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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,
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.
incident rates may be misguiding nurses to overlook the other aspects they also need to
consider.
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
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.
Quality Improvement in Nursing 5
References
1. American Nurses Association. The Code of Ethics for Nurses. Washington, D. C.:
American Nurses Publishing; 2001.
2. Fry ST, Johnstone M-J. Ethics in nursing practice: A guide to ethical decision
making. 2nd ed. Oxford: Blackwell Publishing; 2002.
3. International Council of Nurses. The ICN code of ethics for nurses. In. Geneva:
International Council of Nurses; 2006.
4. American Nurses Association. Nursing Report Card for acute care settings.
Washington, DC: American Nursing Publishing; 1995.
5. American Nurses Association. Nursing Quality Indicators: Definitions and
implications. Washington, DC: American Nursing Publishing; 1996.
6. American Nurses Association. Nursing facts: Nurse-sensitive quality indicators
for acute care settings and ANA's safety & quality initiative. In. Washington, DC: ANA;
1999.
7. Aiken LH, Smith HL, Lake ET. Lower mortality among a set of hospitals known
for good nursing care. Medical Care 1994;32:771-787.
8. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing
and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288(16):1987-
1999.
9. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care
environment on patient mortality and nurse outcomes. The Journal of Nursing
Administration 2008;38(5):223-229.
10. Blegen MA, Vaughn T. A multisite study of nurse staffing and patient
occurrences. Nursing Economics 1998;16(4):196-203.
11. Shindul-Rothchild J, Long-Middleton E, Berry D. 10 keys to quality care.
American Journal of Nursing 1997;97(11):35-43.
12. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of
hospital nurses and surgical patient mortality. Journal of the American Medical
Association 2003;290(12):1617-1623.
13. American Nurses. National database of nursing quality indicators: Frequently
asked questions. Retrieved March 3, 2008 from
http://www.nursingquality.org/FAQPage.aspxIn; 2006.
14. Draper DA, Felland LE, Liebhaber A, Melichar L. The role of nurses in hospital
quality improvement 2008. Washington DC: The Center for Studying Health System
Change. Retrieved May 18, 2008 from http://www.hschange.org/CONTENT/972/