nursing patient outcomes examples

Example: Before discharge, patient will demonstrate nutritional ingestion sufficient for daily metabolic needs as manifested by improving weight measurement and enhanced energy levels. Relationships among nurse staffing, adherence to practice guidelines, and patient outcomes in the treatment of hypoglycemia. Journal of Biomedical Informatics, 42, 1004-1012. doi:10.1016/j.jbi.2009.05.005. Measuring patient outcomes results in the generation of data that can be used to improve results. Doran (Ed), Nursing Outcomes State of the Science (2nd ed, 487-508). SNL/Ts have developed gradually over time beginning with use of the term nursing diagnosis.In a 1953 issue of the American Journal of Nursing, Fry wrote about use of nursing diagnosis as a creative approach to nursing practice. The establishment of evidence-based practice competencies for practicing nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Fratzke, J., Tucker, S., Shedenhelm, H., Arnold, J., Belda, T., & Petera, M. (2014). Although the nursing quality agenda should accommodate measures related to efficiency, accreditation requirements, and VBP, it should be driven by the social contract. This shift will require changes in academic programs and research funding policies. 2, Manuscript 1. Nurse-sensitive indicators suitable to reflect nursing care quality: A review and discussion of issues. Such factors as demographics of the nursing force, education and certification, engagement, and organizational staffing models are associated with patient-experience outcomes, as are cultural and structural practices and processes. (2010). Currently, research evidence exists to support the relationships between higher rates of nursing specialty certification and lower rates of 5 patient outcomes: total patient falls, hospital-acquired pressure injuries, selected hospital-acquired infections, failure to rescue, and death. Nurse-related variables associated with patient outcomes: A review of the literature 2006-2012. Reliable and valid nurse process measures require accurate and complete documentation of nursing care and patient responses to that care. The type of metric driven harm known as tunnel vision is defined as the prioritization of financially incentivized and/or measured care over other valuable aspects of care (Bodrock & Mion, 2008; Rambur, Vallett, Cohen, & Tarule, 2013). Measures that are too burdensome and costly are less likely to be adopted for quality assessment. Western Journal of Nursing Research, 35(6), 760-794. doi:10.1177/01939549137476577, Burston, S., Chaboyer, W., & Gillespie, B. There are still relatively few scientifically acceptable measures that can reliably capture nursing's contributions to patient care. (2004). Include measures that are sensitive to change in the aspect of care being evaluated. This type of research falls under the umbrella of health services and/or nursing administration research which is notoriously underfunded compared to biobehavioral research (Edwardson, 2006; Holubowich & Andos, 2008; Murphy, Scott, & Warshawsky, 2014). More emphasis is needed on establishing clinically meaningful relationships between specific nurse process measures and patient outcomes that reflect the full spectrum included in the nursing profession’s social mandate. Similar to outcomes included in the VBP initiative (Table 1) and the first nurse report card (Table 2), the nurse-sensitive patient outcomes endorsed by the NQF (Table 4) exclusively reflect the nurse role in the prevention of a limited number of adverse events. However, the effect of staffing and nursing education on patient outcomes, though statistically significant, is relatively small by scientific and clinical standards. National Quality Forum. Although nurses may contribute to a broad array of patient outcomes, the expected contribution is variable, and teasing out the unique nursing contribution to patient outcomes is difficult (Needleman et al., 2007). Performance measurement of nursing care. Vol. Advancing the science in the measurement of health care quality influenced by nurses. Safety: (utilizes clinical reasoning and critical thinking that drives a culture of safety to prevent risk … Conceptually, the most valid source of data about nursing care and patient responses to nursing care is nursing documentation. This action translates into a downsized nursing workforce, fewer patient services, and decreased quality of care (Kurtzman et al., 2011; Timmers, Hulstaert, & Leenan, 2014). Table 3. Outcomes are behavioral cues that will describe the patient’s responses, feelings in response to the caring interventions provided. Moreover, measure specifications and data collection procedures are not standardized (Alexander, 2007; Doran, 2011). Regardless of intention, measure selection communicates importance and generates selective attention that ultimately drives selective improvement (Kurtzman & Jennings, 2008). The evidence base linking nurse structures with patient outcomes related to adverse events is much more robust than at the time of the ANA report card initiative (Brennan, Daly, & Jones, 2013; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Krueger, Funk, Green, & Kuznar, 2013; Lankshear, Sheldon, & Maynard, 2005). Consequently, a core group of nurse leaders collaborated to develop an MDS specific to nursing (NMDS). doi:11.1177/1077558707299260, Outland, B., Newman, M. M., & William, M. J. A., & Tarule, J. M. (2013). Edwardson, S. R. (2006). The Obama administration bets yes. Consistent with the SPO framework, an initial measure set was identified and evaluated based on theoretical links to the quality of nursing care (Table 2). Patients typically receive care from teams of semiautonomous providers representing multiple disciplines and specialties working interdependently. Therefore, a comprehensive evidence-based report card to evaluate the quality of nursing care was not achieved. Few would engage in the demanding work of nursing without some degree of belief that their efforts make a difference. The usability standard reflects the degree to which a measure is understandable to those making decisions that influence quality. Crossing the quality chasm: A new health system for the 21st Century. The economic imperative to measure and manage nursing outcomes is an extension of the social contract. Donabedian, A. Consensus standards for development of quality measures now exist and the National Quality Forum (NQF) is recognized as the as the common pathway for review and endorsement of quality measures in healthcare (Quraishi & Jordan, 2014). Although universally accepted taxonomies for diseases (i.e., the international clinical disease classification) and medical intervention (i.e., clinical procedure codes) were fully integrated into practice settings in the 1980s (Outland, Newman, & Williams, 2015), corollary taxonomies for nursing were not fully developed. Conceptual models for population-focused public health nursing interventions and outcomes: The state of the art. External forces are now facilitating this shift toward an outcome-based practice for nursing and strengthening the imperative for outcome measurement. Nursing interventions are absent in most administrative databases and represented patient outcomes are limited to adverse events. Setting the bar: Developing quality measures and education programs to define evidence-based patient-centered, high quality care. Nursing Inquiry, 13(1), 44-51. The care plan made is considered successful once the expected outcomes are met. Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S., & Wilt, T. J. Journal of Health Care Compliance, 12(1), 36-68. Dr. Jones teaches undergraduate and graduate courses focusing on various aspects of leadership, management, evidence-based practice, and quality and safety. Hakes, B., & Whittington, J. Nursing hours per patient day • Skill mix. A key contributing factor in the failure to establish direct causal linkages between nursing care and patient outcomes is the lack of available nursing process measures. Mode of transport or transportation 4. Critical Care Nursing Quarterly, 37(1), 125-134. doi: 10.1097/CNQ.0000000000000011. At the very least, nurse administrators must request and support ongoing testing of user interface screens to maximize efficiency (Hyun, Johnson, Stetson, & Bakken, 2009). The National Database of Nursing Quality Indicators (NDNQI), Online Journal of Issues in Nursing, 12(3). Presumably, nurse structures influence patient outcomes through nursing care processes. 8). Nurses have a social responsibility to evaluate the effect of nursing practice on patient outcomes in the areas of health promotion, injury and illness prevention, and alleviation of suffering. Naomi Reay, PhD, MA, DN, RSCN, RGN,is clinical commissioner/lead clinician (West Yorkshire), NHS Kirklees and Primary Care Research Network. Holubowich, E. J. The discipline has long been criticized as a practice based more on tradition than evidence and this criticism has been met with multiple professional initiatives to stimulate evidence based practice and outcomes research. Electronic prompts and forcing functions can be added to reduce lapses in documentation. Outcomes that are not empirically linked to specific malleable processes are not useful because they do not help decision makers determine how to improve care. Integrate leadership principles and processes in actual organizational systems to ensure safe, quality outcomes of patient-centered care across the health care continuum. Nursing exists for the sole purpose of serving the public good; therefore, the public owns the discipline. Nursing and threats to patient and nurse safety and quality of patient care. The social imperative is described in the American Nurses Association (ANA) Social Policy Statement (ANA, 2010) and is codified in each nurse practice act. Farquhar, M., Kurtzman, E. T., & Thomas, K. A. Dr. Jones completed her PhD in 2004 at The University of Texas at Austin and was selected to participate in the NIH-Sponsored Clinical Scholars Program at The University of Texas Southwestern Medical Center at Dallas from 2007-2010. Typed versus voice recognition for data entry in electronic health records: Emergency physician time use and interruptions. Nursing report card for acute care settings. Quality assessment and outcomes research initiatives have historically been hindered by lack of available data related to nursing processes and patient outcomes across these domains of practice. Journal of Nursing Administration, 44(12), 622-624. Values for staffing and outcomes were calculated for each of the 4 calendar quarters for 2005. Nursing Economic$, 24(3), 160-161. Nurse leaders and scholars have long recognized the need to measure the outcomes of nursing care and have attempted to address the associated challenges at various times throughout history. Assessing the impact of an electronic medical record on nurse documentation time. Advances in Nursing Science, 28(2), 163-174. Moreover, the NQF has not endorsed any additional nurse-sensitive structure, process, or outcome measures since 2004. Here are some factors that may be related to Risk for Injury: External 1. DHHS defined an MDS as the least amount of data needed to evaluate a specific service (Hobbs, 2011) and established the first MDS to evaluate hospital services in 1974: the Uniform Hospital Discharge Data Set (UHDDS). The complex nature of healthcare is well documented (IOM, 2004). The development of robust nurse process measures is hindered by issues related to incomplete and unstandardized documentation, documentation burden, and data collection burden. Despite decades of intentional efforts to this end, the nurse contribution to patient outcomes has not been sufficiently quantified. Kavanagh, K. T., Cimiotti, J. P., Abusalem, S., & Coty, M. (2012). The act of measurement makes phenomena visible and functions to elevate actual and/or potential quality problems in the consciousness of stakeholders. Electronic documentation systems have not reduced the documentation burden for nurses. Each discipline is necessary for recovery of function, yet none is sufficient. Medical Care Research and Review, 64(2), 144S-169S. doi:10.1186/1472-6955-12-7. Notably, nurse-sensitive indicators account for < 3% of the 500-plus measures endorsed by the NQF. The Texas Board of Nursing details various conditions in the provision of patient-centered care. It is just as important, however, to address accessibility, especially for members of the Deaf and Hard of Hearing community. Jones, T. (2011). 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The interventions and action types provide the evidence for measuring the outcomes. Thus, in the instance of surveillance and other interdependent interventions, the ultimate outcome may be influenced as much by other providers as by nurses (Anthony, 2008; Jones, 2011; Kurtzman et al., 2011). surgical procedures), many nursing interventions are more akin to the information transfer process of knowledge workers, and therefore more difficult to isolate and measure (Matney, Maddox, & Staggers, 2014). Sudbury, MA: Jones & Bartlett: Learning, Krueger, L., Funk, C., Green, J., 7 Kuznar, K. (2013). Moreover, healthcare organizations are often hesitant to share clinical and operational data with non-employees, even for research purposes. Outcomes of care are generally regarded as the most important element of quality assessment because they focus on patients and reflect the social mandate and ultimate goals of healthcare providers (i.e., changes in health status) (Donabedian, 2003). Aydin, C. E., Bolton, L. B., Donaldson, N., Brown, D. S., Buffman, M., Elasahoff, J. D., & Sandhu, M. (2004). Ways to stay focused on your patients, not your EHR. Electronic documentation systems have not reduced the documentation burden for nurses. Martinez, K., Battaglia, R., Start, R. Mastal, M.F., & Matlock, A.M. (2015). The outcomes addressed in current VBP policies primarily relate to the prevention of injury (e.g., nosocomial infection, pressure ulcers) and do not address other outcomes germane to the nursing profession’s social contract (i.e., health promotion and the alleviation of suffering). Washington, DC: National Academies Press. (2005). Dubois, C. A., D’Amour, D., Pomey, M. P., Girard, F., & Brault, I. Nursing Management, 46(5), 24-32. doi:10.1097/01.NUMA.0000463882.54.082.64. Expected Outcomes – These are the goals for the nursing care plan made. Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.html, Munyisia, E. N., Yu, P., & Haily, D. (2011). Development and evaluation of nursing user interface screens using multiple methods. Researchers cannot establish specific causal chains without capturing the effects of nurse structures on nurse processes and/or the effects of nurse processes on patient outcomes (Needleman et al., 2007). Therefore, nurses are accountable for and obligated to measure interventions and outcomes in the areas of health promotion, prevention of illness and injury, and alleviation of suffering. Though highly relevant to quality assessment and self-regulation in nursing, development and routine monitoring of nurse process measures has fallen into the “too hard to do” domain. Biological (e.g., immunization level of community, microorganism) 2. Doi:10.1111/j.1547-5069.2010.01364.x. Development of evidence-based, nurse-sensitive quality measures that meet the NQF consensus standards must become a research priority. This gain in efficiency is further enhanced when data fields are standardized across facilities and populated with a standardized taxonomy; therefore, adoption of EHRs may increase adoption of a NMDS. Efforts to develop nurse-sensitive indicators for other practice settings, such as oncology (Fessele, Yendro, & Mallory, 2014), ambulatory care (Martinez, Battaglis, Start, Mastal, & Matlock, 2015), schools (Forward, 2012), public health (Bigbee & Issel, 2012), and women’s health (Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2014) are underway; however, comparable performance databases for these practice settings do not currently exist. Nursing care is often more difficult to conceptualize and measure than care from other disciplines. The last thing a patient wants when going to a hospital for treatment is a hospital … Limited Range of Patient Outcome Measures. In other words, the active ingredients of nursing care must be identified and quantified. One alternative strategy used by physicians to address documentation burden is to hire scribes to shadow clinicians and document clinical activities and observations (Hertz, 2014). The identified outcomes were hospital-centric and did not reflect the full scope of outcomes included in the profession of nursing’s social mandate or the full range of outcomes assumed to result from good nursing care. Doran, D. M. None of the identified patient outcome measures were supported by a direct causal link to nursing structures or processes. Heslop, L. & Lu, S. (2014). As soon as I leave a patient I will chart all my notes about our interaction while they're still … Data from the UHC did not contain information about nurse educati… Efforts to promote a NMDS have continued since the 1980s along with parallel activities to promote a universally accepted taxonomy for nursing diagnoses, interventions, and outcomes (Daly, Maas, & Johnson, 1997; Halloran & Halloran, 2015; Needleman et al., 2007). Aiken, L. H. , Clarke, S. P., & Sloane, D. M. (2001). Therefore, assumptions about the nursing contribution to care must be replaced with empirical evidence of the nursing profession’s actual contributions to care. As a result, the Expected Outcomes were created by using one of the three qualifiers as the proposed Goals of the Care on admission and the Actual Outcomes evaluated as the results of the Care on Discharge.  This process makes it possible to measure and/or evaluate the care process and the interventions provide the evidence for measuring the patient care outcomes. Infection Control. Though highly relevant to quality assessment and self-regulation in nursing, development and routine monitoring of nurse process measures has fallen into the “too hard to do” domain. The study findings demonstrate that higher nurse-to-patient ratio is related to negative nurse outcomes. Evidence suggests that time spent on documentation increases immediately after implementation but eventually returns to baseline (Hakes & Whittington, 2008; Munyisia, Yu, & Hailey, 2011). The selection of quality measures sets is guided by conceptual models of quality, scientific standards, and the pragmatics of data collection. Fessele, K., Yendro, S., & Mallory, G. (2014). Primary data collection and manipulation of non-standardized data are time and resource intensive. Nurses have a social responsibility to evaluate the effect of nursing practice on patient outcomes in the areas of health promotion; injury and illness prevention; and alleviation of suffering. The purposes of this article are to examine the imperatives, ideals, history, and challenges related to effective outcome measurement in nursing and to identify recommendations for action. The act of measurement makes phenomena visible and functions to elevate actual and/or potential quality problems in the consciousness of stakeholders. Thus, the social contract between health professionals and the public dictates that nurses engage in self-regulation to assure quality performance. The predominant conceptual model guiding quality management in healthcare was first described by Donabedian in 1966 and is known as the Structure-Process-Outcomes (SPO) model (Donabedian, 1966; Donabedian, 2003). However, empirical evidence to support the unique contribution of nurses to quality outcomes is currently lacking (Needleman, Kurtzman, & Kizer, 2007). Therefore, surveillance cannot be conceived or measured as a discrete intervention (e.g. (1995). Murphy, L. S., Scott, E. S., & Warshawsky, N. E. (2014). Measures based on data collection methodologies intrinsic to care processes and captured by existing data systems are highly desirable (Burston, Chaboyer, & Gillespie, 2013; Needleman et al., 2007). (2014). (2014). (2009). Execution of a NMDS requires a standardized language to effectively capture nursing services and outcomes of interest (Mac Neela, Scott, Treacy, & Hyde, 2006). Nursing-sensitive indicators in ambulatory care. Journal of Advanced Nursing, 21, 1092-1100. (2015). Applied Nursing Research, 26, 269-272. doi:10.1016/j.apnr.2013.09.001, Raso, R. (2015). Quality assessment and self-regulation cannot move forward without substantial investments to support adequate documentation of nursing practice and patient outcomes. Standards for Quality and Outcome Measurement. Moreover, there is some concern that this burden will result in a shift of attention away from patient care, essentially putting the assessment of quality in competition with the performance of quality. Quality assessment is recognized as an essential aspect of quality management and three essential elements of quality assessment are identified: structures, processes, and outcomes of care (Figure). Laissez-faire Leadership. Refinement of the user interface alone will not likely be sufficient. Measurement is essential to quality assessment. MEDSURG Nursing, 24(6), 397-401. Hospitals and clinics … As empirical evidence emerged and data collection efforts intensified, the number of proposed nurse-sensitive increased incrementally. Table 2. The Donabedian model is a useful organizing framework for quality assessment in healthcare, providing a generic overview of the essential categories of quality measures and supporting the necessity of empirically supported relationships within measure sets. Condition did not change and required no further care to maintain condition. Office of nursing services (ONS) annual report 2009. Citation: Jones, T., (May 31, 2016) \"Outcome Measurement in Nursing: Imperatives, Ideals, History, and Challenges\" OJIN: The Online Journal of Issues in Nursing Vol. DOI:10.3912/OJIN.Vol12No03Man02 Key Words:nursing-sensitive indicators, quality, nurse staffing, patient outcomes, nursing outcomes, performance measurement Quality is a broad term that encompasses various aspects of nursing care. (2011). The possible patient outcomes are generally explained under three terms: the patient’s condition improved, the patient’s condition stabilized, and the patient’s condition worsened. Imperatives for nurses to engage in self-regulation through quality assessment and outcomes management are stronger than ever. British Journal of School Nursing, 7(10), 490-500. DIAGNOSIS ----- Statement of Problem (Nursing diagnosis [NANDA List] plus etiology) NOT. Sustained innovative and collaborative actions from multiple stakeholders are needed. Compared to abstraction of data from paper based documentation systems, retrieval of data from an EHR for quality analysis and reporting is more efficient (Alexander, 2007). While adverse events are important, the question remains as to whether or not they should receive a disproportionate share of nursing attention and organizational resources compared to other quality problems. Nurses are obligated to serve the public good through stewardship of health resources. The term ‘patient outcomes’ is used frequently in healthcare research [3], [4], [5], [6]. In recent times, research linking nurse staffing matters and adverse patient outcomes have got … Journal of Nursing Scholarship, 36(4), 371-378. External forces are now facilitating this shift toward an outcome-based practice for nursing and strengthening the imperative for outcome measurement. Quality assessment initiatives are hindered by the paucity of available data related to nursing processes and patient outcomes across these three domains of practice. In order to define desired patient outcomes or the collaborative “Care Goals”, the “Patient Status” needs to be defined. Institute of Medicine. The efficiency gained in information retrieval is potentially offset by a loss of efficiency related to data entry. Introduction of EHRs has indeed changed nursing documentation processes and retrieval of information for analyses. Willingness to Recommend Hospital to Others/Use Hospital Again, Unscheduled Physician Visits Post-Discharge, Patient Knowledge of Disease/Condition and Care Requirements, Accurate and Timely Execution of Therapeutic Interventions and Procedures, Documentation of Nursing Diagnoses, Therapeutic Objectives, and Care Given, Appropriate Use of Pharmaceutical Restraints, Death among surgical inpatients with treatable serious complications (Failure to Rescue), Catheter-associated urinary tract infections for intensive care unit patients, Central line catheter-associated blood stream infection rate for ICU and High Risk Nursery (HRN) patients, Smoking cessation counseling for heart failure, Smoking cessation counseling for pneumonia, Skill mix (RN, LVN/LPN, UAP, and contract). Therefore, nurses have a social obligation to develop and document the evidence base for the entirety of nursing practice and shift from a task-based practice, which emphasizes what nurses do for patients, to an outcome-based practice that emphasizes what nurses achieve with patients. Measurement of nursing outcomes is a linchpin for both of these important and interrelated activities. State of the science reviews indicate that the challenges of effective quality and outcomes measurement in nursing have changed very little in the past 40 plus years (Alexander, 2007; Griffiths, 1995; Naylor, 2007; Needleman et al., 2007). Fry proposed to nurses that: \"the first major task in our creative approach to nursing is to formulate a nursing diagnosis and design a plan which is individual and which evolves as a result of a synthesis of needs\" (p. 302). When performance on an outcome influences provider reimbursement, the increased attention is often accompanied by a reallocation of resources to correct the problem.

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