Nurses are the "daily face" to hospitalized veterans and their families and are also the linchpins of hospital care. Their important role in assuring the delivery of high quality care is underscored by empirical evidence that both structural features of nursing care (i.e. nurse staffing ratios) and process features of nursing care-the specific activities performed by nurses providing patient care (e.g., nurse surveillance)-are linked to patient outcomes, including mortality. In 2004, the National Quality Forum (NQF) endorsed the first set of nationally standardized performance measures for assessing nursing quality in acute care hospitals. Of the 15 measures endorsed, only 3 are nursing process measures. A lack of nursing process of care measures limits the ability to improve hospital quality as these measures provide a basis for actionable interventions (i.e., quality improvement (QI)). In order to truly improve hospital quality, the relationships between structures, processes, and outcomes of nursing care need to be examined and understood.
This pilot work is foundational to the development and testing of quality indicators specific to nursing processes of care for use in VA. The study aims were to:
(1) Understand unit-level nursing quality improvement in terms of:
- Hospital structure relative to quality improvement and how this plays out on nursing units
- Types of QI projects undertaken on nursing units
- In-house nursing measurement activities: who collects measures that nurse managers receive, how often, which measures, how much do they differ across nursing units?
- The role of larger measurement activities (VANOD or EPRP data collection): do these inform unit-level quality improvement activities?
(2) Identify the most pressing quality issues and the potential processes of care that relate to these issues.
We used a single-site case study approach to produce a snapshot of organizational features, nursing care processes, and measurement/QI activities relevant to pressure ulcer prevention across nursing units in one large, academic VA Medical Center. Between September and November 2008, we conducted semi-structured interviews of 12 key informants whose positions involved responsibility for pressure ulcer prevention. Interviews were transcribed and analyzed for key themes.
Nursing care processes mentioned frequently included the performance of a skin assessment within 24 hours of admission and completing the Braden Scale within 24 hours of admission. Some perceived facilitators of pressure ulcer prevention (e.g., the presence of a wound care team) were frequently reported across nursing units and may be considered characteristics of the hospital as a whole. Conversely, some of the perceived barriers to pressure ulcer prevention (e.g., sub-optimal teamwork) appeared to be specific to individual nursing units and may not apply to the entire hospital. Overall, interviewees did not appear familiar with larger, VA-specific measurement activities (e.g., VA Nursing Outcomes Database (VANOD)). However, nursing leadership and nurse managers frequently mentioned the importance of local measurement activities including some specific to pressure ulcers.
This study identified organizational features and nursing care processes related to pressure ulcer prevention in one VAMC. A broader understanding of these features across VA hospitals can inform the development and/or refinement of VA nursing process measures, which in turn, can inform QI interventions to improve patient outcomes for pressure ulcers. In addition to pressure ulcer-specific features of care, we also identified features of care delivery (e.g., deficits in teamwork) that may affect the quality of nursing care globally; addressing such issues has the potential to improve the overall quality of care that veterans receive in VA hospitals.
- Soban LM, Butler JN, Rose DE, Hamilton A, Rubenstein LV. Influence of organizational context on nurses' delivery of pressure ulcer preventive care: Findings from a pilot study in a large VA Medical Center. Paper presented at: Greater Los Angeles Nursing Research and Evidence-Based Practice Annual Conference; 2012 Mar 2; Los Angeles, CA.
- Soban LM, Rubenstein LV, Yano EM, Needleman J, Sales A. Laying the groundwork to improve the quality of hospital nursing care for pressure ulcer prevention. Poster session presented at: VA Career Development Award Program Annual Conference; 2009 Feb 11; Baltimore, MD.