Naylor, Mary D. PhD*; Lustig, Adam MSc†; Kelley, Heather J. MA‡; Volpe, Ellen M. PhD‡; Melichar, Lori PhD§; Pauly, Mark V. PhD∥
*New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
†National Pharmaceutical Council, Washington DC
‡University of Pennsylvania School of Nursing, Philadelphia, PA
§Robert Wood Johnson Foundation, Princeton, NJ
∥Wharton School of Business, University of Pennsylvania, Philadelphia, PA
The authors declare no conflict of interest.
Reprints: Heather J. Kelley, MA, 3615 Chestnut Street, Office 326, Philadelphia, PA 19104. E-mail: email@example.com.
Background: The Robert Wood Johnson Foundation launched the Interdisciplinary Nursing Quality Research Initiative (INQRI) program in 2005 to generate, disseminate, and translate research to understand how nurses contribute to and can improve patient care quality. This special edition of Medical Care provides an overview of the program’s strategy, goals, and impact, highlighting cross-cutting issues addressed by the initiative.
Methods: INQRI’s leadership and select grantees discuss the implications of a collection of studies on the following: advances in the science of nursing’s contribution to quality, measurement of quality, interdisciplinary collaboration, implementation methodology, dissemination and translation of findings, and the business case for nursing.
Results: A comprehensive review of the scholarly literature published in 2004 and 2009 found that the evidence linking nursing to quality of care has grown. The second paper discusses INQRI’s work on measurement of quality of care, revealing the need for additional comprehensive measures. The third paper examines INQRI’s focus on interdisciplinary collaboration, finding that it can enhance methodological approaches and result in substantive changes in health delivery systems. The fourth paper presents methodological challenges faced in health care implementation, emphasizing the need for standardized terms and research designs. The fifth paper addresses INQRI’s commitment to translating research into practice, illustrating dissemination strategies and lessons learned. The final paper discusses how the INQRI program has contributed to the current evidence regarding the business case for nursing.
Discussion: This supplement describes the accomplishments of the INQRI program, discusses current issues in research design and implementation, and places INQRI research within the larger context regarding advances in nursing science.
Citing the lack of essential evidence linking nursing to the quality of patient care, the Robert Wood Johnson Foundation (RWJF) launched the Interdisciplinary Nursing Quality Research Initiative (INQRI) program in 2005.1 The program’s mission was to generate, disseminate, and translate research to understand how nurses contribute to and can improve the quality of patient care. The INQRI program was led by an interdisciplinary team comprised of a nurse scientist and a health care economist, with the support of a labor economist from RWJF and a communication specialist. INQRI leaders called for and funded interdisciplinary teams that had the greatest promise in conducting rigorous studies designed to advance knowledge linking nursing to patient care processes and outcomes. This special issue of Medical Care provides an overview of the program’s impact and highlights the cross-cutting issues that affect the design, implementation, and dissemination of interdisciplinary science focused on nursing’s contribution to the quality of health care. INQRI grantees participating in this series of papers were asked to provide their perspectives regarding the implications of a collection of related studies on the following topics: measurement of quality, interdisciplinary collaboration, methodology in implementation science, the business case for nursing, and dissemination and translation of research findings. Preliminary ideas from each of the 6 papers included in this edition were presented at a national INQRI program conference held in Washington, DC, on April 26 and 27, 2012.
Over 2½ million registered nurses provide care in a diverse range of settings across the United States (US) including hospitals, primary care practices, home health, hospice, and long-term care.2 Yet, there is limited understanding about nurses’ specific and distinct contribution to the quality of care provided to patients, families, and communities (hereafter referred to as patient). The Institute of Medicine defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”3 High-quality care is safe, beneficial, effective, patient-centered, timely, and efficient.4 The Department of Health and Human Services established a National Strategy for Quality Improvement in Health Care (the National Quality Strategy) to accomplish the aims of high-quality health care outlined in the Affordable Care Act.5 The National Quality Strategy was developed with input from multiple stakeholders, including federal and state agencies, local communities, provider organizations, clinicians, patients, employers, payers, and most prominently, the National Priorities Partnership—a coalition of 50 organizations convened by the National Quality Forum (NQF) committed to health care improvement. The National Quality Strategy identified 3 broad aims: (1) to provide better national health care by increasing quality; (2) to improve the health of people and communities; and (3) to achieve affordable care by reducing costs.5 Therefore, high-quality care must focus on safety and effectiveness, be centered on patients and family caregivers, and address population health and equity. Furthermore, the capabilities of health care infrastructure must be coordinated, efficient, and accessible.6,7 The quality of health care is reflected in patients’ experiences with the care system and processes, in addition to health and quality of life outcome indicators. Achieving higher quality patient care is more than minimizing negative outcomes; facilitation of positive processes that emphasize health promotion is required.8 As nurses are the largest group of health care clinicians in the US, the quality of care they deliver is paramount to the national health care system. To achieve better care and outcomes while ensuring the efficient use of finite resources, it is essential to advance our understanding of the causal linkages between nurses and the care they deliver.
THE INQRI PROGRAM
At the outset of the program, INQRI leaders established a guiding framework, which positioned INQRI’s primary goals within the context of the national discourse on health care and quality (Fig. 1). In developing the framework, the program leaders identified 2 major assumptions, defined as scholarly premises upon which critical analyses are built.9 These assumptions were: (1) the nursing workforce has the skills to influence patient care quality, and research will demonstrate this positive link; (2) science is enhanced by the collaboration of interdisciplinary teams; and (3) stakeholders will use evidence to guide decision making. Therefore, the program strategically focused on supporting interdisciplinary teams who proposed diverse and innovative research initiatives designed to establish and promote those links between nursing and the delivery of high-quality health care.
National health care priorities set the stage for the establishment of the INQRI program. In February 2003, the NQF undertook a 14-month project to examine the relationship between nursing staff and quality and the degree to which national voluntary consensus standards for nursing-sensitive care could be established. The full timeline of the INQRI program is depicted in Figure 2. Although the publication of the committee’s report, “National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set” was an important first step in gaining consensus on measuring nursing performance, much work remained. During their deliberations, the NQF committee identified priority areas for future research. In March 2005, RWJF convened a diverse group of researchers and stakeholders to set priorities for the NQF-identified research agenda. Several of the articles prepared for the convening were included in a special issue of Medical Care Research and Review, “The art and science of nursing quality measurement.” Inspired by the conversations and work of scientists and stakeholders, RWJF launched the INQRI program. To address the lack of standardized evaluations of nurses’ link to quality, INQRI’s initial request for proposals solicited projects that would produce and validate measures that capture nurses’ contributions to quality of care and evaluate the impact of nurse-led initiatives in hospitals.
To address a critical lack of evidence regarding nursing’s contribution to the delivery of high-quality care, Naylor et al10 conducted a comprehensive review designed to identify, synthesize, and critically analyze peer-review papers that addressed the relationships between nursing and the quality of patient care. This review is the first paper in this special edition. This targeted literature review focuses on scholarly literature published in 2004 (pre-INQRI) and 2009 (5 y post-INQRI’s launch) to evaluate the advances in this important line of inquiry and identify the potential contributions of the INQRI program. The review reveals that the evidence linking nursing to quality of care has grown as demonstrated by the increased number of published research studies, higher quality of publications, enhanced methodological rigor, and stronger interdisciplinary reach.
Each of the other 5 papers included in this edition describe key elements of the INQRI program. All principal investigators from INQRI-funded teams were offered the opportunity to collaborate in the development of 1 or more manuscripts focused on cross-cutting topics initially identified by INQRI’s leadership team. The INQRI leadership team initially convened all volunteers representing multiple teams who expressed interest in working on defined issues such as measurement, collaboration, or knowledge dissemination and translation. The leadership group proposed guidelines regarding the development of each topic including the desire to have related INQRI projects serve as case studies to illustrate challenges, lessons learned, and recommendations for future teams who might pursue interdisciplinary science designed to have major impact. Guided by these expectations, the newly formed teams of collaborators then determined how they would pursue each of the topics. Although INQRI’s first request for proposals was focused on nurse-sensitive measurement issues, the second paper of this special edition examines factors related to measuring the contribution of nursing to quality. Beck et al11 synthesized the work of 4 INQRI teams whose research focused on measurement of quality of nursing care. Each team presents the targeted gaps in measurement, strategies to address these gaps, and key findings. The authors reflect on existing challenges and offer recommendations for future endeavors. Although INQRI teams have contributed to the robust set of measures needed to evaluate nurses’ contributions to patient care, the authors conclude that there was a need for additional comprehensive, standardized, practical measures that would be integrated into the electronic health record at the point-of-care.
Because of the assumption that interdisciplinary teams would increase a study’s rigor by providing multidimensional perspectives and diverse methodological expertise, the leadership team selected applicant teams comprised of a range of disciplines and experience. The program required that each team be coled by 2 principal investigators: a nurse scholar and a scholar from another discipline. The latter included social scientists, economists, engineers, and physicians. This interdisciplinary approach also extended to the group of stakeholders selected to advise grantees and program leaders. In addition to the members of INQRI’s national advisory committee (comprised of scholars, policymakers, and health system leaders), the program leaders engaged stakeholders to review proposals and advise grantees on projects’ conceptualization and design. By networking with diverse and potential end-users of their findings, INQRI grantees were able to make substantive additions and changes prior to their studies’ implementation, thus strengthening the probability that their results would be used to effectively advance improvements in quality of health care delivered by nurses.
Two papers in this collection address these innovative aspects of the INQRI program. One focuses on trends in interdisciplinary collaboration and 1 addresses use of selected methodologies in implementation science that have resulted from diverse teams. In their paper, Corbett et al12 present 3 INQRI projects as exemplars of interdisciplinary collaboration. The authors describe the complex issues facing the US health care system and explain how interdisciplinary research provides the opportunity to address issues from a more integrative, rigorous approach. They apply an adapted Interdisciplinary Research Model13 to frame their discussion of barriers and facilitators to designing, conducting, and translating interdisciplinary research. The authors conclude that interdisciplinary collaboration strengthens methodological approaches and accelerates the transformation in health delivery systems and patient outcomes.
Newhouse et al14 explore methodological issues and challenges faced by interdisciplinary teams in the science of health care implementation. Four INQRI studies illustrate challenges in this nascent line of inquiry. These authors suggest areas for continued methodological advances including the need for standardized terminology and designs that promote both external and internal validity to draw more robust conclusions. The authors also highlight the importance of psychometrically sound measures that adequately capture the context of implementation strategies for cross-setting comparisons.
Over the course of the program, INQRI funded 40 interdisciplinary teams with a wide variety of study aims. A few responded to the NQF committee’s recommendations by producing and validating measures that capture nurses’ contributions to improved quality of care. Others examined nursing’s influence on care processes or sought to clarify the profession’s role in maximizing efficiency. Many examined the value of nurses in generating and leading quality improvements or disseminating and implementing proven interventions. For each round of calls for proposals, INQRI sought to build upon lessons learned by previously funded teams. In addition, the initial focus on nursing’s role in acute care settings was broadened to include projects that reflect the national health care priority on care delivered within and across a range of contexts. Program leaders encouraged grantees to include cost analyses when possible and to evaluate the contribution of nurses to high-value care. In addition, INQRI focused on projects that could be disseminated and scaled for wide use. These 2 important program features are addressed in the last 2 papers in this edition.
INQRI’s final request for proposals solicited projects that would focus on knowledge translation, specifically on either dissemination (ie, systematic study of processes and factors that lead to widespread use of an evidence-based intervention by the target population15) or implementation (ie, study of methods, interventions, and variables that promote the uptake and use of evidence-based practices by individuals and organizations to improve clinical and operational decision making with the goal of improving health care quality15) science. Titler et al16 summarize the challenges and lessons learned related to the conduct of 5 INQRI translational studies. They also comment on the use of multiple implementation strategies, including implementation of diverse educational approaches and application of evidence-based tools. In addition, the authors profile 2 studies to further illustrate dissemination strategies, highlighting the projects’ local and national achievements and contributions to improved quality of care for older adults.
In the final paper, Yakusheva et al17 discuss how INQRI projects contribute to the existing evidence of the business case for nursing. The authors discuss how measurement and implementation issues commonly confronted by their INQRI teams often translate into major challenges in demonstrating the benefits of evidence-based innovations. Selected INQRI studies are used to illustrate effective approaches to addressing such challenges. The authors examine the evolving policy environment and conclude that future efforts will require methodologically strong approaches paired with a full understanding of the barriers and facilitators of system changes that affect nursing and patient care.
Since its launch in 2005, INQRI has contributed valuable evidence to support the hypothesis that nurses have a strong link to the quality of health delivery and the improvement of that care. This edition of Medical Care provides an overview of some of the key discoveries made by INQRI grantees, examines cross-cutting issues experienced by research teams, and describes recommended approaches to advance this line of inquiry and its impact.
1. Melichar L. Introduction—improving health care in America through nursing quality measurement research. Med Care Res Rev. 2007;64:3S–9S
2. Bureau of Labor Statistics, US Department of Labor. Occupational Outlook Handbook, 2010-11 Edition, Registered Nurses, 2011. Available at: http://www.bls.gov/oco/ocos083.htm
. Accessed December 1, 2012
3. Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care. 2009 Washington, DC National Quality Forum
4. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001 Washington, DC Institute of Medicine, National Academy of Sciences
5. Report to Congress:National Strategy for Quality Improvement in Health Care. 2011 Washington, DC Department of Health and Human Services
6. Future Directions for the National Healthcare Quality and Disparities Reports. 2010 Washington, DC National Academic Press
7. Forum NQ National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. 2008 Washington, DC National Quality Forum
8. Naylor MD. Advancing the science in the measurement of health care quality influenced by nurses. Med Care Res Rev. 2007;64:144s–169s
9. Shadish WR, Cook TD, Campbell DT Experimental and Quasi-Experimental-Designs for Generalized Causal Inference. 2002 Boston Houghton Mifflin Company
10. Naylor MD, Volpe EM, Lustig A, et al. Linkages between nursing and the quality of patient care: A 2-year comparison. Med Care. 2013;51(suppl 2):S6–S14
11. Beck SL, Weiss ME, Ryan-Wenger N, et al. Measuring nurses' impact on health care quality: Progress, Challenges, and Future Directions. Med Care. 2013;51(suppl 2):S15–S22
12. Corbett CF, Costa LL, Balas MC, et al. Facilitators and challenges to conducting interdisciplinary research. Med Care. 2013;51(suppl 2):S23–S31
13. Larson EL, Cohen B, Gebbie K, et al. Interdisciplinary research training in a school of nursing. Nursing Outlook. 2011;59:29–36
14. Newhouse RP, Bobay KL, Dykes PC, et al. Methodology issues in implementation science. Med Care. 2013;51(suppl 2):S32–S40
15. Rabin BA, Brownson RC, Haire-Joshu D, et al. A glossary for dissemination and implementation research in health. J Public Health Manag Pract. 2008;14:117–123
16. Titler MG, Wilson DS, Resnick B, et al. Dissemination and implementation: INQRI’s potential impact. Med Care. 2013;51(suppl 2):S41–S46
17. Yakusheva O, Wholey DR, Frick KD. What can we learn from the existing evidence of the business case for investments in nursing care: Importance of content, context, and policy environment. Med Care. 2013;51(suppl 2):S47–S52
© 2013 Lippincott Williams & Wilkins, Inc.