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Quality Improvement in Nursing 1


Quality improvement in nursing: administrative mandate or professional ethics?

Shigeko (Seiko) Izumi, RN, PhD

Oregon Health & Science University

Providing quality care is the foundation of professional ethics in nursing (1-3).

Nurses have an ethical obligation not only to provide quality care but also to continually
strive towards excellence in the quality of the care they provide. However, in the midst
of recent nationwide pressure to improve quality of health care in the US, quality
improvement (QI) in nursing is discussed primarily in terms of meeting administrative
mandates, and not as an ethical standard for professional practice. Although it is
encouraging to see the focus of health care shift—from only cost containment to
concern for quality of care—the shift seems to overlook the philosophical and ethical
components of professional practice. In this session, some of the quality improvement
activities related to nursing will be presented to delineate the recent focus of QI in
nursing. The meanings of these QI activities will be examined from the perspective of
professional ethics during the discussions.

Increase in nurse staffing/Decrease in patient-to-nurse ratio

Many quality improvement efforts in nursing focus on increasing the nurse-to-

patient ratio. Within the nursing profession, quality of care is hypothesized to be related
to the number of nurses who provide direct patient care. The American Nurses
Association (ANA) conducted a series of studies in the 1990s to examine the
relationship between nurse staffing and patient outcomes (4-6). Their findings
suggested a strong relationship between RN staffing and patient outcomes. As RN staff
increases, negative patient outcomes (e.g., pressure ulcers, falls) decrease. Their
findings were also supported by other studies (7-11), which suggest a relationship
between nurse staffing and patient mortality and morbidity. With these results as
evidence, emphasis is on increasing and keeping sufficient nurse staffing at the bedside
for safety and quality improvement (6).

According to the literature cited above and many anecdotes from bedside nurses
concerned about the quality of their care because of the lack of time, it makes sense
that increasing nurse staffing would improve patients’ outcomes. If we have more
nurses, each nurse will have more time to provide care for each patient, thereby
improving the quality of nursing care each patient receives. Thus, increasing nurse
staffing is one strategy to improve quality of care. This strategy is partially supported by
Quality Improvement in Nursing 2

American Nurses Association Code of Ethics for Nurses (1). Provision 6 in the Code of
Ethics for Nurses states,

“The nurse participates in establishing, maintaining, and improving healthcare

environments and conditions of employment conducive to the provision of quality
health care and consistent with the values of the profession through individual
and collective action.” (1)

According to the Code, it is nurses’ ethical responsibility to create environments of

practice and conditions of employment that support nurses in fulfilling their ethical
obligations, such as providing high quality care. Therefore, securing enough nurses to
provide high quality care seems to be an ethically valid way to accomplish this. Yet,
what is often missed in the discussion of increasing the number of nurses as a QI
strategy is whether it is “consistent with the values of the profession”. It is rarely
discussed what quality of health care is improved by increasing the number of nurses. It
is unknown whether changes created by increasing nurses are consistent with nursing
professional values.

Safety as quality standard

Safety is the most commonly used indicator for quality outcomes. The ANA has
selected patient falls, pressure ulcers, and nosocomial infections as nursing quality
indicators (6). Although patient mortality, failure to rescue (deaths following
complications), length of stay, and medication errors are used as indicators for quality of
health care in other quality researches (7-9, 11, 12), these patient outcomes are thought
to be more related to other aspects of institutional care than solely nursing care.
Therefore, in the nursing QI effort, patient outcome quality indicators are focused mostly
on falls, pressure ulcers, and/or infection rates. The data regarding these indicators are
collected from multiple hospitals and accumulated in a national database. Using the
database, it is possible to see if a unit is doing well compare to peer hospitals, doing
better compared to last year, or what the rates should be to be in the best 25% of all
units in the country (13). Now, in terms of quality improvement, nurses in each unit are
encouraged to improve or maintain these numbers thereby indicating safety of the care
in their unit.

The nurses’ ethical responsibility to protect safety of the patient is stated in

provision 3 of ANA Code of Ethics for Nurses. The provision reads “the nurse promotes,
advocates for and strives to protect the health, safety and rights of the patient.” Safety
needs to be protected as well as health and patients' rights. Because protection of
health and patients’ rights are not measured in the current quality indicators, QI effort in
nursing is solely focusing on the safety. Too much emphasis on improving safety
Quality Improvement in Nursing 3

incident rates may be misguiding nurses to overlook the other aspects they also need to

Because the scores on patient safety indicators become a part of hospital/unit

evaluation, the requests for the data collections and orders to improve the scores often
come from administration of the hospital. Protecting patient safety is an intrinsic part of
nursing care, and professional nurses take patient safety as their responsibility.
However, when an order is given to improve safety scores from the top-down, nurses
tend to view it as a mandatory activity, not a professional autonomous responsibility.
Setting certain scores (e.g., fall rate, pressure ulcer rate) as standards to meet and
maintain contains some risks to de-professionalize nurses. Nurses may become
workers who work to meet the given standard, not professionals who strive for
excellence. Use of patient safety as the only indicator to measure quality of nursing care
may dismiss the professional values in nursing and erode the nursing ethical standard.

Demand for nurses to be involved in hospital QI

Besides improving the quality of nursing care, nurses are taking a pivotal role in
hospital-wide quality improvement. Because nurses are an integral part of hospitalized
patients’ care, hospitals demand that nurses more often participate in QI activities, with
the number of QI activities increasing as QI demands for hospitals increase (14).
Nurses are asked to collect (often duplicative) data for quality assessment purpose.
Nurses are also encouraged to be involved, take leadership, and translate their
knowledge into an effective quality improvement effort. But there is a limit to how much
work can be added to nurses who are already short staffed. It is a trade-off whether to
allocate nursing resources to direct patient care or to quality improvement. Contributing
to improve quality of care patients receive in hospitals is nurses’ ethical responsibility.
As an integral part of hospital patient care, nurses should be involved and take an active
role in hospital QI activities. But, is it fair and safe to add more work to nurses’ plate?
Does removing nurses from direct patient care to QI contribute to improve quality of
care? What is nurses’ ethical obligation? Providing quality patient care at bedside, or
participating QI activities to make changes on the unit/hospital level? Or do nurses have
to chose one of them?

Discussion points

Three examples of QI activities and efforts related to nursing are delineated

above. Although nurses have long-standing concerns about quality of care in the health
care system, some of the current QI activities are imposed upon nurses as an
administrative mandate, not derived from nurses’ professional values. For nurses to
participate in QI as meaningful members of the health care profession and to make the
QI activities meaningful in nursing, we need to examine the philosophical and ethical
Quality Improvement in Nursing 4

meanings and implications of the QI activities for professional nursing. In the discussion,
we will explore what quality nursing care is, and examine nurses’ responsibility and
roles of providing quality care and quality improvement.
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