Nursing
Nursing is a major component of the Foundation's focus on improving the quality of health care for all Americans.
Having an adequate supply of nurses is essential to achieving care that is safe, effective, patient-centered, timely, efficient and equitable. One of our key objectives is to transform the way that care is delivered in hospitals to allow nurses to spend more time with their patients, with the ultimate goal of improving the quality of care in hospitals.
There is a clear link between the care that nurses provide and improved patient outcomes—fewer falls, reduced pressure ulcers, fewer unanticipated deaths. We need to do a better job of understanding and measuring nursing's contribution to high-quality care. Transforming Care at the Bedside (TCAB) is a program of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement (IHI) to increase nurse retention and improve the quality of patient care. Hospitals participating in TCAB are tracking measures of quality care that are linked to the work of nurses. The National Quality Forum (NQF), an organization focused on health care quality measurement and reporting, has identified and endorsed 13 of these nursing-sensitive measures. TCAB hospitals are using four of these: fall prevalence, pressure ulcer prevalence, failure to rescue (that is, death among patients with serious but treatable conditions) and voluntary nurse turnover. We are learning through TCAB how best to track these measures; our goal is for every TCAB hospital to see improvement in at least two of these measures by 2007.
The TCAB hospitals have already made good progress on one important indicator of high-quality care: a low rate of voluntary nurse turnover. Nurses are the health care professionals who spend the most time providing direct care to patients, so when turnover is high and experienced nurses leave, patient care is compromised. Across the hospitals currently participating in TCAB, IHI reports annual nurse turnover on TCAB units has decreased from about 15 percent when the program began in 2003 to about 5 percent in 2006.
As the TCAB hospitals continue their efforts to make progress on the other NQF-endorsed nursing-sensitive measures, they report reducing falls through changes to the design of patients' rooms (for example, the installation of safety bars) and changes to hospital culture to ensure that every staff member—from the janitor to nurses to the chief executive officer—has a role and a responsibility in preventing patient falls.
And several TCAB hospitals report that they are improving rates of rescuing as they introduce rapid response teams—groups of experienced clinicians that nurses and other hospital staff (and, in some cases, even patients and their family members) can call on if they sense that a patient's condition is deteriorating. Because these teams intervene before a patient reaches a more critical point of distress, hospitals believe that rapid response teams are improving their rates of rescuing.
A key challenge to understanding and quantifying the hospitals' progress on nursing-sensitive measures has been a lack of consistent data and reporting. Tracking staff turnover rates is standard practice at almost any hospital. However, a common definition of a fall (for instance, does an “assisted fall”—when a nurse catches a patient and eases him to the ground safely—constitute a fall?), or a failure to rescue, requires more nuanced effort and attention. Through a national effort led by the NQF, we are tracking collection of the NQF nursing-sensitive measures, along with barriers and facilitators to using these measures for improvement. These results will both assist and be informed by the measurement efforts of the TCAB hospitals.
In 2006, with support from an evaluation team, TCAB hospitals began using a standardized reporting form to track their data, which we expect will provide a more efficient, less burdensome reporting system in the future. Hospitals track progress on the NQF-endorsed measures as well as other dimensions of care, such as percentage of nurses' time spent caring for patients, average length of patient stay, and staff and patient satisfaction.
Although we know anecdotally and intuitively that the work of nurses has a direct effect on length of patient stay and patient satisfaction, there is limited research that demonstrates the causal link between nurses' contributions and improved patient outcomes. In 2007 the Foundation's Interdisciplinary Nursing Quality Research Initiative will continue to build and share evidence of nurses' effect on care quality through processes such as care coordination, pain management and symptom assessment. As we continue to generate, disseminate and translate evidence that demonstrates nurses' direct link to improved patient care, the program will explore opportunities to reward nurses for high-quality outcomes such as offering pay-for-performance incentives.
Looking ahead, as the nursing profession ages—the average age of a nurse is nearly 47—the Foundation is expanding its efforts beyond TCAB to identify successful strategies for retaining experienced nurses. In 2006 the Foundation launched a new program, Wisdom at Work: Retaining Experienced Nurses, which will assess promising interventions to retain older nurses through human resources policies, the use of new technology, and changes in ergonomics and the physical design of the hospital.
Although we recognize the importance of retaining experienced nurses, we also understand that retention strategies alone will not be sufficient to curb the persistent nursing shortage in the United States. An aging faculty also creates tremendous challenges for the nursing workforce. With the majority of nurses educated at the associate degree level, with less than 12 percent going on for a baccalaureate degree, the pipeline for faculty is severely diminished. Moreover, a recent study by the National League for Nursing found that almost two-thirds of all full-time nurse faculty members are 45 to 60 years old and likely to retire in the next five to 15 years. Schools of nursing already report turning away more than 40,000 qualified student applications annually, largely because of a lack of faculty. In 2007 the Foundation will invest significant resources to address this critical shortage of nurse faculty.
For more information about our initiatives and objectives, visit www.rwjf.org/nursing.
Annual Patient Falls at Cedars-Sinai
NOTE: Average annual patient falls resulting in injury, per 10,000 patient days
SOURCE: Cedars-Sinai Medical Center