AHRQ Director says Nurses are Important Leaders in Improving Health Care Quality

Carolyn M. Clancy, M.D., also sees "nurses at the forefront in working with policy-makers and other leaders to achieve a more effective and efficient health care system."

    • January 21, 2009

Carolyn M. Clancy, M.D., is director of the Agency for Healthcare Research and Quality (AHRQ) and one of the nation’s most influential health experts. Under her leadership and with additional funding from the Robert Wood Johnson Foundation, last year AHRQ prepared a three-volume handbook for nurses on patient safety and quality.  Patient Safety and Quality: An Evidence-Based Handbook for Nurses has won numerous awards from the American Journal of Nursing and remains in high demand.  Here, Dr. Clancy answers questions posed by the Foundation about the role nurses play in delivering care and the role they can and should play in the nation’s debate about health care reform:

Patient Safety and Quality: An Evidence-Based Handbook for Nurses has won four awards from the American Journal of Nursing, and the demand has been tremendous. Can you share the reasons you believe this book is in such demand?

Dr. Clancy: This handbook has turned out to be an influential publication for nursing. It is the first to provide, in one place, so much critical and timely information on patient safety and quality improvement to nurses. The book synthesizes what we know about the impact of nurses and other clinicians on patient safety and health care quality, and what evidence can be used in everyday practice. It is readable and applies to the depth and breath of nursing. All nurses should read this terrific resource.

There’s a section of the book that addresses working conditions and the work environment for nurses.  What changes do you think are needed in those areas going forward?

Dr. Clancy: Complexity pervades health care. Nurses see this both in the scope of their own work and its effect on patients. Unfortunately, it’s difficult to appreciate fully the complex nature and nuances of the work environment and working conditions in health care. Chaos in the care environment places too many demands on nurses, pulling them in too many directions and making it too difficult for nurses to care for patients. This chaos leads to low job satisfaction and greater numbers of nurses leaving the profession, and too many patients being dissatisfied with their care. Our challenge is to enable nurses to maximize their time and to capitalize on their skills, experience and insights. Without that, we devalue the significance of nursing and prevent nurses from providing care that patients need.

What role do nurses play in improving the quality of care in this country, and what role should they play in the future?

Dr. Clancy: Providing care that is consistently safe and high quality is a team sport; nurses are essential members of the team. In fact, nurses are important leaders in improving health care quality. They have valuable insight as to how to navigate the health care system, interpret information, and demystify the clinical experience for patients. They are, at their best, knowledgeable and caring patient advocates. Nurses are pivotal in ensuring that patients have safe, high-quality health care. If not for the critical thinking, monitoring, and surveillance that are inherent in nursing, we would have even more errors and poorer patient outcomes. Because nurses are at the heart of health care, particularly in interdisciplinary care, nurses must be empowered to take a leadership role.

Where are the key opportunities for nurses to address cost, quality and access, in addition to eliminating health disparities?

Dr. Clancy: We must make sure that patients receive the right care at the right time, every time. Nurses can lead this effort, because of what they can do, their proximity to patients, and the amount of time they have with patients. Nurses have the clinical training, multi-tasking capabilities and holistic approach to help patients navigate the chaos of health care. Having nurses work closely with patients is critical to making sure we use health care resources wisely and treat the whole patient rather than simply react to acute needs. In doing so, we will realize more efficient and effective care, addressing concerns about access, disparities and quality.

There seems to be a general consensus that policy-makers may advance a health care reform initiative [next] year.  What are the unique contributions of nurses to a more effectively and efficiently run health care system, especially given the primary care shortages and our nation’s increased demand for chronic care management?

Dr. Clancy: There are several. First, one of the most obvious opportunities for improvement is treatment of patients with chronic conditions. Given the aging population, the largest proportion of need will be care for patients with chronic conditions. And because patients with chronic conditions tend to have more than one at a time, treatment needs to be holistic, not piecemeal. Frankly, today, we’re not doing a good job of meeting the needs of patients with chronic conditions. But nurses are trained to look at the whole patient, not just as a possessor of a disease or cluster of symptoms. We need to consider health reform as directing us toward a patient-centric system that meets a patient’s needs entirely.

Secondly, nurses can work with patients to help meet their primary, preventive, acute, and chronic care needs. Each of these care needs is important and must not be overlooked.

Third, I see nurses at the forefront in working with policy-makers and other leaders to achieve a more effective and efficient health care system. An important component of this would be a greater emphasis on primary and preventive care. We suffer a great shortage of nurses and other primary care clinicians, but if we properly utilized the resources we now have and capitalized on what nurses can contribute, we would maximize our resources differently and better manage the chronic care needs of our patients.

What should policy-makers know about the role nurses play in delivering quality care as they craft and consider reform proposals?

Dr. Clancy: Policy-makers need nurses to inform them about the realities of providing care. Effective and sustainable reform has to work for those on the frontlines providing care. The more policy-makers understand the depth and breath of nursing, the more nurses will be regarded as instrumental in reform efforts.

Nurses must approach policy-makers armed not only with anecdote and personal experience but also with quantifiable facts. This handbook is an invaluable resource for that purpose as well.

What should nurses themselves do to make their voices heard in the reform debate?

Dr. Clancy: Nurses need to be actively engaged in the reform debate, individually as well as through professional organizations. Nurses should understand the issues being discussed during the reform debate and be engaged in the process. 

President Obama’s plan for health care reform will target affordable health insurance coverage for all Americans. Nurses must have an equal role in this part of the debate. Nurses understand the plight of those without insurance all too well—that lack of coverage or underinsurance leads patients to delay their care, often with disastrous results. Nurses should speak up on behalf of patients to ensure that all Americans have health coverage and that we focus on primary care and chronic care management.

How is the nursing shortage affecting quality of care in this country, and how do you think it will affect quality, cost and access in coming years?

Dr. Clancy: The nursing shortage is severe and getting worse, and it greatly impacts quality. So, first of all, let’s not go backwards: we must not consider any reduction in the number of nursing positions or resources. Instead, we should increase our nursing resources; first, by enhancing nurse education programs, and, secondly, by utilizing the right number and skill mix of nurses in our system. This means mitigating the absurd workload for nurses, and not trying to reduce costs by cutting nurse positions.

What challenges and opportunities does the economic downturn create for health systems that are trying to address the nursing shortage?

Dr. Clancy: While the full impact of the recession won’t be understood for some time, we fear that, first, some patients will postpone care; and, secondly, that health care organizations will seek to cut costs by eliminating nurse positions. That said, this is the ideal time for workers who have lost their jobs in other industries to seek retraining as nurses; while not everyone is an ideal candidate to become a nurse, many people have or can develop the appropriate skill set. To do so, however, we need to enhance nurse education opportunities. As we address resource constraints, there may be opportunities to revisit the scope of practice and roles of nursing throughout care delivery sites. We may also find that we are not using our nurse workforce in the best ways possible. Creative strategies to incorporate evidence on the work environment and working conditions and patient-centered care will be key, and from the perspective of nurses, invaluable.

What opportunities does AHRQ have for nurses to become more involved in improving quality in this country?

Dr. Clancy: AHRQ has numerous opportunities for nurses. There are opportunities to develop new knowledge and apply available research and tools to improve practice through large and small research grants. We also have a great deal of research that nurses can incorporate into their practice and use to bolster the argument of nurses’ central role in patient safety. In particular, of course there is the recently published Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Also of interest is an Institute of Medicine report, sponsored by AHRQ, called Keeping Patients Safe: Transforming the Work Environment for Nurses. To learn more about these opportunities, please visit the nursing section of our Web site, www.ahrq.gov/about/nursing/.

There are also opportunities to partner with AHRQ, to focus on issues critical to practice through small conference grants and training grants, as well as internships and dissertation awards. As a starting place, the handbook identified numerous research gaps that nurses and others can target. So if anyone has ideas, please share them with us. We really value nurses and are eager to work with nurses to improve the quality of American health care.

Learn more about AHRQ’s work at www.ahrq.gov and view Patient Safety and Quality: An Evidence-Based Handbook for Nurses at  http://www.rwjf.org/pr/product.jsp?id=37715

View Dr. Clancy’s bio at:

http://www.ahrq.gov/about/clancybio.htm