Measuring the Work Nurses Do in Coordinating Care

    • March 27, 2008

Two of the grantees from the Robert Wood Johnson Foundation's Interdisciplinary Nursing Quality Research Initiative (INQRI) recently addressed the prominent National Quality Forum's 2008 Spring Conference on Care Coordination.

Shoshanna Sofaer, Dr.P.H. M.P.H., School of Public Affairs, Baruch College, gave the keynote presentation, and Gerri Lamb, Ph.D., R.N., Emory University School of Nursing, participated on a panel. INQRI National Program Director Mary Naylor, Ph.D., R.N., University of Pennsylvania School of Nursing, also participated on a panel.

The three women's appearance is significant. “The National Quality Forum is important,” says Lori Melichar, Ph.D., RWJF director. “Our grantees are presenting and sharing their work at a meeting convened by one of the key players in the quality field. Their findings then can be incorporated into those of others working in the area of care coordination.”

RWJF funded Sofaer and Lamb in the first round of INQRI grants made in 2006, two of nine grantees in the $10-million, five-year program that aims to generate, disseminate and translate research to understand how nurses contribute to and can improve the quality of patient care. Both lead interdisciplinary teams for projects that are researching the same measure—nurse care coordination—from the patient and nurse vantage points, respectively.

Care coordination is one of 20 priorities for national action to transform the health care system—as identified by the Institute of Medicine in a 2003 report. (Institute of Medicine, Priority Areas for National Action: Transforming Health Care Quality, Washington: National Academies Press, 2003)

“We have a health care system that is not aligned to meet the needs of patients who are chronically ill,” says Naylor. “The current model of care is designed to help people survive an acute event. But with advances in medical technology and science, we now have many people living longer with multiple conditions being cared for by multiple providers. Care coordination has emerged as an important issue.

“The human and economic consequences for not coordinating care are profound—multiple breakdowns in care, increased medical errors, poor ratings of the health care experience from the consumers' and family caregivers' perspectives, and high rates of unnecessary hospitalization and emergency room use,” says Naylor.

Nurses are in a unique position to coordinate a patient's care. “Nurses are with patients 24 hours a day,” says researcher Lamb. “They are the ‘switchboard' for activity, making sure that all the members of the team are on the same page and have current information. When something needs to happen differently it is often the nurses who are mobilizing their team members so that the patient gets the right service at the right time.”

To better define what care coordination entails, Lamb and her research team have interviewed some 60 nurses and team members and observed them in daily practice for almost 200 hours. As a result, they have identified a new working definition of nurse care coordination as “actions initiated by nurses with patients, families and/or members of their health care team to manage and correct the sequence, timing and/or effectiveness of patient care from hospital admission to hospital discharge.”

“When we share this definition and our examples with nurses in the field,” Lamb says, “we are gratified to see them nodding ‘yes, yes,' agreeing that is exactly what they do when they coordinate care.”

Further, Lamb and her team have identified several specific care coordination activities, and now are beginning to provide words and detail for nurses to describe this critical process. They next plan to test the reliability and validity of a new tool to measure these activities—aptly called the Nurse Care Coordination Instrument—in several hospitals.

“Care coordination is one of the most important nursing processes,” says Lamb. “It is a process central to all health care; all patients need to have their care coordinated.”

To determine what specific behaviors nurses apply in coordinating care, Sofaer's research team is interviewing nurses in hospitals in New York and Washington. Using hypothetical patient situations, the researchers are asking the nurses what they would do specifically to coordinate care.

As she has done in earlier RWJF-funded research, Sofaer's team will speak with patients who have recently been in the hospital. “We do not understand how patients experience care coordination or the lack of care coordination,” she says. “My passion is all about the patients. Patients really depend on nurses because they are there when a patient or the family has a question—or an issue with any aspect of their care.”

While Lamb and Sofaer come at care coordination from different vantage points, they also see the potential for collaboration.

“They recognize we will have the most robust measure of care coordination when it is one that captures the nurses' perspective and also resonates with consumers,” says Naylor.

“We think that an issue as complicated as care coordination benefits from having two separate teams work on it,” agrees RWJF's Melichar. “By having both perspectives and integrating them with what is already known about this topic, we can then confidently go out to the stakeholders with the results—and have the impact that we hope for.”

“When you are trying to convince stakeholders—decision-makers, policy-makers, health care organization leaders, purchasers and payers—that they should be investing in nurses and positioning them to deliver the highest quality care, you have to have evidence to support that case,” says Naylor. “INQRI is substantially advancing efforts to make the business case for nurses' contributions to quality—to the delivery of care that is patient-centered, safe and that contributes to promoting efficiency and eliminating waste.”

Lamb's and Sofaer's INQRI Interdisciplinary Teams:

Nurse-Sensitive Measurement of Hospital Care Coordination
Gerri Lamb, Ph.D., and Ingrid Duva, M.S., Emory University Nell Hodgson Woodruff School of Nursing
Francois Sainfort, Ph.D. and Paula Edwards, Ph.D., Health Systems Institute, Georgia Institute of Technology College of Engineering
Madeline Schmitt, Ph.D., University of Rochester School of Nursing

Developing and Testing Nursing Quality Measures with Consumers and Patients
Shoshanna Sofaer, Dr.P.H., School of Public Affairs, Baruch College
Kirsten Firminger, Doctoral Candidate, City University of New York Graduate Center
Jean Johnson, Ph.D., Ellen Dawson, Ph.D., Christine Pintz, Ph.D., Andrea Brassard, D.N.Sc., M.P.H., George Washington University School of Medicine and Health Sciences