
la
ti
o
n
s
h
ip
.2
3
).
a
g
n
e
t
h
o
s
p
it
a
l
c
h
a
ra
c
te
ri
s
ti
c
s
m
e
d
ia
te
d
e
e
ff
e
c
t
o
f
S
E
o
n
n
u
rs
e
s
’
p
e
rc
e
p
ti
o
n
s
o
f
p
a
ti
e
n
t
c
a
re
u
a
lit
y
in
e
ir
u
n
it
.
864 Journal of Nursing Management, 2014, 22, 855–871
studies included reported Cronbach alpha reliabilities
Cai et al. (2011) assessed job satisfaction by Idaszak
satisfaction.
job satisfaction
a
b
le
(C
o
n
ti
n
u
e
d
)
R
e
la
ti
o
n
s
h
ip
b
e
tw
e
e
n
S
E
a
n
d
/o
r
P
S
a
n
d
jo
b
s
a
ti
s
fa
c
ti
o
n
O
th
e
r
o
u
tc
o
m
e
s
m
e
a
s
u
re
d
R
e
la
ti
o
n
s
h
ip
s
b
e
tw
e
e
n
e
m
p
o
w
e
rm
e
n
t
a
n
d
o
th
e
r
o
u
tc
o
m
e
s
C
h
a
n
g
e
s
in
e
rc
e
p
ti
o
n
s
o
f
S
E
p
ro
d
u
c
e
s
ta
ti
s
ti
c
a
lly
ig
n
ifi
c
a
n
t
c
h
a
n
g
e
s
in
E
(b
0
.3
8
)
a
n
d
J
S
=
0
.7
0
).
–
1
0
E
p
re
d
ic
te
d
2
9
.5
%
f
th
e
v
a
ri
a
n
c
e
in
J
S
(R
=
0
.2
9
,
=
1
6
4
.9
,
P
0
.0
0
1
)
E
a
n
d
P
E
to
g
e
th
e
r
p
re
d
ic
te
d
3
8
%
f
th
e
v
a
ri
a
n
c
e
J
S
d
ju
s
te
d
R
2
=
0
.3
8
).
E
p
re
d
ic
te
d
a
d
d
it
io
n
a
l
7
.2
%
f
th
e
v
a
ri
a
n
c
e
in
J
S
.
o
th
E
a
n
d
P
E
w
e
re
ig
n
ifi
c
a
n
t
in
d
e
p
e
n
d
e
n
t
p
re
d
ic
to
rs
f
J
S
(b
0
.3
9
a
n
d
0
.3
3
re
s
p
e
c
ti
v
e
ly
).
a
s
te
ry
n
d
A
c
h
ie
v
e
m
e
n
t
e
e
d
s
.
a
s
te
ry
e
e
d
s
d
id
o
t
m
o
d
e
ra
te
e
e
m
p
o
w
e
rm
n
t
s
a
ti
s
fa
c
ti
o
n
re
la
ti
o
n
s
h
ip
.
a
s
te
ry
e
e
d
s
w
e
re
e
a
k
ly
la
te
d
to
E
(r
0
.1
2
),
P
E
(r
0
.2
5
)
a
n
d
J
S
=
0
.1
4
).
c
h
ie
v
e
m
e
n
t
n
e
e
d
s
w
e
re
o
t
s
tr
o
n
g
ly
la
te
d
to
n
y
v
a
ri
a
b
le
s
.
1
E
h
a
d
a
d
ir
e
c
t
p
o
s
it
iv
e
e
ff
e
c
t
o
n
J
S
=
0
.3
0
).
E
h
a
d
a
d
ir
e
c
t
p
o
s
it
iv
e
e
ff
e
c
t
o
n
J
S
=
0
.3
8
)
a
n
d
a
n
d
ir
e
c
t
p
o
s
it
iv
e
e
ff
e
c
t
o
n
J
S
=
0
.1
5
).
o
b
S
tr
a
in
E
h
a
d
a
d
ir
e
c
ti
v
e
n
e
g
a
ti
v
e
e
ff
e
c
t
o
n
jo
b
s
tr
a
in
=
�0
5
).
o
n
s
ig
n
ifi
c
a
n
t
jo
b
s
tr
a
in
/j
o
b
s
a
ti
s
fa
c
ti
o
n
p
a
th
u
g
g
e
s
ts
a
t
o
n
c
e
th
e
e
ff
e
c
t
f
P
E
a
re
c
c
o
u
n
te
d
fo
r,
jo
b
s
tr
a
in
n
o
t
a
p
re
d
ic
to
r
o
f
w
o
rk
a
ti
s
fa
c
ti
o
n
.
1
2
E
h
a
d
b
o
th
ir
e
c
t
a
n
d
in
d
ir
e
c
t
e
ff
e
c
t
o
n
J
S
.
ig
h
e
r
le
v
e
l
o
f
S
E
w
e
re
s
s
o
c
ia
te
d
w
it
h
in
c
re
a
s
e
d
J
S
=
0
.4
6
)
(d
ir
e
c
t
e
ff
e
c
t)
.
E
in
fl
u
e
n
c
e
d
w
o
rk
a
ti
s
fa
c
ti
o
n
th
ro
u
g
h
tr
u
s
t
in
a
n
a
g
e
m
e
n
t
(0
.1
4
1
)
(i
n
d
ir
e
c
t
e
ff
e
c
t)
te
rp
e
rs
o
n
a
l
tr
u
s
t
a
t
w
o
rk
,
o
m
m
it
m
e
n
t
E
h
a
d
a
d
ir
e
c
t
e
ff
e
c
t
o
n
a
ff
e
c
ti
v
e
c
o
m
m
it
m
e
n
t
(0
.3
1
)
a
n
d
a
n
d
ir
e
c
t
e
ff
e
c
t
th
ro
u
g
h
it
s
im
a
c
t
o
n
tr
u
s
t
in
a
n
a
g
e
m
e
n
t
(0
.1
6
).
E
w
a
s
s
tr
o
n
g
ly
s
s
o
c
ia
te
d
w
it
h
tr
u
s
t
(b
0
.5
1
).
ru
s
t
w
a
s
s
ig
n
ifi
c
a
n
tl
y
a
n
d
n
e
g
a
ti
v
e
ly
s
s
o
c
ia
te
d
w
it
h
c
o
n
ti
n
u
a
n
c
e
o
m
m
it
m
e
n
t
(b
�0
8
).
Journal of Nursing Management, 2014, 22, 855–871 865
866 Journal of Nursing Management, 2014, 22, 855–871
Journal of Nursing Management, 2014, 22, 855–871 867
868 Journal of Nursing Management, 2014, 22, 855–871
been extensively established (Ellenbecker & Cushman
2012).
Journal of Nursing Management, 2014, 22, 855–871 869
870 Journal of Nursing Management, 2014, 22, 855–871
Journal of Nursing Management, 2014, 22, 855–871 871
Table of Contents
Process
Outcome
2 NQF Endorsed Nursing-Sensitive Indicator “NQF-15”
3 The RN Survey is annual, whereas the other indicators are quarterly
Table 3
) using the draft data collection materials and review data; also interview hospital study coordinators to identify additional threats to reliability and validity
E-mail:
Article published September 30, 2007
© 2020 American Nurses Association. All rights reserved
American Nurses Association – 8515 Georgia Avenue – Suite 400 – Silver Spring, MD 20910
ISSN: 1091-3734 | 1-800-274-4ANA |
end
s
earch
Engagement: Relationship-based
Care in a Changing Health Care
System
s health care providers, we rarely partici-
1
and cap not shown.)
2
Yet widespread
3
In 2006,
4
A
6(p493)
6(p497)
MA, BSN, RN, CNOR
BETH ISRAEL DEACONESS MEDICAL CENTER
7
8
TM
9
By using inter-
10
11
12
MSN, RN, MHSA, CNOR, NEA-BC
ANMED HEALTH
ANDERSON, SC
13
14
Addressing the link
MD, FACS
SURGEONS
PROFESSOR
BOSTON, MA
MD, CASC, CHCQM, CHC, CPHRM, LHRM
TALLAHASSEE, FL
15
16
13
16
17
6
Engaging patients
RN, MJ, CNOR, FAAN
OFFICER, PATIENT CARE SERVICES
PRESENCE HEALTH CARE
18
FORMER DIRECTOR, EXECUTIVE SERVICES
PATIENT MEMBER, BOARD OF DIRECTORS
SAFETY
19
of the Affordable Care Act,
a statute the
22
23
23
23
24
n Creating a Practice
n Patient Safety (http://
1
which endorses successful
2
Members of the Part-
n AORN Tool Kits
n Workplace Safety Tool Kit (http://www.aorn
n Patient Hand Off Tool Kit (http://www.aorn
Additional resources are available from the
25
8
to propose a strategic
MSN, RN, CNOR, NEA-BC, FAAN
OFFICER
DENVER, CO
mark of the National Patient Safety Foundation,
1. A New Definition of Patient Engagement: Why is Patient
Model. Reprinted with permission from aorn.org.
Copyright ª 2014, AORN, Inc, Denver, CO. All rights
reserved.
ture. J Adv Nurs. 1997;25(1):130-138.
January 13, 2014.
Care Manage. 2012;35(2):80-89.
www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW
or emailed to multiple sites or posted to a listserv without the copyright holder’s express
written permission. However, users may print, download, or email articles for individual use.