Round 3 Grants
Round 3 Grants
The Robert Wood Johnson Foundation (RWJF) awarded the third round of grants through its Interdisciplinary Nursing Quality Research Initiative (INQRI) program on September 1, 2008. Eight teams of nurse scholars and scholars from other disciplines were selected to conduct two-year research projects to examine the link between nurses' contributions and the safety and quality of patient care.
The Impacts of Nurse Staffing, Skill Mix, and Experience on Quality and Costs in Long-Term Care
Palo Alto Institute for Research and Education
Dr. Patricia Stone
Dr. Ciaran Phibbs
This project will examine whether there is a causal relationship between nursing input (ie. staffing and human capital characteristics) and patient outcomes in long-term care (LTC) facilities, and will analyze efficiency by studying the tradeoffs between nursing personnel costs and cost savings due to improved patient outcomes. Using a unique longitudinal database of the entire population of LTC facilities operated by the Veterans Administration in fiscal years 2003-2007, the team will link a variety of patient outcomes to detailed measures of the nursing input, controlling for other factors that can influence patient outcomes. Site visits will also be conducted and multivariate fixed-effect regressions will be estimated using monthly data. This project is co-led by Ciaran Phibbs, PhD, an economist and Patricia Stone, PhD, a nurse researcher.
The Effect of Off-peak Hospital Environments on Nurses' Work: an Institutional Ethnography
Midwestern State University
Dr. Patti Hamilton
Dr. Gretchen Gemeinhardt
Research shows that patients admitted to hospitals during "off-peak" hours, like evenings and weekends, experience more health problems. Led by Patti Hamilton and Gretchen Gemeinhardt, researchers at Midwestern State University , studied the differences in the ways nurses provide care during peak and off-peak times and how managerial, economic and health care policies influence nurses' work environments, actions and judgments during those periods. The team conducted interviews with more than 70 nurses and other health care providers and executives in Texas and found that 64% of hours worked by nurses are off-peak and communication with other providers is more difficult during those shifts. Their preliminary results, published in the March 2010 Journal of Nursing Administration ("Expanding What We Know About Off-peak Mortality in Hospitals"), show that nurses' "off-peak" work environments play a significant role in the increased patient mortality during these time periods. The study provides new knowledge of the effects of managerial productivity tracking on the nursing workplace and patient outcomes. Further, the study reveals how state-mandated nurse staffing policies can increase rather than decrease off-peak nurses' work intensity and result in less time to care for patients. The researchers have identified key strategies to mitigate off-peak risks for patients.
Impact of Medical Surgical Acute Care Microsystem Nurse Characteristics and Practices on Patient Outcomes
University of California, San Francisco
Dr. Nancy Donaldson
Dr. Carolyn Aydin
Led by Nancy Donaldson and Carolyn Aydin, researchers from the Collaborative Alliance for Nursing Outcomes (CALNOC) at the University of California, San Francisco and Cedars-Sinai Medical Center developed an empirically derived predictive model examining individual and collective effects of unit level nurse workload, staff nurse characteristics and selected risk assessment and preventive intervention processes of care on variance in nursing sensitive outcomes of acute care medical-surgical units. The model used data collected by hospitals engaged in ongoing CALNOC benchmarking, as well as data collected explicitly for this study. The team found that patient outcomes were predicted by combinations of all elements in their model, including: unit/patient characteristics, nursing workload, registered nurse expertise and clinical processes. Interestingly, they found that falls and falls with injury were predicted by patient characteristics and clinical process variables, but not by nurse expertise. However, hospital acquired pressure ulcer prevalence was predicted by a combination of all elements in the model. Finally, the team also found that unit and patient characteristics and workload could predict medication practice errors and that workload and practice errors predicted medication outcome errors. These findings can guide hospitals in efforts to improve staffing effectiveness and patient safety, reducing medication administration errors and understanding prevalence of facility acquired pressure ulcers.
The Res-Care-AL Intervention Study
University of Maryland, Baltimore
Dr. Barbara Resnick
Dr. Sheryl Zimmerman
Researchers at the University of Maryland, led by Barbara Resnick and Sheryl Zimmerman, conducted a randomized controlled trial to test Function Focused Care – Assisted Living (FFC-AL), an intervention designed to maintain and improve function, physical activity, muscle strength, psychosocial outcomes (efficacy expectations and life satisfaction) and decrease adverse events (pain, falls and hospitalizations) among assisted living residents. FFC-AL was implemented by a research Function Focused Care Nurse (FFCN). The FFCN worked with the intervention sites 15 hours per week for the first 6 months of the 12-month intervention, 8 hours a week for the next 3 months, and 4 hours a week for the final 3 months of the intervention. To assure sustainability of the function focused care philosophy, each treatment site identified a facility champion who worked with the FFCN, learned the implementation process, and helped to institutionalize function focused care within the community. Working with the facility champion, the FFCN implemented the four components of the intervention: (I) Environment and Policy/Procedure Assessments; (II) Education; (III) Developing Function Focused Goals; and (IV) Mentoring and Motivating. Four assisted living communities were randomly assigned to treatment (FFC-AL) or to placebo control (FFC-education only). A total of 171 residents and 96 direct care workers (DCW) were followed for 12 months. Based on observations of care interactions, DCWs in treatment sites provided more function focused care by 12 months than those in the control sites. Residents in treatment sites demonstrated fewer declines in function and spent more time in moderate level physical activity at 4 months and more overall counts of activity at 12 months when compared to residents in control sites. There were no differences in muscle strength, falls, pain, life satisfaction or efficacy expectations between the groups. There were, however fewer transfers to the hospital among those in the treatment sites. There was evidence of dissemination and implementation of FFC-AL within the sites that endured beyond the study period (e.g, policy and environmental changes). The study findings suggest that using a FFC-AL approach may help to prevent some of the persistent functional decline commonly noted in these communities, increase time spent in physical activity, and decrease the need for acute care transfers.
Multidisciplinary Organization and Outcomes for Chronic Heart Failure Patients in the VA
University of Minnesota
Dr. Joanne Disch
Dr. Douglas Wholey
This research team will test a theory of the effect of nurse-physician co-leadership, the effective modeling by nurses and physicians of individual role behaviors and a strong shared inter-professional relationship, in chronic heart failure (CHF) care groups in Veterans Health Administration (VHA) medical centers. The outcomes will be waste in care processes, patient outcomes of receiving dietary and medication instructions at discharge, adult smoking cessation advice/counseling, and readmissions and provider outcomes of nurse burnout and CHF knowledge. The unit of analysis is patients and providers nested in VHA CHF care groups. The project has an observational design, with patient outcomes being followed for a year after a survey of CHF care groups. The project is being co-led by Douglas Wholey, PhD, MBA, a scholar with a background in Mathematics, General Management and Organizational Behavior/Industrial Relations, and Joanne Disch, PhD, RN, a nurse scholar.
The Effects of Nurse Presenteeism on Quality of Care and Patient Safety
University of North Carolina, Greensboro
Dr. Susan Letvak
Dr. Christopher Ruhm
A team at the University of North Carolina, Greensboro, led by Susan Letvak and Christopher Ruhm, evaluated the influence of presenteeism (decreased productivity due to health problems) on hospital registered nurses' (RNs) quality of patient care. This study focused on presenteeism among RNs suffering musculoskeletal pain and/or depression. In addition, they assessed the economic costs to the health care system associated with presenteeism. Using a mixed methods approach, including a survey and focus groups of RNs in North Carolina, researchers documented a depression prevalence of 18% in hospital nurses. Seventy-one percent of nurses interviewed reported working with some pain and the majority of nurses interviewed reported that a health problem had negatively affected their productivity on the job in the previous two weeks. The team found that pain and depression were significantly associated with presenteeism and that presenteeism was significantly associated with patient falls, medication errors and the perceived quality of care. Finally, the team found that the productivity loss due to pain and/or depression was $14,339 per nurse and $876.9 million for the state of North Carolina. If these numbers were extrapolated to the nation, the productivity loss would be $22.7 billion.
Small Troubles, Adaptive Responses [STAR]: Fostering a Quality Culture in Nursing
University of Texas Health Science Center, San Antonio
Dr. Kathleen Stevens
Dr. Robert Ferrer
A team led by Kathleen Stevens and Robert Ferrer at the University of Texas Health Science Center, San Antonio recently completed a project to improve nursing units' quality and efficiency, using a program designed to identify and address small problems encountered by nurses in patient care. The intervention combined a methodology for measuring minor operational failures in routine nursing care with a set of quality improvement strategies for tackling the small problems nurses encounter in practice. Researchers launched the study at two sites. Although tracking small problems with pocket cards was an effective strategy to raise awareness of small problems, nursing units' ability to improve practice was limited, because there were few effective communication channels with clinical leadership and frontline nurses had limited time and expertise for improvement projects.
Empowering Home Care Nurses to Efficiently Resolve Medication Discrepancies
Washington State University
Dr. Cynthia Corbett
Dr. Stephen Setter
A team led by Cynthia Corbett and Stephen Setter at Washington State University used information technology to help home care nurses more efficiently and effectively identify and resolve medication discrepancies as patients transitioned from the hospital to home. These discrepancies occur when a patient's discharge instructions regarding their medication differ from the medications the patient actually took once arriving home. Researchers evaluated whether the intervention had an impact on patients' emergency department visits during the first 30 days after hospital discharge. They found that nurses identified a mean of nearly three medication discrepancies per participant, while the pharmacists identified a mean of six medication discrepancies per participant. Medication discrepancies were found for virtually all classes of medications, including those considered high risk, such as antidiabetic medications, anticoagulants and narcotics. The intervention group participants had fewer emergency department visits during the first 30 days after the index hospitalization. These findings demonstrate both the importance and the complexity of medication information transfer during care transitions from hospital to home.