INQRI Blog

Nurse Staffing Ratios Can Affect Outcomes for Cardiac Patients

2013-05-21T10:51:00.002-04:00

A study published online in JAMA Internal Medicine finds that hgher nurse-to-patient staffing ratios may improve survival rates for cardiac patients and help reduce the incidence of inhospital cardiac arrest. The study, led by Lena Chen of the University of Michigan, found that one factor that was constant in hospitals with higher survival rates and lower arrest rates was higher nurse staffing.

The study included more than 100,000 patients at 358 hospitals, it is reported on in Medpage Today.

Several INQRI studies have focused on the impact of nursing staffing on patient outcomes. A study led by Mary Blegen and Tom Vaughn found that higher nurse staffing levels reduce rates of infection, mortality due to congestive heart failure, failure to rescue, and prolonged hospital stays.

These findings support the need to address the nursing faculty shortage and the projected nursing shortage by preparing a larger, more diverse and more highly educated nursing workforce. The Bureau of Labor Statistics projects that by 2020, the nation will require an additional 1.2 million nurses to meet the need for health care. Developing that workforce is one goal of The Future of Nursing: Campaign for Action, which is working in all 50 states to advance nursing education, leadership and practice.

The Value-Added of Electronic Medical Records

2013-05-20T13:44:00.001-04:00

An article in ADVANCE for Nurses looks at the ways in which health information technology is improving care, outcomes and nurses' work environments in health care settings around the country, particularly when that IT is built with nursing in mind.

At Baptist Health South Florida, patient barcodes allow nurses quick and easy access to their patients' full profiles. The barcodes have dramatically reduced wait time for pain medication and also helped to ensure that nurses know the exact doses and frequency of dosage for each of their patients' medications. Several INQRI studies have addresses nurses' role in medication management, including reducing medication errors and improving regimen adherence post hospital discharge.

Other uses of health IT, include automating the admissions process, so that when information on a patient is recorded during intake, that information is shared with other health care providers and hospital staff who may help provide care.

The article also discusses younger nurses' higher comfort level with information technology and ways that hospitals are successfully orienting new hires to their electronic medical records (EMR) systems and how schools of nursing are preparing students to use those records. A recent post on the RWJF Human Capital Blog by Ann Marie Mauro, an associate professor at NYU College of Nursing discusses how the college's simulation program also helps nursing students learn how to use EMR.

American Nurses Foundation Supports Nursing Research Into Bullying, Loneliness, Walking

2013-05-17T11:10:00.001-04:00

Nursing research runs the gamut from investigations into nursing processes that affect patient care to testing whether seniors are better able to age in place if their homes are adapted to meet their needs. No matter, the topic, the body of research conducted by nurses continues to grow exponentially.

The latest issue of The American Nurse highlights the studies of three nurse researchers who have received grants from the American Nurses Foundation (ANF), including RWJF Nurse Faculty Scholar Laurie Theeke.

Theeke's research, funded by ANF and RWJF, involves exploring the emotions associated with loneliness, specifically among older adults living with chronic illness in Appalachia. She has found that older adults who scored high on a loneliness index felt stigma, sadness, anxiety, depression, anger, and fear. Theeke plans to test interventions that target specific components of loneliness. She suggests that further research might address whether people isolate themselves because of functional decline or whether isolation speeds that decline.

Other highlighted research studies explore how novice nurses cope with workplace bullying by nurse colleagues and whether safer walking areas influence health outcomes of low-income residents.

New Survey: Physicians, Nurse Practitioners Disagree on Nurses’ Role in Providing Primary Care

2013-05-16T14:50:00.000-04:00

By Lori Melichar Gadkari, PhD, MA

Lori Melichar Gadkari, PhD, MA, is a senior program officer at the Robert Wood Johnson Foundation (RWJF), in the Research and Evaluation Unit and the program officer for INQRI.

Yesterday the New England Journal of Medicine published the results of a study co-funded by the Robert Wood Johnson Foundation, Johnson & Johnson, and the Gordon and Betty Moore Foundation. “Perspectives of Physicians and Nurse Practitioners on Primary Care Practice” finds that 96 percent of nurse practitioners and 76 percent of physicians agreed with the Institute of Medicine report recommendation that “nurse practitioners should be able to practice to the full extent of their education and training.” The new study is authored by Karen Donelan, ScD, EdM, Catherine M. DesRoches, DrPH, Robert S. Dittus, MD, MPH, and Peter Buerhaus, PhD, RN.

When asked how increasing the supply of nurse practitioners would potentially affect the United States health care system, the authors found that the majority of physicians (73%) said increasing the supply of primary care nurse practitioners (PCNPs) would lead to improvements in the timeliness of care. A much smaller majority of physicians (52%) said increasing the supply of PCNPs would lead to improvements in access to care for people in the country.

However, the new survey found significant disagreement between primary care physicians and PCNPs about whether increasing the supply of PCNPs would improve patient safety and the effectiveness of care, and whether it would reduce costs. There was also a large professional divide about proposed changes to PCNPs’ scope of practice, putting PCNPs in leadership roles, and the quality of care that PCNPs provide.

These findings are consistent with the results of an RWJF study conducted within the online Sermo.com community, in which nearly half the physicians surveyed agree that “allowing APRNs [advanced practice registered nurses] to practice independently would increase access to primary care in the U.S.” In the Sermo study, physicians predicted a decrease in average quality of care provided to patients if all states allowed APRNs to practice independently.

These predictions are not evidence based. In a review of studies comparing the primary care provided by nurse practitioners to the primary care provided by physicians (MDs), researchers found that patients of both groups had comparable health outcomes. Nurse practitioners were found to out-perform MDs in measures of consultation time, patient follow-up, and patient satisfaction.

The new Donelan study also highlights disagreement between primary care physicians and PCNPs on the clinical services that PCNPs provide. Those who work in collaborative practices with one another indicate that both types of providers perform a wide range of primary care services. But only 23 percent of physicians say that nurse practitioners in their practices provide services to complex patients with multiple conditions, while more than 60 percent of PCNPs say they care for these patients.

A resource created by RWJF to inform members of the IOM committee shows the overlap in health care services for the two professions.

The new study in the New England Journal of Medicine is based on a survey mailed to a random sample of 2,000 primary care clinicians; 467 nurse practitioners and 505 physicians responded.

Will Dr. Robot Open New Doors for Nurses?

2013-05-15T10:21:00.002-04:00

By Olga Yakusheva, PhD and Richard C. Lindrooth, PhD

Olga Yakusheva, PhD, is an associate professor of economics at Marquette University. Richard C. Lindrooth, PhD, is an associate professor at the University of Colorado Anschutz Medical Campus. Both are INQRI grantees.

Technological innovation is rapidly transforming patient care. A new generation of innovations will potentially change the most fundamental aspect of the patient experience – patients’ interactions with physicians and nurses. The FDA recently approved the first autonomous telemedicine robot for use in acute care hospitals. Even more advanced technologies, some capable of processing up to tens of millions of pages of plain medical text per second, are being tested and may soon be used to diagnose conditions and recommend treatment, with limited input from clinicians.

This new technology has the potential to perform several tasks more efficiently than clinicians, albeit with some limitations. It can quickly and effectively sift through large amounts of information and, based on a complex set of guidelines, create a probability-weighted list of diagnoses and recommendations. The result will be purely evidence-based and free of human cognitive decision-making biases. The technology can drastically speed diffusion of new research and guidelines through electronic dissemination, similar to automatic software updates, and make most novel treatment regimens instantly available to patients.

However, even the smartest technology may not perform well when guidelines require information that is not easily quantifiable, nor when decision-making requires patient-specific judgment. Furthermore, technology is unlikely to supplant humans in direct patient care, including procedures and tasks that require empathy and emotional support.

That said, these technological innovations will most likely replace some of the current work of clinicians—in much the same way the electronic health records systems supplanted unskilled medical records personnel with highly-educated health care IT professionals. As technology evolves to the point when it is capable of independently diagnosing patients and prescribing treatments, it will increase the productivity and reward clinicians whose skills are enhanced by that technology, while potentially displacing clinicians whose tasks can be performed better, or more cheaply, by the technology.

This type of technological innovation is likely to complement nurses’ skills. The Occupational Information Network (ONET) lists social perceptiveness, active listening, and coordination as nurses’ top three skills, and new technology will most likely enhance rather than undermine the value of these skills. For example, a hospitalized patient’s clinical information would be continuously updated and monitored by the technology against a set of clinical guidelines, immediately flagging patients at risk for an adverse event and triggering nurse actions to mitigate the risks (providing oxygen, medications, etc.), without lengthy delays and errors that may otherwise occur.

In an outpatient setting, as the technology takes over clinical decision-making, highly trained nurses might even be able to assume the role of the primary interface between the patient and the technology. Thus the return on nurses’ skills in direct patient care activities—performing examinations to collect information for the new technology, carrying out the recommended treatment, administering medications, and providing health promotion, counseling, and education services—will increase.

In contrast, the new technology may well substitute for physicians’ diagnostic work. ONET lists physicians’ three most critical skills as scientific, complex problem solving, and critical thinking. The activities associated with these skills, including those performed by nurse practitioners and physician assistants, could be taken over by technological innovation that might, someday, produce cost-saving substitutes for clinicians. These clinicians will need to specialize in diagnosing and treating cases that don't have reliable guidelines or that require patient-specific judgment. The good news is that the technology would free clinicians from routine work and enable them to focus their time on aspects of care in which they would have a comparative advantage, and let the technology handle clear-cut, guideline-driven cases.

Widespread adoption of technological innovations has the potential to elevate and enhance nurses’ role in patient care. We suggest that nurses should embrace rather than fear these innovations, and hospitals and other health systems should devote resources to nurse training and education that enhances nurses’ ability to adopt new technology and effectively interact with it, in providing high-quality and affordable patient care.

Nurses' Home Visits Decrease Postpartum Depression

2013-05-13T14:28:00.001-04:00

Nurses' knowledge and skills can often serve patients well after they've been discharged from the hospital. A new study in the current issue of the Journal of Obstetric, Gynecologic and Neonatal Nursing finds an additional instance in which nurses can provide post-discharge care and improve outcomes for patients: reducing the incidence of postpartum depression in new mothers. The study findings were also reported in Advance for Nurses.

According to the study, led by June Andrews Horowitz at the William Connell School of Nursing at Boston College, nurses who visited new mothers and provided a sympathetic ear, assistance with referrals and help recognizing infants' cues were able to significantly improve mother-child interaction and symptoms of depression in the new mothers.

The nurses visited mothers in their homes at six weeks and three, six and nine months postpartum. Each visit lasted an hour.

An INQRI-funded study led by Linda Costa and Robert Feroli and published in the Journal of Nursing Quality Care, revealed that nurses who consulted with pharmacists and visited patients and their families at home post-discharge helped improve patients' adherence to their medication regimens.

The nurses conducted at-home interviews with patients about their medication, and observed whether patients had obtained the prescribed medication, how they were organizing their medication, how often they took it, and whether they obtained refills. They were also able to educate and coach patients about their medication and help them develop plans and systems to ensure they took the correct doses of medications at the correct intervals.

Higher Nurse Staffing Ratios Also Reduce Children's Hospital Readmissions

2013-05-10T11:25:00.000-04:00

A study published in the online journal BMJ Quality and Safety in Health Care finds that higher nurse-to-patient ratios are directly correlated with reduced hospital readmissions for children with common medical and surgical conditions.

The research team was led by Heather Tubb-Cooley of Cincinnati Children's Hospital Medical Center, and included Douglas Sloane and Linda Aiken, who have conducted research into several aspects of nursing care and nurse staffing.

The study found that an increase of just one patient in a hospital's average nurse staffing ratio increased the likelihood of readmission for medical pediatric within 15 - 30 days by 11 percent, and for surgical patients by 48 percent. Researchers examined outcomes of more than 90,000 children in 225 hospitals.

A recent post on the Human Capital blog by Nancy Ryan-Wenger addresses the importance of ascertaining children's perceptions of the care they receive in the hospital. Ryan-Wenger's study to elicit children's perceptions of nursing care was funded by INQRI. She has gone on to develop a checklist that Nationwide Children's Hospital now uses in daily interviews with pediatric patients and for nurses' daily evaluations.

Research Grants Awarded to Study Nurse Residency Programs, Scope of Practice, Primary Care Workforce

2013-05-09T13:10:00.000-04:00

The Robert Wood Johnson Foundation and INQRI today announced the recipients of four new grants from the Future of Nursing National Research Agenda. The grants will support research into key issues being addressed by the Future of Nursing: Campaign for Action: nursing education and scope of practice regulations.

A fifth study funded last year, to determine the how emerging models of primary care will affect future primary care workforce needs, is nearing completion.That study was co-funded by the Donaghue Foundation. It's being conducted by David Auerbach of the RAND Corporation.

The other four studies are:

A team from the University of Pennsylvania will examine the impact of the provision of the Prescription for Pennsylvania law that removed practice barriers for APRNs. The research team will evaluate the development and architecture of the bill, and the success of the provision in expanding access to health care, particularly in medically underserved communities.

A team from the University of Texas Health Science Center at Houston will evaluate the effect of state regulations on APRN and physician teamwork, collaboration, and patient outcomes. They will compare six states with the most restrictive regulations on APRN practice with the 10 states that have the least restrictive regulations.
A team from the MGH Institute of Health Professions in Boston will examine whether loosening state restrictions on scope of practice for nurse practitioners affects cost; quality or access to care; brings more nurse practitioners into the state; and the role organizations play in interpreting regulations.
A team from the University of North Carolina Chapel Hill will evaluate the University HealthSystem Consortium/American Association of Colleges of Nursing Nurse Residency Program (NRP) to determine whether these programs provide a return on investment and to which entities. The NRP is the largest and only baccalaureate degree, graduate–focused, standardized residency program in the U.S.

The Robert Wood Johnson Foundation (RWJF) created the Future of Nursing National Research Agenda in 2012 to support research that would inform implementation of the recommendations in the Institute of Medicine’s (IOM) groundbreaking report The Future of Nursing: Leading Change, Advancing Health. The project is coordinated by RWJF’s Interdisciplinary Nursing Quality Research Initiative (INQRI).

The Case for Nurse Residency Programs

2013-05-07T12:12:00.000-04:00

The Institute of Medicine Report, The Future of Nursing: Leading Change, Advancing Care, includes several recommendations for strengthening nursing education. Nurse residency programs are one avenue for doing that, while also boosting nurse staffing at hospitals and helping those hospitals retain new nurses.

An article in the Anchorage Daily News looks at one nursing residency program at Alaska Regional Hospital and how it's preparing nursing school graduates and increasing nurse staffing. In addition to classroom instruction, Alaska Regional's program includes nurse-to-nurse mentoring, daily debriefing and frequent testing and evaluation.

The Future of Nursing: Campaign for Action includes several Action Coalitions working to develop or expand nurse residency programs. Most recently, the Rhode Island Action Coalition launched a statewide clinical nurse residency and mentoring program with a State Implementation Program grant from the Robert Wood Johnson Foundation. The Rhode Island program will place nursing school graduates in a range of settings from nursing homes to community clinics, as well as hospitals.

Nurse-Led Program Helps Improve Diabetes Parameters

2013-05-06T15:44:00.000-04:00

A study presented at the American Association of Clinical Endocrinologists and reported on in MedPage Today showed that a Diabetes Self-Management Training program administered by certified diabetes nurse educators helped patients lower their fasting home glucose levels and reduce their glycosylated hemoglobin A1c (HbA1c). The latter at higher levels than a control group who received only diabetes titration instruction.

The program was administered in a community outpatient clinic. Eighty-four patients received titration instruction and of those 45 also received Diabetes Self-Management Training. While both experienced improvements in the key parameters, those who had the second intervention had an additional 1.92 percent decrease in HbA1c levels.

An INQRI study recently published in the Journal of Health Disparities Research and Practice and conducted by a research team led by Robin Whittemore and Alana Rosenberg underscored the difficulties of ensuring adherence to diabetes prevention programs. The study highlights the need for culturally relevant programs for public housing residents that include behavioral and psychosocial support.

A Broader Role for the Federal Trade Commission in Regulating APRN Nursing Scope of Practice

2013-05-03T14:38:00.002-04:00

By Safiyyah Okeye, BSN, RN, Jill Vanek, BSN, MSN, and Julie Fairman, PhD, RN, FAAN

The 2011 Institute of Medicine (IOM) report “Future of Nursing: Leading Change, Advancing Health” pointed out that because nursing scope of practice regulations vary across states, and because there is little rationale for these variations, the federal government, through the Federal Trade Commission (FTC) and the Antitrust Division of the Department of Justice, “is well situated to promote effective reforms [related to regulation of APRN scope of practice] by collecting and disseminating best practices from across the country and incentivizing their adoption.”

The IOM recommended that the FTC and the Department of Justice review existing and proposed state regulations related to advanced practice registered nurses (APRNs) to identify those that limit competition without contributing to the health and safety of the public, and urge such states to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.

Created in 1914 to promote consumer protection by eliminating and preventing anticompetitive, unsafe, or deceptive business practices, the FTC is the logical agency to address scope of practice laws. The FTC’s responsibility is to promote competition, inform consumer choice, and protect consumer safety. All are directly related to APRN scope of practice regulations, including those mandating physician supervision and oversight of APRNs when there is not “a compelling consumer protection rationale” for doing so. That includes evidence justifying restrictions on APRNs’ ability to provide health care services that could override the public interests with regard to choice, cost or competition.

Individual states regulate the professional licensure and practice of registered nurses through state nursing boards or similar entities (e.g., state boards of medicine). Because boards are entrusted to uphold larger public interests by establishing and enforcing parameters of safe nursing practice, boards should base scope of practice on educational and training standards grounded in best practices and evidence-based outcomes. If a state regulatory board mandates physician supervision or oversight of APRNs even when those nurses meet the educational and practice parameters established by that board, the rationale should be consumer protection. Otherwise, mandating physician oversight and supervision may limit consumer choice, decrease competition, and increase health care costs. For example, if physicians refuse to supervise or meet collaboration requirements, or charge exorbitant fees for these services, they may prevent APRNs from practicing.

Medical professional groups argue that patient safety is the primary reason for requiring oversight and supervision, and that these practices are not anticompetitive and arein the public interest. They often cite the length of study required to be licensed as a physician as proof that physicians provide safer care, but there is no compelling evidence that program length directly affects outcomes, and this criterion should not be the basis for compulsory physician oversight.

FTC promotes competition and consumer choice and protects consumer safety through research, education, advocacy and law enforcement.

· Research, Education, and Advocacy: The FTC examines the effects of certain practices or legislation (both actual and potential) on competition and consumer protection. Research findings are disseminated through the following:

o Studies and Reports

o Advocacy statements to stateand federal legislators, courts, agencies, regulating bodies and the public. Advocacy statements may complement other FTC activities such as litigation and studies, and are cost-effective actions.

o Workshops and hearings

· Law Enforcement: The FTC investigates possible violations of competition and consumer protection laws. Investigations require extensive resources and time, eliminate the potential for negotiation, and are typically used only when other efforts have failed. The courts have been reluctant to hear hospital and scope of practice antitrust cases. Judges tend to be deferential to existing practices and reluctant to get involved in hospital decision-making. To date, the FTC has not taken any legal action directly relating to scope of practice issues for APRNs, but has participated in obtaining consent orders and filed an amicus curae on behalf of nurse midwives. The following are types of enforcement actions taken by the FTC when violations in the health care sector were found:

o Consent orders (sometimes referred to as “cease and desist” orders), which generally instruct respondents on what to do after they have been found in violation on competition and/or consumer protection laws

o Amicus curiae, or “friend of the court” filings, in which the FTC weighs in on a case in which they are not a party

The FTC becomes involved with advocacy and policy issues at the request of state legislators or professional organizations, and through public comment periods during legislation. To support FTC action, advocates for expanding scope of practice can:

Conduct and disseminate state-based empirical research regarding how limiting APRN practice may affect consumers through higher costs or lack of access to services.
Monitor state regulatory activity and request FTC action before a regulation is established. Once established or while in process of public comment, advocates can inform regulators and legislators.
Develop strong connections with consumer groups to educate and inform them about scope of practice regulations and the effect an actual or potential regulation may have on their access to high quality health care services. Advocacy statements are most influential (although not necessarily effective in implementing change) when the regulation is directly related to some consumer protection or competition issue such as access to care, and consumer support is mobilized.

By Safiyyah Okeye, BSN, RN, and Jill Vanek, BSN, MSN, are students at the University of Pennslyvania School of Nursing and Julie Fairman, PhD, RN, FAAN , is Nightingale Professor of Nursing, and Director of the Barbara Bates Center for the Studdy of the History of Nursing at the University of Pennsylvania.

Coordinated Care Still Needs Some Work

2013-05-02T12:42:00.001-04:00

While coordinated care is widely considered the best way to keep costs down and provide better patient care and is a centerpiece of the Affordable Care Act, too often care coordination isn't really happening according to a story produced by Kaiser Health News in collaboration with the Washington Post.

Kaiser Health News quotes leading health policy analyst Lucian Leape: "nobody is responsible for coordinating care." According to the story, lack of coordination is resulting in an estimated 44,000 to 98,000 deaths from medical errors annually. This, despite health care's strong response to the landmark Institute of Medicine report, To Err Is Human, published in 1999. That study was the subject of an INQRI blog carnival in 2010, featuring posts from several INQRI-funded researchers.

There is good news, however -- an article HealthLeadersMedia, published earlier this week indicates that nurses have the skills and experience provide effective and successful coordinated care. According to sources in the article, nurses' experience at the bedside - caring for multiple patients and handling their varying needs - makes them uniquely suited to understand and provide coordinated care.

Several INQRI teams have investigated how nurses' contribute to improved care coordination, especially in times of transition from hospital to home.

Nurse Staffing Matters - New INQRI Study

2013-05-01T18:33:00.000-04:00

A study led by Robin Newhouse and Laura Morlock published in the current issue of Medical Care underscores the importance of nurse staffing in providing quality care. The researchers tested in 23 ruaral hospitals a quality collaborative intervention to improve care for heart failure patients.

The intervention focused on four key measures of heart failure care. At the end of the study, the researhceers found no quantitative difference between the intervention and control groups on implementation of the key measures. They did find that hospitals with more stable nurse staffing - lower turnover - implemented more of the measures.

The researchers assert that the study speaks to the central role of nurses in quality improvement.

RWJF President and CEO Is One of Foreign Policy's 500 Most PowerfulPeople in the World

2013-04-29T12:03:00.001-04:00

Risa Lavizzo-Mourey is among the .00007 percent - one of the 500 most powerful people in the world according to Foreign Policy, out today. The list includes people who have made their mark through: politics, using a bully pulpit, force, brains, money, doing good, or doing evil.

While the Robert Wood Johnson Foundation could justifiably be included on the list for its use of money, brains, and a bully pulpit, too, Foreign Policy has tagged Lavizzo-Mourey for RWJF's greatest contribution - doing good.

More Evidence that Supplemental Nurses Provide High Quality Care

2013-04-26T12:37:00.000-04:00

The supplemental nursing workforce is crucial to keep hospitals adequately staffed in states suffering from a nursing shortage and at hospitals that have gaps in staffing due to nurse turnover. A new study by Linda Aiken, who serves on the National Advisory Committee for INQRI and has conducted several studies into outcomes of nursing care, shows that any hesitation hospital executives may have about using "travel nurses" is unfounded.

An article on ADVANCE for Nurses reports on the results of Aiken's recent study examining patient outcomes when they are cared for in hospitals that have a substantial number of agency nurses. The study included more than 1.3 million patients and 40,000 nurses in more than 600 hospital and found no evidence negative outcomes associated with care provided by supplemental nurses.

The article also reports on a study conducted at the Columbia School f Nursing that suggests that supplemental nurses' image may suffer because they often work in hospitals with poor work environments. The study's authors suggest that hospitals with poor work environments would have more trouble recruiting and retaining permanent nurses and rely heavily on agency nurses.

Aiken's study underscores the findings of an INQRI research team led by Ying Xue and Deborah Freund which determined that supplemental nurses had no negative impact on patient or nurse outcomes. They also found that supplemental nurses tend to have the same amount of experience as permanent RNs.

Transition-to-Practice Programs: Can They Improve Patient Safety and Quality of Care?

2013-04-24T12:48:00.001-04:00

An article in Nurse.com looks at several pioneering transition-to-practice programs that are helping new RNs get the skills and experience they need to more easily make the transition from nursing student to practicing RN.

According to the National Council of State Board of Nursing (NCSBN), more than 40 percent of new graduate nurses report making medication errors and 50 percent do not believe they would recognize life-threatening complications that would require intervention. Moreover, the NCSBN reported that average turnover rates for nurses in their first year are 35 to 60 percent.

To address these issues, leading educators, hospitals and health systems have developed nurse residency and other transition programs that help nurses develop and practice the critical thinking and clinical judgement skills needed, as well as the clinical experience they need to feel more confident and less stressed when they take on their first nursing job.

Results of these early efforts are promising, including lower turnover rates. NCSBN is currently conducting a study into the effect of a transition-to-practice program model on patient safety and and quality outcomes.

The IOM report, The Future of Nursing: Leading Change, Advancing Care, calls for strengthening nursing education, and many of the Action Coalitions that are part of Campaign for Action to implement the IOM report recommendations are working to develop or expand nurse residency programs.

Interdisciplinary, Team-Based, Patient-Centered Care Better for Older Patients, Too

2013-04-23T11:46:00.000-04:00

INQRI teams have conducted several studies illustrating the benefits of an interdisciplinary, team-based, patient-centered approach to fall prevention, medication management, managing delirium in critically ill patients, and more.

Now, a study published in JAMA Internal Medicine finds that the same kind of approach can reduce adverse events and shorten hospital stays for older patients. The study compared the Mobile Acute Care of the Elderly service (MACE) provided by Mount Sinai Hospital with general medical service. MACE teams include a geriatrics attending physician, a geriatrics fellow, geriatrics nurse coordinator and social worker. They focus on frail elderly patients with acute illnesses and complex needs and work to ensure safe, seamless continuity of care from hospital to home.

The study was conducted from November 2008 through August 2011. Researchers found that patients in MACE groups experienced fewer adverse events and had shorter hospital stays. In addition, Care Transition Scores, which provide patients' perspectives on quality of care during transition, were 7.4 percent higher in the MACE group.

Consumer Reports' 2013 Hospital Safety Ratings Show Significant Room for Improvement

2013-04-22T12:39:00.000-04:00

Consumer Reports has released its hospital safety ratings for 2013, and while the publication has nearly doubled the number of hospitals rated, many hospitals received low scores for their performance on readmissions, complications, communication, overuse of CT scans, and infections.

These measures are among the issues studied by INQRI-funded research teams investigating the role of nurses in improving the quality of patient care. Several of these studies have shown that nursing has a significant impact on reducing readmissions and infection rates, for instance.

The Consumer Reports Health Ratings Center scores hospitals on a 100-point scale. This year, the average score for the 2,031 hospitals included in the ratings was 49. Two-thirds of the 258 teaching hospitals in the U.S. received scores that were below that average.

Several hospitals have contested their low scores, pointing out that that data used for the scoring was more than two years old.

The U.S. Department of Health and Human Services' Hospital Compare site also provides hospital ratings. The Health Compare ratings are based on more current data but for an expanded list of measures, some of which are different. Those measures include: timely and effective care for several conditions; readmissions, complications and death; use of medical imaging; a survey of patients' hospital experiences; number of Medicare patients; and spending per Medicare patient.

Minimum Nurse Staffing Ratios, Mentoring Programs Are Part of New Senate Bill

2013-04-19T12:16:00.000-04:00

Earlier this week, U.S. Senator Barbara Boxer (D-CA) introduced the National Nursing Shortage Reform and Patient Advocacy Act, aimed at improving patient care and addressing the nursing shortage.

The bill would:

establish minimum nurse-to-patient staffing ratios;
invest in nursing mentorship demonstration programs; and
provide for whistleblower protections to allow nurses to report violations of minimum standards of care without fear of reprisal.

In a statement, Boxer said, “I am proud to introduce legislation that will help save the lives of countless patients by improving the quality of care in our nation’s hospitals. We must support the nurses who work tirelessly every day to provide the best possible care to their patients.”

Several INQRI studies (as well as numerous other studies) have established that higher nurse staffing levels improve patient outcomes, including research led by Mary Blegen and Tom Vaughn, and Linda Flynn and Dong-Churl Suh.

Better Nurse Staffing, Education and Work Environment Contribute to Magnet Hospitals' Patient Outcomes

2013-04-18T12:48:00.000-04:00

A new study in Medical Care, conducted by Matthew McHugh, an RWJF Nurse Faculty Scholar, finds that the lower mortality rates at Magnet Hospitals are achieved in part because of investments in nursing. This study reflects many of the findings of INQRI studies into the impact of nurse staffing, work environment and education on quality of patient care.

McHugh and his colleagues compared investment in nursing and patient outcomes at Magnet and non-Magnet hospitals in California, Florida, Pennsylvania and New Jersey. They found significant differences in nursing at Magnet hospitals, including better work environments, higher nurse-to-patient staffing ratios, and higher proportions of nursing with bachelor's degrees and specialty certification. Magnet hospitals also had better patient outcomes, including lower "failure to rescue" and mortality rates. They also reported that the Magnet application process may also play a role in promoting higher quality care.

A summary of the study is on Science Codex.

New JAMA Study Underscores Why the Business Case for Nursing Is Problematic

2013-04-16T17:05:00.000-04:00

A new study to be published tomorrow in the Journal of the American Medical Association (JAMA) finds that hospitals profit when patients have complications during surgery. According to a report in the Washington Post's Wonkblog, this counter-intuitive finding is a function of the payment structure in our nation's health care system. Hospitals earn money for every procedure done, even if that procedure is necessary to correct an error that occurs during surgery.

It's for just this reason,according to Olga Yakusheva, Douglas Wholey and Kevin Frick, that it has been so difficult to make a business case for investing in nursing care. In their article in the INQRI Medical Care supplement published last month, the INQRI researchers point out that because investments in nursing care improve patient outcomes, they hurt hospitals' bottom line. The authors go on to suggest that the roll out of the Affordable Care Act, which includes penalties for high rates of hospital acquired infections among, will help to address this confounding issue. They, like the authors of the JAMA study, also encourage taking more aggressive steps to make health care payments outcome-based, rather than service-based.

According to the Post blog, the JAMA study found that a hospital's profit margin jumped from $16,936 to $55,953 when there was a surgical complication.

Nurses Are Concerned that Patient Safety Programs Aren't Up to Par

2013-04-15T13:51:00.000-04:00

An online survey commissioned by by the American Nurses Association finds only two in five hospital nurses in the United States, United Kingdom and China describe their hospitals as "safe." While more than nine in ten nurses report their hospitals have safety programs, more than two in five don't believe the programs are effective. This is particularly dismaying in light of numerous efforts to improve hospital safety.

The survey is covered on the Human Capital Blog.

Also from Human Capital is a story on INQRI's contributions to interdisciplinary research into nursing as documented in Medical Care's special supplement, in the current issue of Sharing Nursing's Knowledge, out today. The story also highlights a study published in JAMA Pediatrics by Eileen Lake and Jeannette Rogowski on the impact of nurse staffing levels in neonatal intensive care units on patient outcomes.

AARP and Leapfrog Group Identify Some of the Best Safety Innovations in Hospitals

2013-04-12T10:46:00.000-04:00

INQRI researchers have developed and tested numerous interventions to improve patient safety and several of those interventions are being implemented today in various health care settings. Patient safety is an ongoing concern and one that receives much-deserved attention. This month's AARP Magazine identifies some of the most innovative programs being implemented in hospitals to prevent errors and improve patient safety. The Leapfrog Group scored the hospitals and created an online tool individuals can use to locate the best scoring hospitals in their communities.

These are just a few of the practices identified by AARP and Leapfrog:

a program through which each day, a nurse assess patients for their fall risks and gives high-risk patient yellow slippers which identify them as being at a high risk for falling;
bar codes on medications and patients' wristbands to ensure patients receive the right medications;
a "time out towel" placed on the instrument stand in the operating room to remind staff to follow standardized procedures; and
a "red zone" prohibiting staff from interrupting nurses who are dispensing medication.

Fall Prevention in a Psychiatric Hospital Requires Creativity

2013-04-11T10:00:00.000-04:00

Falls in hospitals can result in serious injuries and setbacks for patients. They're a particular problem for older patients as noted by Patti Dykes, who led the INQRI team that tested a fall prevention tool kit. They're also a problem for psychiatric patients, as an article in Advance for Nurses notes.

The article, by Christine Waszynski, a geriatric nurse practitioner at Hartford Hospital in Connecticut, reports on a fall prevention program being implemented in the psychiatric hospital within Hartford Hospital. Psychiatric patients are encouraged to remain ambulatory and independent to the extent possible during their hospital stays, so any interventions that limit their mobility or require close supervision can have a deleterious effect on their mental health. Moreover, many psychiatric medications can cause dizziness or an unsteady gait.

Waszynski describes the multidisciplinary fall prevention program which includes "post fall huddles" and "mini root cause analysis" after each fall. A Fall Rounding Tool is used to discuss existing fall risks and how they can be mitigated. Patients now wear shower shoes to avoid falls in the shower and shorter pajama pants to avoid tripping. Other strategies include a Fall Prevention Teaching Sheet which is reviewed with each patient upon admission.

Data collected a year prior to inception of the program up until 2012 shows the hospital has made noticeable improvements, decreasing overall number of falls and falls resulting in injury by 25 percent.

Modern Healthcare Names Top 25 Women in Healthcare

2013-04-10T16:28:00.000-04:00

RWJF President and CEO Risa Lavizzo-Mourey and Mary Wakefield, an INQRI grantee and current administrator of the Health Resources and Services Administration are among Modern Healthcare's Top 25 Women in Healthcare in 2013.

U.S. Surgeon General Regina Benjamin, FDA Commissioner Margaret Hamburg, Leapfrog President and CEO Leah Binder and IHI President and CEO Maureen Bisognano are also among the remarkable and accomplished women on this list.