Transition to the Nursing profession
RUA: Transitions Paper (Summuraize this article as an essay 2 full pages not including title page and reference page) (I upload below the article and the student paper to follow as an example)
The title of the essay is “Safety”
“Does Nursing Home Compare Reflect Patient Safety In Nursing Homes? Article upload to write about”
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CINAHL with Full Text
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1) Include the following sections.
A. Introduction – 20 points/13%
• Clearly establishes the purpose of the paper
• Includes key points to be covered
• Captures the reader’s interest
B. Body of Paper – 60 points/40%
• Complete, well-developed discussion of key points
• Supports the purpose or main idea of the paper
• Logical development of ideas with clear and accurate information
• Ideas and statements are supported by three or more examples from personal and/or professional experiences
• Provides own perspectives on the topic that is reflective, insightful, and original
C. Conclusion – 30 points/20% • Clear and concise
• Summarizes key points discussed in the paper
• Leaves a strong impression, message, or idea on the reader
D. Writing Style – 15 point/10% e. Correct use of standard English grammar, paragraph, and sentence structure
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• There is a correct and appropriate use of margins, spacing, font, and headers
• Document setup includes title and reference pages in correct APA format NR103 Transition to the Nursing Profession Transitions Paper Guidelines NR103_Transitions_Paper_Guidelines 2
• Citation of sources included in the body of the paper uses the correct APA format for direct and indirect quotes
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ByDaniel Brauner, Rachel M. Werner, Tetyana P. Shippee, John Cursio, Hari Sharma, and
R. Tamara Konetzka
AGING & HEALTH
Does Nursing Home Compare
Reflect Patient Safety In
Nursing Homes?
ABSTRACT The past several decades have seen significant policy efforts
to improve the quality of care in nursing homes, but the patient safety
movement has largely ignored this setting. In this study we compared
nursing homes’ performance on several composite quality measures
from Nursing Home Compare, the most prominent recent example of a
national policy aimed at improving the quality of nursing home care, to
their performance on measures of patient safety in nursing homes such
as pressure sores, infections, falls, and medication errors. Although
Nursing Home Compare captures some aspects of patient safety, we
found the relationship to be weak and somewhat inconsistent, leaving
consumers who care about patient safety with little guidance. We
recommend that Nursing Home Compare be refined to provide a
clearer picture of patient safety and quality of life, allowing consumers
to weight these domains according to their preferences and priorities.
T
he Institute of Medicine (IOM)
inspired the quality improvement
movement for US nursing homes
with its 1986 report titled Improving
the Quality of Care in Nursing
Homes.1 The report noted the “shockingly defi-
cient” care that people were receiving in many
government-licensed nursing homes. This re-
port led to the Nursing Home Reform Act of
1987, which mandated extensive regulatory con-
trols; regular inspections; and the development
of a resident-level assessment, data collection,
and care planning system.
It wasn’t until 1999 that another groundbreak-
ing report by the IOM, To Err Is Human, ignited
the patient safety movement.2 Focusing on the
prevention of medical errors in acute care, the
patient safety movement inspired a proliferation
of attention focused on creating evidence-based
methods for improving the safety of care,3,4 along
with systems analysts calling for an “integrated
framework” to create a universally applicable
and coherent approach to quality and patient
safety.5
However, until recently, attention to patient
safety in nursing homes remained conspicuously
absent. A 2015 review of evidence on patient
safety in nursing homes concluded that patient
safety outcomes in such facilities have not been
well studied and that patient safety measures
taken from the hospital setting are unlikely to
apply to the nursing home context, with its
unique set of resident characteristics and regu-
latory environment.6 A related article noted the
weak and mixed evidence base on interventions
for improving patient safety in nursing homes.7
At the time when patient safety in acute care
was gaining momentum, policy makers re-
mained focused on improving the quality of care
in nursing homes and did not define these efforts
as promoting patient safety. Notably, in 2002 the
Centers for Medicare and Medicaid Services
(CMS) substantially expanded its quality im-
provement efforts by launching Nursing Home
Compare (NHC), a national effort to publicly
report the quality of care in all US nursing
doi: 10.1377/hlthaff.2018.0721
HEALTH AFFAIRS 37,
NO. 11 (2018): 1770–1778
©2018 Project HOPE—
The People-to-People Health
Foundation, Inc.
Daniel Brauner is an associate
professor in the Department
of Medicine, University of
Chicago, in Illinois.
Rachel M. Werner is a
professor of medicine in the
Division of General Internal
Medicine at the Perelman
School of Medicine and a
professor of health care
management at the Wharton
School of Business, both
at the University of
Pennsylvania, and core
faculty at the Center for
Health Equity Research
and Promotion, Corporal
Michael J. Crescenz Veterans
Affairs Medical Center, in
Philadelphia.
Tetyana P. Shippee is an
associate professor in the
Division of Health Policy
and Management, School of
Public Health, University of
Minnesota, in Minneapolis.
John Cursio is a research
assistant professor in the
Department of Public Health
Sciences, University of
Chicago.
Hari Sharma is an assistant
professor in the Department
of Health Management and
Policy, University of Iowa, in
Iowa City. At the time this
research was conducted,
Sharma was a doctoral
student in the Department
of Public Health Sciences,
University of Chicago.
R. Tamara Konetzka
(konetzka@uchicago.edu) is a
professor in the Department
of Public Health Sciences
and in the Department of
Medicine, University of
Chicago.
1770 Health Affairs November 2018 37:11
Aging & Health
homes, thereby informing consumers and in-
centing the improvement of quality. NHC was
modified to feature a five-star composite rating
system for overall quality in late 2008, assigning
each nursing home a rating of one to five stars
(with more stars indicating higher quality).
The notions of health care quality and patient
safety are often conflated. Although they over-
lap, patient safety—in the IOM’s sense of preven-
tion of harm to patients from medical errors2—
may be considered a subdomain of quality that is
associated with distinct approaches, processes,
and outcomes. The emphasis in patient safety is
on identifying errors, determining their cause,
and preventing them from happening again, of-
ten by addressing gaps or failures in the relevant
system of care. In the nursing home setting, res-
ident falls are a good example of a typical patient
safety target. If a nursing home finds that fall
rates are high, a patient safety approach would
examine the circumstances that lead to the falls.
For example, a fall might result from a loss of
balance that may be due to the side effects of
medications, environmental hazards, or lack of
appropriate staffing to provide oversight and
assistance. To prevent future falls, each of these
items might be addressed. Ultimately, these ef-
forts can result in improved patient safety.
A quality improvement perspective, on the
other hand, would consider avoiding adverse
events from errors as one of a broader set of
goals. Quality improvement efforts also work
to enable positive health outcomes beyond im-
proving safety. For nursing homes, some of these
other goals have been defined as improving or
maintaining functional status, treating pain,
maintaining weight, avoiding incontinence and
catheter use, avoiding depression, avoiding
physical restraints and the inappropriate use of
antipsychotic medications, and improving vacci-
nation rates. There has been little attention
placed on differentiating patient safety from oth-
er types of quality outcomes in tools designed to
measure nursing home quality.
Our goal was to examine the relationship be-
tween nursing homes’ performance on standard
quality measures overall and on measures spe-
cific to patient safety in nursing homes. To do so,
we focused on quality measures from NHC, a
national, policy-driven public reporting system.
Prior research has established that providers
monitor their ratings and attempt to improve
them,8,9 and NHC scores have generally im-
proved over time.10 Yet it is unclear whether nurs-
ing homes that score well on NHC also perform
well from a patient safety perspective.While NHC
was intended first and foremost to help consum-
ers choose high-quality nursing homes, arguably
it is the extreme examples of poor patient safety
outcomes, sometimes associated with neglect,
that consumers fear most when considering
nursing home placement.
NHC star ratings are based on three domains
of quality: state regulatory health inspections,
staffing ratios, and clinical quality. Each facility
is assigned a star rating for each domain. The
health inspections domain rating is based on the
number, scope, and severity of health deficien-
cies found at state inspections and the number of
repeat visits needed to confirm the correction of
deficiencies, all relative to other facilities in the
state. One key area of patient safety, medication
errors, appears in several potential health defi-
ciencies in this domain. The staffing domain rat-
ing is based on case-mix-adjusted measures of
total nurse hours per resident day and registered
nurse hours per resident day, relative to specific
national thresholds. The clinical quality domain
rating is based on meeting national thresholds
across a group of individual outcome measures,
some of which are patient safety measures.
The overall star rating combines the three do-
mains, using the health inspection star rating as
a base and potentially adjusting the rating up or
down depending on the staffing and clinical
quality star ratings. The health inspections do-
main is given thegreatest weight, as itis based on
the results of inspections by state surveyors rath-
er than facility self-reported data and is therefore
considered the most objective. The three individ-
ual domain star ratings are reported on NHC in
addition to the overall star rating. Details of the
process for calculating the star ratings can be
found on the NHC website.11
NHC does include some patient safety mea-
sures, such as pressure sores and injurious falls,
that are often associated in the minds of consum-
ers with neglect. However, because NHC mea-
sures many factors, its signal in terms of patient
safety performance may be weak. How much
NHC reflects patient safety and what consumers
can learn from NHC scores about patient safety
have not been established.
Study Data And Methods
Data Source We merged data for the first quar-
ter of 2017 from the Nursing Home Compare
archives with data from Certification and Survey
Provider Enhanced Reporting (CASPER) to cre-
ate a nursing home–level data set. The archives, a
historical compilation of ratings published on
the NHC website, provided us with each home’s
overall and domain-specific star ratings and
facility-level performance on individual patient
safety measures that appear in the quality mea-
sures domain. CASPER is a compilation of data
collected by surveyors during regular inspec-
November 2018 37:11 Health Affairs 1771
tions of nursing facilities for Medicare and Med-
icaid certification. From CASPER, we obtained
profit status, payer mix, and chain status, as well
as whether the nursing home was cited for medi-
cation errors in its most recent prior health
inspection—information not published as part
of the NHC archives.
Methods We examined six key measures
of patient safety in nursing homes: injurious
falls, urinary tract infections, and pressure sores
among long-stay residents; pressure sores
among short-stay residents; and two measures
of medication errors. Applying the IOM’s sense
of safety as the prevention of harm to patients
from medical errors,2 which we took to include
acts of omission and commission, we defined the
domain of nursing home measures of safety as
negative outcomes that were potentially avoid-
able. These measures have been identified as
safety concerns in the literature as well.6 Al-
though the distinction is not always sharp, other
types of NHC quality measures (such as pain
control, functional status, and vaccination rates)
are typically not considered patient safety mea-
sures. Each of our selected outcomes is impor-
tant in that it potentially leads to hospitalization
and subsequent health consequences that are
costly in terms of health care use, morbidity,
and mortality. Some evidence (though mixed)
exists on interventions that could help avoid
each of these outcomes.7 Falls could be avoided
through education programs, mobility aids, re-
ducing polypharmacy, and increased or more
consistent staffing levels.12,13 Urinary tract infec-
tions could be reduced through minimizing the
use of urinary catheters and ensuring their prop-
er use, including through better hygiene.14,15
Pressure sores could be reduced through fre-
quent turning of mobility-limited residents and
ensuring proper nutrition and hydration.16 Fi-
nally, medication errors could be reduced
through medication review and improved com-
munication across care providers.17,18
The first four measures (injurious falls, uri-
nary tract infections, and the two pressure sore
measures) were originally based on federally
mandated assessments of residents’ condition at
regular intervals, the data from which are com-
piled into the Minimum Data Set 3.0. The data
are reported by the nursing homes and reviewed
by nursing home inspectors. Following technical
specifications for each measure,19 CMS uses
the data to define the cohort at risk. Long-stay
residents are defined as those who have been
residing in the facility for at least 100 days, and
short-stay residents as those with shorter lengths-
of-stay, primarily for post–acute care rehabilita-
tion. In addition, a resident must be considered
at risk for the outcome being measured. For ex-
ample, for the long-stay pressure sore measure,
residents at risk are those with mobility limita-
tions. Each resident who qualifies for the cohort
is then coded as having had the adverse outcome
or not, with regression-based risk adjustment
incorporated into some measures. The resi-
dent-level binary outcomes are aggregated into
a facility-level percentage that is averaged over
four quarters and reported on NHC. We used
these facility-level percentages in our analysis.
The two measures of medication errors are
based on deficiency citations from health inspec-
tions. Each nursing home in the US that qualifies
for Medicare, Medicaid, or both must be in-
spected by state surveyors at least once every
fifteen months to ensure compliance with regu-
lations.When a facility is found to be out of com-
pliance, it is cited with a deficiency that needs to
be corrected. There are hundreds of possible de-
ficiencies. We focused on two related to medica-
tion errors, as these errors are prototypical safe-
ty failures across health care settings. The first
identifies significant medication errors among
one or more residents; the second is for a medi-
cation error rate of more than 5 percent of all
doses prescribed, at any level of significance.
These deficiencies are each defined as equal
to 1 (cited) or 0 (not cited) at the facility level.
Each deficiency is also assigned a score for the
scope and severity of the violation. We ignored
this information because its use complicated
the measure without substantively changing our
results.
Analysis Our primary goal was to examine
the relationship between nursing homes’ perfor-
mance on standard quality measures overall and
on measures specific to patient safety in nursing
homes. We first tested the Pearson correlation
between performance on each patient safety
Our results highlight
the differences
between patient
safety and quality
improvement, two
related but distinct
approaches to
improving health care.
Aging & Health
1772 Health Affairs November 2018 37:11
measure and both the NHC overall star rating
and the NHC health inspection star rating. Next,
we tested the correlation between patient safety
measures and NHC ratings graphically by strati-
fying nursing homes on overall star level and
displaying the average percentage for each mea-
sure. The average percentage was calculated as
the unweighted average across facilities in each
star category of the reported percentage of res-
idents who trigger each measure—that is, the
average of facility-level percentages.The medica-
tion error measures represent the average per-
centage of facilities cited for the deficiency.
We used analysis-of-variance tests to test for
groupwise differences. If NHC serves as a good
marker for patient safety, the means should be
highest for one-star homes and lowest for five-
star homes, with a monotonic trend in between.
The patient safety measures we studied are in-
cluded in NHC, so some correlation is to be ex-
pected. At the same time, their role in the overall
score may be limited. Medication errors are cap-
tured only to the extent that nursing homes are
cited with a regulatory deficiency for having iso-
lated or frequent errors and are just two possible
deficiencies among hundreds that feed into a
complex formula for the health inspection score.
That score and associated star rating do not iden-
tify which deficiencies had an impact on the
score. One can find the full health inspection
results, including specific deficiencies cited, on
the NHC website, but these are far less promi-
nent than the star ratings and require multiple
clicks through the website. The other four pa-
tient safety measures we studied (injurious
falls, urinary tract infections, and pressure sores
among long-stay residents; and pressure sores
among short-stay post–acute care residents) are
included as separate measures within the clinical
quality domain on NHC. Although all four mea-
sures are included in the star rating for clinical
quality, they constitute a minority of the twenty-
four measures (sixteen of which are included in
the star rating). Thus, the extent to which patient
safety is reflected in NHC depends on whether
patient safety variation drives, or is correlated
with, overall variation in quality.
Our secondary goal was to identify the types of
nursing homes in which patient safety was likely
to present the greatest challenges. To do this, we
compared rates of patient safety outcomes by
key nursing home characteristics: profit status,
chain status, and payer mix (whether the facility
is dominated by Medicaid, using 90 percent of
residents on Medicaid as our threshold).20
Limitations Our approach was subject to sev-
eral limitations. First, it is possible that neither
the NHC ratings nor the individual patient safety
measures reflect true quality or safety. Our goal
was to examine the relationships among types of
measures, not to assess their underlying validity.
Second, we examined six typical measures of
patient safety that were available in our data, but
these measures might not provide a complete
picture of patient safety and might not be equally
important.
Third, the relationships we studied might not
be causal and could be the result of unobservable
factors that were correlated with both quality
and safety, such as the ability of facility manag-
ers. We were mainly interested in whether the
NHC ratings acted as a signal for performance
in patient safety and did not intend to explore the
underlying mechanisms.
Study Results
Our national sample of nursing homes in the
first quarter of 2017 is summarized in online
appendix exhibit 1.21 We analyzed data on 15,652
nursing homes, which includes all nursing
homes in the country certified for Medicare,
Medicaid, or both.
We expected measures of patient safety (all of
which were constructed as adverse outcomes,
so that lower rates are better) to have a negative
correlation with the Nursing Home Compare
overall star rating, in which more stars are
better. Exhibit 1 shows that this expected nega-
tive relationship was the norm (with some ex-
ceptions), but the correlations were quite low.
The highest correlation (in absolute value) was
for pressure sores among long-stay residents
(−0.21), and the lowest was for urinary tract
infections among the same population (−0.05).
Exhibit 1
Correlations between patient safety measures and Nursing Home Compare overall and
health inspection star ratings in the first quarter of 2017
Nursing Home Compare star
rating
Safety measure Overall Health inspection
Pressure sores (long-stay residents only) −0.21 −0.13
Pressure sores (short-stay residents only) −0.12 −0.05
Urinary tract infections (long-stay residents only) −0.05 0.04
Injurious falls (long-stay residents only) −0.06 0.02
Medication error rate >5% (all residents) −0.15 −0.17
Significant medication error(s) (all residents) −0.13 −0.14
SOURCE Authors’ analysis of data from Nursing Home Compare and Certification and Survey Provider
Enhanced Reporting (CASPER). NOTES The Nursing Home Compare health inspection star rating is for
the health inspections domain only, which is one of the three components used to calculate the
Nursing Home Compare overall star rating. Long-stay residents are defined as people who have been
residing in the nursing home for at least a hundred days. Short-stay residents are defined as people
with a shorter length-of-stay, usually for post–acute care purposes. All correlations were significant
(p < 0:05). Although we focused our analysis on a single quarter for ease of exposition, similar results
were obtained for 2012–16.
November 2018 37:11 Health Affairs 1773
This means that nursing homes with higher star
ratings generally had lower rates of both pres-
sure sores and urinary tract infections, but these
relationships were quite weak. Pearson correla-
tion coefficients in general run from 0 to 1 in
absolute value, with 0 indicating no relationship
between two variables and 1 indicating the stron-
gest possible relationship. The correlations be-
tween patient safety measures and the star rating
for the health inspections domain, which is one
of three components used in the overall star rat-
ing, were generally even lower.
Nursing homes’ performance on patient safety
measures appears to track somewhat with the
overall star rating. Notably, for the nondefi-
ciency measures (injurious falls, urinary tract
infections, and the two pressure sore measures),
the differences were most pronounced at the
extremes (one-star versus five-star ratings), with
little meaningful difference between nursing
homes with ratings in the two- to four-star range
(exhibit 2). The one exception was pressure
sores among long-stay residents, which exhib-
ited a more monotonic trend by star rating,
with the difference from one star (7.1 percent)
to five stars (4.2 percent) constituting a clinically
meaningful magnitude. In contrast to most of
the nondeficiency measures, the relationship be-
tween the overall star rating and deficiency cita-
tions for medication errors was more consistent.
The difference between the pattern for medi-
cation-related deficiencies and other patient
safety measures is likely due to the fact that defi-
ciencies inherently affect the health inspection
rating (even if medication-related deficiencies
are only two of many), and the health inspection
rating is weighted more heavily than the other
domains in the overall star rating. To explore this
explanation, exhibit 3 displays the relationship
between mean patient safety outcomes and the
star rating in the health inspection domain. Oth-
er than pressure sores, the clinical outcomes had
little relationship with the health inspection star
rating, with two measures (urinary tract infec-
tions and injurious falls) even suggesting a posi-
tive relationship. However, medication-related
deficiency rates still reflected the expected down-
ward slope. Deficiencies for this classic patient
safety issue—medication errors—appeared to be
better correlated with health inspection ratings
Exhibit 2
Nursing homes’ performance on patient safety measures in the first quarter of 2017, by Nursing Home Compare overall
star rating
SOURCE Authors’ analysis of data from Nursing Home Compare and Certification and Survey Provider Enhanced Reporting. NOTES The
average percentages are calculated as the unweighted average across facilities in each star category of the reported percentage of
residents who trigger each measure—that is, the average of facility-level percentages. The medication error measures represent the
average percentage of facilities cited for the deficiency. Long-stay residents (LS) and short-stay residents (SS) are defined in the notes
to exhibit 1.
Aging & Health
1774 Health Affairs November 2018 37:11
and therefore with overall NHC ratings.
Our exploration of heterogeneity by nursing
home type (profit or nonprofit, independent
or chain, and high or low Medicaid) revealed
no substantial differences in the relationship
between the NHC ratings and patient safety mea-
sures, but at least one nursing home character-
istic was associated with worse absolute perfor-
mance on several of the patient safety measures:
For-profit facilities had higher rates of both de-
Exhibit 3
Nursing homes’ performance on patient safety measures in the first quarter of 2017, by Nursing Home Compare health
inspection star rating
SOURCE Authors’ analysis of data from Nursing Home Compare and Certification and Survey Provider Enhanced Reporting. NOTES The
average percentages are calculated as explained in the notes to exhibit 2. The Nursing Home Compare health inspection star rating is
for the health inspections domain only, which is one of the three components used to calculate the Nursing Home Compare overall star
rating. Long-stay residents (LS) and short-stay residents (SS) are defined in the notes to exhibit 1.
Exhibit 4
Performance on patient safety measures in the first quarter of 2017, by key nursing home characteristics
Characteristic
For profit Chain High Medicaid
Safety measure Yes No Yes No Yes No
All nursing
homes
Pressure sores (long-stay residents only) 6.0% 5.0% 5.8% 5.8% 6.2% 5.7% 5.7%
Pressure sores (short-stay residents only) 1.1 1.1 1.0 1.2 1.1 1.1 1.1
Urinary tract infections (long-stay residents only) 4.3 5.1 4.4 4.7 3.6 4.6 4.6
Falls (long-stay residents only) 3.2 3.8 3.3 3.4 2.5 3.4 3.4
Medication error rate >5% (all residents) 15.1 9.2 13.8 13.5 15.1 13.6 13.4
Significant medication error(s) (all residents) 7.3 4.0 6.4 6.0 5.7 6.3 6.3
SOURCE Authors’ analysis of data from Nursing Home Compare and Certification and Survey Provider Enhanced Reporting (CASPER). NOTES High Medicaid is defined as
having at least 90 percent of residents with Medicaid as their primary payer. Long-stay residents and short-stay residents are defined in the notes to exhibit 1. The
percentages are averages, calculated as explained in the notes to exhibit 2.
November 2018 37:11 Health Affairs 1775
ficiency-based patient safety measures and pres-
sure sores among long-stay residents (exhibit 4).
As for-profit, chain, and high-Medicaid facilities
also tended to score lower on health inspections
and on the NHC star ratings, this result for
for-profit status was consistent with expecta-
tions.22,23 At the same time, rates of urinary tract
infections and falls exhibited the opposite pat-
tern: For-profit, chain, and high-Medicaid facili-
ties reported consistently lower rates than non-
profit and independent facilities did.
Discussion
Our results highlight the differences between
patient safety and quality improvement, two
related but distinct approaches to improving
health care. In nursing homes, quality improve-
ment has been emphasized, with less attention
paid to patient safety. Our results reveal that
Nursing Home Compare, a key policy initiative
aimed at improving quality and empowering
consumers to make better choices, does not pro-
vide them with much information on which to
judge patient safety in nursing homes. Triangu-
lating among several sources of data, we found
that although there was some correlation be-
tween NHC star ratings and patient safety mea-
sures, these tended to be weak—and for many
safety measures, nonexistent. A rating of one
star or five stars seemed to give the most infor-
mation about patient safety, with one-star nurs-
ing homes having higher rates of adverse safety
events and five-star nursing homes having the
lowest rates. However, for nursing homes in the
middle—those with two, three, or four stars—
there was no meaningful difference in adverse
safety events between nursing homes with differ-
ent star ratings. This lack of correlation makes
interpretation more difficult for consumers, as
the difference between a one-star and a two-star
facility is quite different from the difference be-
tween a three-star and a four-star facility. Finally,
nursing home characteristics such as profit and
chain status and payer mix do not serve as con-
sistent proxies for patient safety performance.
Nursing homes that scored well on NHC did
exhibit a more consistent relationship between
the star ratings and two important measures of
patient safety—rates of pressure sores among
long-stay residents and citations for medication
errors—but again, these correlations were small.
Furthermore, a high star rating says little about
therates of such outcomes as fallsand infections.
In fact, we found that those facilities with the
highest star ratings in the health inspections
domain (arguably the most objective domain
we studied) reported more falls and urinary tract
infections. These measures may simply present
different clinical challenges. However, another
possible explanation for this seemingly paradox-
ical finding is that superior facilities may be
better able to identify and track falls and urinary
tract infections, which suggests an ascertain-
ment bias that exposes an inherent problem in
reporting systems such as NHC.
Overall, our findings suggest that NHC does
not adequately reflect patient safety in nursing
homes, even though it contains some patient
safety measures. Accordingly, consumers who
prioritize patient safety might not find NHC a
useful tool with which to assess the performance
of nursing homes. This conclusion suggests one
straightforward and plausible solution: Nursing
home performance on patient safety should be
emphasized more in NHC. Specifically, to rectify
the lack of focus on patient safety in NHC, we
recommend that patientsafety measures be iden-
tified as a separate subset within the clinical
quality measures. Precedent exists for this type
of grouping of measures in some state report
cards.24 The development and inclusion of a mea-
sure of medication errors would be a helpful
addition to current patient safety measures,
which could be as simple as explicitly reporting
medication-related deficiencies as a new mea-
sure. Despite the importance of medication er-
rors to patient safety, NHC captures this safety
failure only as one deficiency among many used
to calculate the health inspection star rating.
Raising the visibility of patient safety measures
should serve not only to inform consumers but
also to provide a stronger incentive for nursing
homes to improve on these measures.
More broadly, our findings suggest that the
patient safety movement has not been well inte-
To rectify the lack of
focus on patient
safety, we recommend
that patient safety
measures be
identified as a
separate subset within
the clinical quality
measures.
Aging & Health
1776 Health Affairs November 2018 37:11
grated into the nursing home setting. This is a
missed opportunity, but it may also reflect the
challenges of patient safety in nursing homes.
These include the challenges of providing appro-
priate care to older people with long-term care
needs and the potential incompatibility between
patient safety models and the nursing home
setting, as the models were designed largely in
the context of acute care. Not only do nursing
homes serve particularly complex and vulnera-
ble residents, they are also residents’ homes.
Thus, care providers must balance patient safety
needs with residents’ autonomy and freedom.
Recent criticisms of patient safety models sug-
gest that many aspects of medical care are too
complex to be corrected using the models, which
are based on industrial and occupational safety
methods.25 This criticism may be best exempli-
fied by the lack of correlation we found between
nursing home star ratings and rates of falls. An
outcome such as a fall represents a much more
complex event, the result of myriad combina-
tions of problems—for example, cognitive im-
pairment, arthritis, and lack of balance. In addi-
tion, other positive factors such as becoming
more mobile with therapy and gaining an in-
creasing degree of autonomy are both associated
with an increasing possibility of falling, com-
pared with being confined to one’s bed. Achiev-
ing this possibility with its increased risk of
falling may represent a major improvement in
quality and greater resident autonomy at the
same time it heralds an adverse event.
In the quest to improve patient safety in nurs-
ing homes, the need to reconcile competing pri-
orities for long-stay residents will present an
ongoing challenge in NHC and other contexts.
However, the answer to this challenge is not to
deemphasize important patient safety concerns.
Rather, NHC needs to do a better job of repre-
senting the competing concerns of long-stay
residents by incorporating measures related to
quality of life, such as resident and caregiver
satisfaction. Although this would be inherently
challenging because these measures are not con-
veniently derived from administrative data, it is
feasible. Indeed, some states have made substan-
tial progress in measuring and reporting resi-
dent and caregiver satisfaction.26–28 A public re-
porting system that included both patient safety
concerns and quality of life would be the most
straightforward way to represent these two po-
tentially conflicting goals in NHC, while allow-
ing consumers to weight the domains according
to their preferences and priorities.
The challenges of patient safety in nursing
homes will remain embedded in the much
broader challenges of providing appropriate
care to elderly people with long-term care needs.
At the same time, the predominant focus in nurs-
ing homes is improving selected aspects of the
quality of care, with an emphasis on nursing
home star ratings.While tweaking NHC to more
completely measure and report patient safety
metrics is important, there remains the more
central challenge of addressing the tensions and
potential incompatibilities that exist between
patient safety, quality of care, and quality of
life in nursing homes. Within the limited scope
of what a public reporting system can do, NHC
should strive to achieve a more comprehensive
picture that reflects all important domains of
quality—including patient safety and quality of
life, both of which are currently underrepre-
sented. ▪
The authors are grateful for funding
for this work from the Agency for
Healthcare Research and Quality
(Grant No. R01HS024967).
NOTES
1 Institute of Medicine. Improving the
quality of care in nursing homes.
Washington (DC): National Acade-
mies Press; 1986.
2 Corrigan JM, Kohn LT, Donaldson
MS editors. To err is human:
building a safer health system.
Washington (DC): National Acade-
mies Press; 1999.
3 Leape LL, Berwick DM, Bates DW.
What practices will most improve
safety? Evidence-based medicine
meets patient safety. JAMA. 2002;
288(4):501–7.
4 Shojania KG, Duncan BW,
McDonald KM, Wachter RM. Safe
but sound: patient safety meets evi-
dence-based medicine. JAMA. 2002;
288(4):508–13.
5 Runciman WB, Williamson JA,
Deakin A, Benveniste KA, Bannon K,
Hibbert PD. An integrated frame-
work for safety, quality, and risk
management: an information and
incident management system based
on a universal patient safety classi-
fication. Qual Saf Health Care. 2006;
15(Suppl 1):i82–90.
6 Simmons S, Schnelle J, Slagle J,
Sathe NA, Stevenson D, Carlo M,
et al. (Vanderbilt Evidence-based
Practice Center, Nashville, TN).
Resident safety practices in nursing
home settings [Internet]. Rockville
(MD): Agency for Healthcare Re-
search and Quality; 2016 May [cited
2018 Sep 28]. (Technical Brief
No. 24). Available from: https://
effectivehealthcare.ahrq.gov/sites/
default/files/pdf/nursing-home-
safety_technical-brief
7 Simmons SF, Schnelle JF, Sathe NA,
Slagle JM, Stevenson DG, Carlo ME,
et al. Defining safety in the nursing
home setting: implications for future
research. J Am Med Dir Assoc. 2016;
17(6):473–81.
8 Mukamel DB, Spector WD, Zinn JS,
November 2018 37:11 Health Affairs 1777
Huang L, Weimer DL, Dozier A.
Nursing homes’ response to the
Nursing Home Compare report card.
J Gerontol B Psychol Sci Soc Sci.
2007;62(4):S218–25.
9 Perraillon MC, Brauner DJ,
Konetzka RT. Nursing home re-
sponse to Nursing Home Compare:
the provider perspective. Med Care
Res Rev. 2017 Aug 1. [Epub ahead
of print].
10 Abt Associates. Nursing Home
Compare five-star quality rating
system: year five report [public ver-
sion]: final report [Internet]. Balti-
more (MD): Centers for Medicare
and Medicaid Services; 2014 Jun 16
[cited 2018 Sep 28]. Available
from: https://www.cms.gov/
Medicare/Provider-Enrollment-
and-Certification/Certificationand
Complianc/Downloads/NHC-
Year-Five-Report
11 Medicare.gov. About Nursing Home
Compare data: technical details [In-
ternet]. Baltimore (MD): Centers for
Medicare and Medicaid Services;
[cited 2018 Sep 28]. Available from:
https://www.medicare.gov/Nursing
HomeCompare/Data/About.html#
technicalDetails
12 Vlaeyen E, Coussement J, Leysens G,
Van der Elst E, Delbaere K, Cambier
D, et al. Characteristics and effec-
tiveness of fall prevention programs
in nursing homes: a systematic re-
view and meta-analysis of random-
ized controlled trials. J Am Geriatr
Soc. 2015;63(2):211–21.
13 Cameron ID, Gillespie LD,
Robertson MC, Murray GR, Hill KD,
Cumming RG, et al. Interventions for
preventing falls in older people in
care facilities and hospitals.
Cochrane Database Syst Rev. 2012;
12:CD005465.
14 Washington EA. Instillation of 3%
hydrogen peroxide or distilled vine-
gar in urethral catheter drainage bag
to decrease catheter-associated bac-
teriuria. Biol Res Nurs. 2001;3(2):
78–87.
15 Fendler EJ, Ali Y, Hammond BS,
Lyons MK, Kelley MB, Vowell NA.
The impact of alcohol hand sanitizer
use on infection rates in an extended
care facility. Am J Infect Control.
2002;30(4):226–33.
16 Sullivan N, Schoelles KM. Prevent-
ing in-facility pressure ulcers as a
patient safety strategy: a systematic
review. Ann Intern Med. 2013;
158(5 Pt 2):410–6.
17 Marasinghe KM. Computerised
clinical decision support systems
to improve medication safety in
long-term care homes: a systematic
review. BMJ Open. 2015;5(5):
e006539.
18 Fleming A, Browne J, Byrne S. The
effect of interventions to reduce po-
tentially inappropriate antibiotic
prescribing in long-term care facili-
ties: a systematic review of rando-
mised controlled trials. Drugs Aging.
2013;30(6):401–8.
19 RTI International. MDS 3.0 quality
measures: user’s manual (v10.0 03-
25-2015): effective April 1, 2016
[Internet]. Baltimore (MD): Centers
for Medicare and Medicaid Services;
2016 Apr [cited 2018 Sep 28].
Available from: https://www.cms
.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/
NursingHomeQualityInits/
Downloads/MDS-30-QM-
Users-Manual-V10
20 Mor V, Zinn J, Angelelli J, Teno JM,
Miller SC. Driven to tiers: socioeco-
nomic and racial disparities in the
quality of nursing home care. Mil-
bank Q. 2004;82(2):227–56.
21 To access the appendix, click on the
Details tab of the article online.
22 Harrington C, O’Meara J, Kitchener
M, Simon LP, Schnelle JF. Designing
a report card for nursing facilities:
what information is needed and why.
Gerontologist. 2003;43(Spec No 2):
47–57.
23 Konetzka RT, Gray ZS. The role of
socioeconomic status in nursing
home quality ratings. Seniors Hous
Care J. 2017;25(1):3–14.
24 Arling G, Job C, Cooke V. Medicaid
nursing home pay for performance:
where do we stand? Gerontologist.
2009;49(5):587–95.
25 Braithwaite J,Wears RL, Hollnagel E.
Resilient health care: turning patient
safety on its head. Int J Qual Health
Care. 2015;27(5):418–20.
26 Shippee TP, Henning-Smith C,
Gaugler JE, Held R, Kane RL. Family
satisfaction with nursing home care.
Res Aging. 2017;39(3):418–42.
27 Shippee TP, Henning-Smith C, Kane
RL, Lewis T. Resident- and facility-
level predictors of quality of life in
long-term care. Gerontologist. 2015;
55(4):643–55.
28 Williams A, Straker JK, Applebaum
R. The nursing home five star rating:
how does it compare to resident and
family views of care? Gerontologist.
2016;56(2):234–42.
Aging & Health
1778 Health Affairs November 2018 37:11
Brauner D, Werner RM, Shippee TP, Cursio J, Sharma H, Konetzka RT. Does nursing home compare reflect patient
safety in nursing homes? Health Aff (Millwood). 2018;37(11).
Appendix Exhibit 1: Summary of the Sample
Number of Nursing Homes 15,652
Size and Occupancy, mean (SD)
Total residents 86.1 (54.0)
Certified beds 106.2 (60.9)
Occupancy, % 80.6 (16.1)
Ownership
For profit 10,855 (69.4%)
Government 1,114 (7.1%)
Nonprofit 3,683 (23.5%)
Certification
Medicaid only 382 (2.4%)
Medicare only 758 (4.8%)
Medicaid and Medicaid 14,512 (92.7%)
% Medicare residents, mean (SD) 14.6 (15.0)
% Medicaid residents, mean (SD) 58.5 (24.8)
Hospital-based
No 14,862 (94.9%)
Yes 790 (5.0%)
Nursing Home Compare Overall Star
Rating
1 (lowest quality) 2,540 (16.2%)
2 2,954 (18.9%)
3 2,843 (18.2%)
4 3,537 (22.6%)
5 (highest quality) 3,647 (23.3%)
Patient Safety Measures, mean percent
of residents (SD)
Pressure Sores (long stay) 5.7 (4.4)
Pressure Sores (short stay) 1.1 (1.7)
Urinary tract infections (long stay) 4.6 (4.3)
Falls (long stay) 3.4 (2.8)
Medication error deficiency citations
Error rate > 5%, number (%) cited 2,106 (13.4)
Significant medication error(s),
number (%) cited
984 (6.3)
SOURCE: Authors’ analysis of Nursing Home Compare and CASPER data.
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.
NR103 Transition to the Nursing Profession
Transitions Paper Guidelines
NR103_Transitions_Paper_Guidelines 1
The purpose of this assignment is to explore a critical concept in nursing. The student will be able to demonstrate
application of information literacy and ability to utilize resources (library, writing center, Center for Academic Success
[CAS], APA resources, Turnitin, and others) through literature search and writing the paper.
Course outcomes: This assignment enables the student to meet the following course outcomes.
CO 2: Identify characteristics of professional behavior including emotional intelligence, communication, and conflict
resolution.
CO 3: Demonstrate information literacy and the ability to utilize resources.
Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to
this assignment.
Total points possible: 150 points
Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
1) Locating Evidence
a. Using the Chamberlain University library, search for a recent (published within the last five years) evidence-
based article from a scholarly journal that addresses one of the topics listed.
• Safety
• Delegation
• Prioritization
• Caring
2) Include the following sections.
a. Introduction – 20 points/13%
• Clearly establishes the purpose of the paper
• Includes key points to be covered
• Captures the reader’s interest
b. Body of Paper – 60 points/40%
• Complete, well-developed discussion of key points
• Supports the purpose or main idea of the paper
• Logical development of ideas with clear and accurate information
• Ideas and statements are supported by three or more examples from personal and/or professional
experiences
• Provides own perspectives on the topic that is reflective, insightful, and original
c. Conclusion – 30 points/20%
• Clear and concise
• Summarizes key points discussed in the paper
• Leaves a strong impression, message, or idea on
the reader
d. Writing Style – 15 point/10%
e. Correct use of standard English grammar, paragraph, and sentence structure
f. No spelling or typographical errors
g. Organized around required components
h. Information flows in a logical sequence that is
easy for the reader to follow
i. APA Format, and References – 25 points/17%
• There is correct and appropriate use of margins, spacing, font, and headers
• Document setup includes title and reference pages in correct APA format
NR103 Transition to the Nursing Profession
Transitions Paper Guidelines
NR103_Transitions_Paper_Guidelines 2
• Citation of sources included in the body of the paper uses correct APA format for direct and indirect quotes
• All elements of each reference are included in the correct order
• All information taken from the source, even if summarized, is cited and listed on the Reference page
• All sources used are nursing journals published within the last five years
For writing assistance (APA, formatting, or grammar) visit the APA Citation and Writing page in the online library.
Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned.
https://library.chamberlain.edu/APA
NR103 Transition to the Nursing Profession
Transitions Paper Guidelines
NR103_Transitions_Paper_Guidelines 3
Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory Level
of Performance
Unsatisfactory
Level of
Performance
Section not
present in paper
Introduction
(20 points/13%)
20 points 19 points 15 points 7 points 0 points
Required criteria
1. Clearly establishes the purpose of the paper
2. Includes key points to be covered
3. Captures the reader’s interest
Includes no fewer
than 3 requirements
for section.
Includes no fewer
than 2 requirements
for section.
Includes no less than
1 requirement for
section.
Present, yet includes
no required criteria.
No requirements for
this section
presented.
Body of Paper – 60 points/40%
(60 points/40%)
60 points 55 points 46 points 23 points 0 points
Required criteria
1. Complete, well-developed discussion of key
points
2. Supports the purpose or main idea of the paper
3. Logical development of ideas with clear and
accurate information
4. Ideas and statements are supported by three or
more examples from personal and/or
professional experiences
5. Provides own perspectives on the topic that is
reflective, insightful, and original
Includes 5
requirements for
section.
Includes 4
requirements for
section.
Includes 3
requirements for
section.
Includes 1-2
requirements for
section.
No requirements for
this section
presented.
Conclusion
(30 points/20%)
30 points 27 points 23 points 12 points 0 points
Required criteria
1. Clear and concise
2. Summarizes key points discussed in the paper
3. Leaves a strong impression, message, or idea on
the reader
Includes 3
requirements for
section.
Includes 2
requirements for
section.
Includes 1
requirement for
section.
Section present yet
includes no required
criteria.
No requirements for
this section
presented.
NR103 Transition to the Nursing Profession
Transitions Paper Guidelines
NR103_Transitions_Paper_Guidelines 4
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory Level
of Performance
Unsatisfactory
Level of
Performance
Section not
present in paper
Writing Style
(15 points/10%)
15 points 14 points 11 points 6 points 0 points
Required criteria
1. Correct use of standard English grammar,
paragraph, and sentence structure
2. No spelling or typographical errors
3. Organized around required components
4. Information flows in a logical sequence that is
easy for the reader to follow
Includes 4
requirements for
section.
Includes 3
requirements for
section.
Includes 2
requirements for
section.
Includes 1
requirement for
section.
No requirements for
this section
presented.
APA Style and Organization
(25 points/10%)
25 points 23 points 19 points 9 Points 0 points
Required criteria
1. There is correct and appropriate use of margins,
spacing, font, and headers.
2. Document setup includes title and reference
pages in correct APA format.
3. Citation of sources included in the body of the
paper uses correct APA format for direct and
indirect quotes.
4. Sources are cited correctly on the Reference
page. All elements of each reference are
included in the correct order.
5. All information taken from the source, even if
summarized, must be cited and listed on the
Reference page.
6. All sources used are nursing journals published
within the last five years.
Includes 6
requirements for
section.
Includes 5
requirements for
section.
Includes 3-4
requirements for
section.
Includes 1-2
requirements for
section.
No requirements for
this section
presented.
Total Points Possible = 150 points
- Purpose
Preparing the assignment
Grading Rubric
NR103 Transition to the Nursing Profession
Transitions Paper Guidelines
NR103_Transitions_Paper_Guidelines 1
The purpose of this assignment is to explore a critical concept in nursing. The student will be able to demonstrate
application of information literacy and ability to utilize resources (library, writing center, Center for Academic Success
[CAS], APA resources, Turnitin, and others) through literature search and writing the paper.
Course outcomes: This assignment enables the student to meet the following course outcomes.
CO 2: Identify characteristics of professional behavior including emotional intelligence, communication, and conflict
resolution.
CO 3: Demonstrate information literacy and the ability to utilize resources.
Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to
this assignment.
Total points possible: 150 points
Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
1) Locating Evidence
a. Using the Chamberlain University library, search for a recent (published within the last five years) evidence-
based article from a scholarly journal that addresses one of the topics listed.
• Safety
• Delegation
• Prioritization
• Caring
2) Include the following sections.
a. Introduction – 20 points/13%
• Clearly establishes the purpose of the paper
• Includes key points to be covered
• Captures the reader’s interest
b. Body of Paper – 60 points/40%
• Complete, well-developed discussion of key points
• Supports the purpose or main idea of the paper
• Logical development of ideas with clear and accurate information
• Ideas and statements are supported by three or more examples from personal and/or professional
experiences
• Provides own perspectives on the topic that is reflective, insightful, and original
c. Conclusion – 30 points/20%
• Clear and concise
• Summarizes key points discussed in the paper
• Leaves a strong impression, message, or idea on
the reader
d. Writing Style – 15 point/10%
e. Correct use of standard English grammar, paragraph, and sentence structure
f. No spelling or typographical errors
g. Organized around required components
h. Information flows in a logical sequence that is
easy for the reader to follow
i. APA Format, and References – 25 points/17%
• There is correct and appropriate use of margins, spacing, font, and headers
• Document setup includes title and reference pages in correct APA format
NR103 Transition to the Nursing Profession
Transitions Paper Guidelines
NR103_Transitions_Paper_Guidelines 2
• Citation of sources included in the body of the paper uses correct APA format for direct and indirect quotes
• All elements of each reference are included in the correct order
• All information taken from the source, even if summarized, is cited and listed on the Reference page
• All sources used are nursing journals published within the last five years
For writing assistance (APA, formatting, or grammar) visit the APA Citation and Writing page in the online library.
Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned.
https://library.chamberlain.edu/APA
NR103 Transition to the Nursing Profession
Transitions Paper Guidelines
NR103_Transitions_Paper_Guidelines 3
Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory Level
of Performance
Unsatisfactory
Level of
Performance
Section not
present in paper
Introduction
(20 points/13%)
20 points 19 points 15 points 7 points 0 points
Required criteria
1. Clearly establishes the purpose of the paper
2. Includes key points to be covered
3. Captures the reader’s interest
Includes no fewer
than 3 requirements
for section.
Includes no fewer
than 2 requirements
for section.
Includes no less than
1 requirement for
section.
Present, yet includes
no required criteria.
No requirements for
this section
presented.
Body of Paper – 60 points/40%
(60 points/40%)
60 points 55 points 46 points 23 points 0 points
Required criteria
1. Complete, well-developed discussion of key
points
2. Supports the purpose or main idea of the paper
3. Logical development of ideas with clear and
accurate information
4. Ideas and statements are supported by three or
more examples from personal and/or
professional experiences
5. Provides own perspectives on the topic that is
reflective, insightful, and original
Includes 5
requirements for
section.
Includes 4
requirements for
section.
Includes 3
requirements for
section.
Includes 1-2
requirements for
section.
No requirements for
this section
presented.
Conclusion
(30 points/20%)
30 points 27 points 23 points 12 points 0 points
Required criteria
1. Clear and concise
2. Summarizes key points discussed in the paper
3. Leaves a strong impression, message, or idea on
the reader
Includes 3
requirements for
section.
Includes 2
requirements for
section.
Includes 1
requirement for
section.
Section present yet
includes no required
criteria.
No requirements for
this section
presented.
NR103 Transition to the Nursing Profession
Transitions Paper Guidelines
NR103_Transitions_Paper_Guidelines 4
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Highest Level of
Performance
High Level of
Performance
Satisfactory Level
of Performance
Unsatisfactory
Level of
Performance
Section not
present in paper
Writing Style
(15 points/10%)
15 points 14 points 11 points 6 points 0 points
Required criteria
1. Correct use of standard English grammar,
paragraph, and sentence structure
2. No spelling or typographical errors
3. Organized around required components
4. Information flows in a logical sequence that is
easy for the reader to follow
Includes 4
requirements for
section.
Includes 3
requirements for
section.
Includes 2
requirements for
section.
Includes 1
requirement for
section.
No requirements for
this section
presented.
APA Style and Organization
(25 points/10%)
25 points 23 points 19 points 9 Points 0 points
Required criteria
1. There is correct and appropriate use of margins,
spacing, font, and headers.
2. Document setup includes title and reference
pages in correct APA format.
3. Citation of sources included in the body of the
paper uses correct APA format for direct and
indirect quotes.
4. Sources are cited correctly on the Reference
page. All elements of each reference are
included in the correct order.
5. All information taken from the source, even if
summarized, must be cited and listed on the
Reference page.
6. All sources used are nursing journals published
within the last five years.
Includes 6
requirements for
section.
Includes 5
requirements for
section.
Includes 3-4
requirements for
section.
Includes 1-2
requirements for
section.
No requirements for
this section
presented.
Total Points Possible = 150 points
- Purpose
Preparing the assignment
Grading Rubric
Running head: GUIDED IMAGERY AND PROGRESSIVE MUSCLE RELAXATION
2
12
Guided Imagery
Guided Imagery
and
Progressive Muscle Relaxation
in Group Psychotherapy
Hannah K. Greenbaum
Department of Psychology, The George Washington University
PSYC 3170: Clinical Psychology
Dr. Tia M. Benedetto
October 1, 2019
Guided Imagery and
Progressive Muscle Relaxation in Group Psychotherapy
A majority of Americans experience stress in their daily lives (American Psychological Association, 2017). Thus, an important goal of psychological research is to evaluate techniques that promote stress reduction and relaxation. Two techniques that have been associated with reduced stress and increased relaxation in psychotherapy contexts are guided imagery and progressive muscle relaxation (McGuigan & Lehrer, 2007). Guided imagery aids individuals in connecting their internal and external experiences, allowing them, for example, to feel calmer externally because they practice thinking about calming imagery. Progressive muscle relaxation involves diaphragmatic breathing and the tensing and releasing of 16 major muscle groups; together these behaviors lead individuals to a more relaxed state (Jacobson, 1938; Trakhtenberg, 2008). Guided imagery and progressive muscle relaxation are both cognitive behavioral techniques (Yalom & Leszcz, 2005) in which individuals focus on the relationship among thoughts, emotions, and behaviors (White, 2000).
Group psychotherapy effectively promotes positive treatment outcomes in patients in a cost-effective way. Its efficacy is in part attributable to variables unique to the group experience of therapy as compared with individual psychotherapy (Bottomley, 1996; Yalom & Leszcz, 2005). That is, the group format helps participants feel accepted and better understand their common struggles; at the same time, interactions with group members provide social support and models of positive behavior (Yalom & Leszcz, 2005). Thus, it is useful to examine how stress reduction and relaxation can be enhanced in a group context.
The purpose of this literature review is to examine the research base on guided imagery and progressive muscle relaxation in group psychotherapy contexts. I provide overviews of both guided imagery and progressive muscle relaxation, including theoretical foundations and historical context. Then I examine guided imagery and progressive muscle relaxation as used on their own as well as in combination as part of group psychotherapy (see Baider et al., 1994, for more). Throughout the review, I highlight themes in the research. Finally, I end by pointing out limitations in the existing literature and exploring potential directions for future research.
Guided Imagery
Features of Guided Imagery
Guided imagery involves a person visualizing a mental image and engaging each sense (e.g., sight, smell, touch) in the process. Guided imagery was first examined in a psychological context in the 1960s, when the behavior theorist Joseph Wolpe helped pioneer the use of relaxation techniques such as aversive imagery, exposure, and imaginal flooding in behavior therapy (Achterberg, 1985; Utay & Miller, 2006). Patients learn to relax their bodies in the presence of stimuli that previously distressed them, to the point where further exposure to the stimuli no longer provokes a negative response (Achterberg, 1985).
Contemporary research supports the efficacy of guided imagery interventions for treating medical, psychiatric, and psychological disorders (Utay & Miller, 2006). Guided imagery is typically used to pursue treatment goals such as improved relaxation, sports achievement, and pain reduction. Guided imagery techniques are often paired with breathing techniques and other forms of relaxation, such as mindfulness (see Freebird Meditations, 2012). The evidence is sufficient to call guided imagery an effective, evidence-based treatment for a variety of stress-related psychological concerns (Utay & Miller, 2006).
Guided Imagery in Group Psychotherapy
Guided imagery exercises improve treatment outcomes and prognosis in group psychotherapy contexts (Skovholt & Thoen, 1987). Lange (1982) underscored two such benefits by showing (a) the role of the group psychotherapy leader in facilitating reflection on the guided imagery experience, including difficulties and stuck points, and (b) the benefits achieved by social comparison of guided imagery experiences between group members. Teaching techniques and reflecting on the group process are unique components of guided imagery received in a group context (Yalom & Leszcz, 2005).
Empirical research focused on guided imagery interventions supports the efficacy of the technique with a variety of populations within hospital settings, with positive outcomes for individuals diagnosed with depression, anxiety, and eating disorders (Utay & Miller, 2006). Guided imagery and relaxation techniques have even been found to “reduce distress and allow the immune system to function more effectively” (Trakhtenberg, 2008, p. 850). For example, Holden-Lund (1988) examined effects of a guided imagery intervention on surgical stress and wound healing in a group of 24 patients. Patients listened to guided imagery recordings and reported reduced state anxiety, lower cortisol levels following surgery, and less irritation in wound healing compared with a control group. Holden-Lund concluded that the guided imagery recordings contributed to improved surgical recovery. It would be interesting to see how the results might differ if guided imagery was practiced continually in a group context.
Guided imagery has also been shown to reduce stress, length of hospital stay, and symptoms related to medical and psychological conditions (Scherwitz et al., 2005). For example, Ball et al. (2003) conducted guided imagery in a group psychotherapy format with 11 children (ages 5–18) experiencing recurrent abdominal pain. Children in the treatment group (n = 5) participated in four weekly group psychotherapy sessions where guided imagery techniques were implemented. Data collected via pain diaries and parent and child psychological surveys showed that patients reported a 67% decrease in pain. Despite a small sample size, which contributed to low statistical power, the researchers concluded that guided imagery in a group psychotherapy format was effective in reducing pediatric recurrent abdominal pain.
However, in the majority of guided imagery studies, researchers have not evaluated the technique in the context of traditional group psychotherapy. Rather, in these studies participants usually met once in a group to learn guided imagery and then practiced guided imagery individually on their own (see Menzies et al., 2014, for more). Thus, it is unknown whether guided imagery would have different effects if implemented on an ongoing basis in group psychotherapy.
Progressive Muscle Relaxation
Features of Progressive Muscle Relaxation
Progressive muscle relaxation involves diaphragmatic or deep breathing and the tensing and releasing of muscles in the body (Jacobson, 1938). Edmund Jacobson developed progressive muscle relaxation in 1929 (as cited in Peterson et al., 2011) and directed participants to practice progressive muscle relaxation several times a week for a year. After examining progressive muscle relaxation as an intervention for stress or anxiety, Joseph Wolpe (1960; as cited in Peterson et al., 2011) theorized that relaxation was a promising treatment. In 1973, Bernstein and Borkovec created a manual for helping professionals to teach their clients progressive muscle relaxation, thereby bringing progressive muscle relaxation into the fold of interventions used in cognitive behavior therapy. In its current state, progressive muscle relaxation is often paired with relaxation training and described within a relaxation framework (see Freebird Meditations, 2012, for more).
Research on the use of progressive muscle relaxation for stress reduction has demonstrated the efficacy of the method (McGuigan & Lehrer, 2007). As clients learn how to tense and release different muscle groups, the physical relaxation achieved then influences psychological processes (McCallie et al., 2006). For example, progressive muscle relaxation can help alleviate tension headaches, insomnia, pain, and irritable bowel syndrome. This research demonstrates that relaxing the body can also help relax the mind and lead to physical benefits.
Progressive Muscle Relaxation in Group Psychotherapy
Limited, but compelling, research has examined progressive muscle relaxation within group psychotherapy. Progressive muscle relaxation has been used in outpatient and inpatient hospital settings to reduce stress and physical symptoms (Peterson et al., 2011). For example, the U.S. Department of Veterans Affairs integrates progressive muscle relaxation into therapy skills groups (Hardy, 2017). The goal is for group members to practice progressive muscle relaxation throughout their inpatient stay and then continue the practice at home to promote ongoing relief of symptoms (Yalom & Leszcz, 2005).
Yu (2004) examined the effects of multimodal progressive muscle relaxation on psychological distress in 121 elderly patients with heart failure. Participants were randomized into experimental and control groups. The experimental group received biweekly group sessions on progressive muscle relaxation, as well as tape-directed self-practice and a revision workshop. The control group received follow-up phone calls as a placebo. Results indicated that the experimental group exhibited significant improvement in reports of psychological distress compared with the control group. Although this study incorporated a multimodal form of progressive muscle relaxation, the experimental group met biweekly in a group format; thus, the results may be applicable to group psychotherapy.
Progressive muscle relaxation has also been examined as a stress-reduction intervention with large groups, albeit not therapy groups. Rausch et al. (2006) exposed a group of 387 college students to 20 min of either meditation, progressive muscle relaxation, or waiting as a control condition. Students exposed to meditation and progressive muscle relaxation recovered more quickly from subsequent stressors than did students in the control condition. Rausch et al. (2006) concluded the following:
A mere 20 min of these group interventions was effective in reducing anxiety to normal levels
. . . merely 10 min of the interventions allowed [the high-anxiety group] to recover from the stressor. Thus, brief interventions of meditation and progressive muscle relaxation may be effective for those with clinical levels of anxiety and for stress recovery when exposed to brief, transitory stressors. (p. 287)
Thus, even small amounts of progressive muscle relaxation can be beneficial for people experiencing anxiety.
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
Combinations of relaxation training techniques, including guided imagery and progressive muscle relaxation, have been shown to improve psychiatric and medical symptoms when delivered in a group psychotherapy context (Bottomley, 1996; Cunningham & Tocco, 1989). The research supports the existence of immediate and long-term positive effects of guided imagery and progressive muscle relaxation delivered in group psychotherapy (Baider et al., 1994). For example, Cohen and Fried (2007) examined the effect of group psychotherapy on 114 women diagnosed with breast cancer. The researchers randomly assigned participants to three groups: (a) a control group, (b) a relaxation psychotherapy group that received guided imagery and progressive muscle relaxation interventions, or (c) a cognitive behavioral therapy group. Participants reported less psychological distress in both intervention groups compared with the control group, and participants in the relaxation psychotherapy group reported reduced symptoms related to sleep and fatigue. The researchers concluded that relaxation training using guided imagery and progressive muscle relaxation in group psychotherapy is effective for relieving distress in women diagnosed with breast cancer. These results further support the utility of guided imagery and progressive muscle relaxation within the group psychotherapy modality.
Conclusion
Limitations of Existing Research
Research on the use of guided imagery and progressive muscle relaxation to achieve stress reduction and relaxation is compelling but has significant limitations. Psychotherapy groups that implement guided imagery and progressive muscle relaxation are typically homogeneous, time limited, and brief (Yalom & Leszcz, 2005). Relaxation training in group psychotherapy typically includes only one or two group meetings focused on these techniques (Yalom & Leszcz, 2005); thereafter, participants are usually expected to practice the techniques by themselves (see Menzies et al., 2014). Future research should address how these relaxation techniques can assist people in diverse groups and how the impact of relaxation techniques may be amplified if treatments are delivered in the group setting over time.
Future research should also examine differences in inpatient versus outpatient psychotherapy groups as well as structured versus unstructured groups. The majority of research on the use of guided imagery and progressive muscle relaxation with psychotherapy groups has used unstructured inpatient groups (e.g., groups in a hospital setting). However, inpatient and outpatient groups are distinct, as are structured versus unstructured groups, and each format offers potential advantages and limitations (Yalom & Leszcz, 2005). For example, an advantage of an unstructured group is that the group leader can reflect the group process and focus on the “here and now,” which may improve the efficacy of the relaxation techniques (Yalom & Leszcz, 2005). However, research also has supported the efficacy of structured psychotherapy groups for patients with a variety of medical, psychiatric, and psychological disorders (Hashim & Zainol, 2015; see also Baider et al., 1994; Cohen & Fried, 2007). Empirical research assessing these interventions is limited, and further research is recommended.
Directions for Future Research
There are additional considerations when interpreting the results of previous studies and planning for future studies of these techniques. For example, a lack of control groups and small sample sizes have contributed to low statistical power and limited the generalizability of findings. Although the current data support the efficacy of psychotherapy groups that integrate guided imagery and progressive muscle relaxation, further research with control groups and larger samples would bolster confidence in the efficacy of these interventions. In order to recruit larger samples and to study participants over time, researchers will need to overcome challenges of participant selection and attrition. These factors are especially relevant within hospital settings because high patient turnover rates and changes in medical status may contribute to changes in treatment plans that affect group participation (L. Plum, personal communication, March 17, 2019). Despite these challenges, continued research examining guided imagery and progressive muscle relaxation interventions within group psychotherapy is warranted (Scherwitz et al., 2005). The results thus far are promising, and further investigation has the potential to make relaxation techniques that can improve people’s lives more effective and widely available.
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