Demands on Nurses Grow as Hospital Quality Improvement Activities Increase

Nurses are pivotal to quality improvement efforts, but shortages could curtail involvement.

    • March 20, 2008

Hospitals face growing tensions and trade-offs when allocating nurses between the competing priorities of direct patient care and quality improvement efforts, according to a study released today by the Center for Studying Health System Change (HSC).

Commissioned by the Robert Wood Johnson Foundation (RWJF), the study included interviews with hospital leaders in Detroit, Memphis, Minneapolis-St. Paul and Seattle to examine the role of nurses in hospital quality improvement activities.

"Nursing has the biggest impact on a patient's experience in the hospital, so involving nurses in quality improvement is critical," said John Lumpkin, M.D., M.P.H., senior vice president and director of the Health Care Group at RWJF. "We commissioned this study to gain a better understanding of the role that nurses play in quality improvement and the challenges nurses face when balancing the competing priorities of direct patient care and quality improvement efforts."

RWJF has been on the forefront of efforts to involve nurses and other front-line staff in quality improvement. Transforming Care at the Bedside, a joint initiative with the Institute for Healthcare Improvement, has significantly improved the quality and safety of patient care on medical and surgical units, increased retention of nurses in hospital-based jobs and helped to improve the effectiveness of the entire health care team.

According to the HSC study, hospital organizational cultures set the stage for quality improvement, including nurses' involvement. Hospitals with supportive leadership; a philosophy of quality as everyone's responsibility; individual accountability; physician and nurse champions; and effective feedback reportedly offer greater promise for successfully involving nurses in quality improvement activities.

Even when hospitals are committed to including nurses in quality improvement, they often face various problems, including a shortage of nurses; growing demands to participate in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving role in today's contemporary hospital setting, the study found.

"The stakes for hospitals to demonstrate high quality are increasing at the same time that resources—especially nurses—are in short supply," said Debra A. Draper, Ph.D., HSC associate director and co-author of the study with Laurie Felland, M.S., an HSC health researcher; Allison Liebhaber, an HSC health research assistant; and RWJF Pioneer Interim Team Director Lori Melichar, Ph.D.

"While quality improvement isn't solely the domain of nurses, they are critical because of their day-to-day patient responsibilities, and hospitals will need to guard against diminishing nurses' involvement in quality improvement activities," Draper said

The study's findings are detailed in a new HSC research brief, The Role of Nurse in Hospital Quality Improvement, available online at www.hschange.org.

Other key study findings include:

  • Hospitals face ever-growing demands to participate in more quality improvement activities, many of which are viewed as duplicative. The lack of standardization in quality measurement and reporting intensifies the challenge, according to hospital respondents.
  • Respondents reported that nurses are well positioned to serve on the front lines of quality improvement since they directly affect the care patients receive during a hospital stay. As one hospital chief nursing officer noted, "Nurses are the safety net. They are the folks that are right there, real time, catching medication errors, catching patient falls, recognizing when a patient needs something, avoiding failure to rescue."
  • The scarcity of nurses is a major challenge for hospitals. Hospital respondents in two communities—Memphis and Seattle—reported being significantly affected by a nursing shortage, which some believed would only worsen, particularly as more nurses age out of the workforce and demand continues to exceed supply.
  • Another dilemma hospitals face is that they want their best nurses at the bedside caring for patients and these same nurses leading their quality improvement activities. This poses an even greater quandary when nurses are in scarce supply. Some respondents said that trying to balance nurses' work at the bedside with their involvement in quality improvement activities has sometimes resulted in nurses receiving mixed messages about the importance of their role in quality improvement.
  • Respondents discussed that to optimize the role of nurses in quality improvement, it is important for nursing education programs to strengthen curricula to emphasize the concepts and skills needed to participate in quality improvement activities. Respondents also emphasized the need for effective continuing education programs to help nurses be more adept at translating their observations of problems at the beside into an effective improvement effort.

The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation's changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded in part by the Robert Wood Johnson Foundation and affiliated with Mathematica Policy Research, Inc.

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