A matrix to record data extracted from each publication was developed by the leadership team, pilot tested, and refined for deployment by the research staff (see protocol). Major categories included primary aims, design, major findings, and conclusions. Data were independently abstracted and then cross-checked by research staff. The analyses of these data focused on the nature of studies (aims), composition of the study teams (and when relevant, intervention), rigor of the study designs, variables used in measurement, rigor of analysis, and the quality and reach of journals that published the studies. Comparisons of findings on these data elements at year 2004 and 2009 were conducted.
The final analysis focused on 389 unique, published research articles. A summary of the major findings of this analysis is presented in Table 1 and is organized as follows: (1) aims; (2) designs (including analytic plans and cost analysis); (3) interventions (when relevant); (4) outcome domains (measurements of quality); (5) study findings (including conclusions); and (6) dissemination (eg, diversity and impact of publishing journals). The results are presented using the following format: [number (%) of studies in 2004 vs. number (%) of studies in 2009].
The aims of the reviewed studies were diverse. Approximately one third of the studies described associations between nursing processes and the quality of patient care [38 (24%) vs. 48 (21%)] (eg, relationship between nurse practitioner-delivered primary care and patient satisfaction).9 A smaller percentage explored relationships between workplace characteristics and the quality of patient care [17 (11%) vs. 15 (7%)], such as the associations between RN unionization and patient outcomes.10 The majority of studies assessed the effects of nurse-led interventions [60 (37%) vs. 72 (32%)], including educational and support interventions for patients with chronic conditions or health promotion interventions. Other intervention studies examined the effects of nurses as members of multidisciplinary teams [16 (10%) vs. 25 (11%)] (eg, impact of nurse-led and dietitian-led case management intervention to prevent cardiovascular disease).11 Interventions that targeted nurses by providing additional education and/or training to improve care provided to patients were also represented [16 (10%) vs. 40 (18%)]. One such example is the use of process evaluation intervention to improve nursing assessment and treatment of surgical patients.12 The greatest changes shown between 2004 and 2009 regarding the aims of these studies were an increase among those designed to enhance patient outcomes through nurse-administered interventions or those that included nurses as members of the care team [8 (5%) vs. 40 (18%)], and those that assessed the impact of innovative technologies by nurses only or teams including nurses [4 (2%) vs. 18 (8%)]. The number and proportion of studies that aimed to address issues of health equity also increased in 2009 [30 (19%) vs. 47 (21%)]. Such interventions include asthma-based self-management support in community and public health settings.13
Despite the increase in rates of published research, study designs remained proportionally similar in 2004 and 2009. The majority of reviewed studies were nonexperimental in both years [72 (45%) vs. 97 (43%)]. Among this subgroup, a substantial increase in longitudinal studies [11 (15%) vs. 25 (26%)] was observed. The number of quasi-experimental studies increased between 2004 and 2009 [55 (34%) vs. 80 (35%)], as did the number of randomized controlled trials (RCTs) [34 (21%) vs. 51 (22%)]. Reports of pilot studies increased between the 2 comparison years [15 (9%) vs. 28 (12%)]. Quality improvement initiatives or projects targeting care processes were not as frequently represented by proportion, but still increased in number [7 (4%) vs. 15 (7%)].
There also were enhancements in the conduct of RCTs in 2009 compared with 2004. An increased number of such studies reported intervention fidelity checks, [7 of the 34 RCTs (21%) in 2004 vs. 12 of the 51 RCTs (24%) in 2009]. Furthermore, the number of multisite RCTs was higher in 2009 (compared with 2004) [6 (4%) vs. 21 (9%)].
The primary setting for all reviewed studies was hospitals; an increase in number and percentage of studies conducted within this setting was observed in 2009 as compared with 2004 [51 (32%) vs. 89 (39%)]. There was little change in the number of studies conducted in long-term care facilities at these comparison time points [25 (16%) vs. 28 (12%)] or primary care settings [35 (22%) vs. 41 (18%)].
In both 2004 and 2009, most reviewed studies used quantitative analyses [155 (96%) vs. 213 (93%)], whereas a much smaller number used a qualitative approaches [36 (22%) vs. 34 (15%)]. A limited number of studies used mixed methods (ie, both qualitative and quantitative analyses), but this number decreased over time [25 (16%) vs. 20 (9%)]. Papers reporting a power analysis increased after 5 years, but remained a relatively small proportion of both samples [36 (22%) vs. 45 (20%)]. Although infrequently reported, intent-to-treat analyses increased in 2009 compared with 2004 [10 (6%) vs. 24 (11%)].
Cost analyses were conducted only in a limited number of studies in both years [15 (9%) vs. 23 (10%)]. The use of preintervention and postintervention cost analyses increased from a single case to 5 [1 (0.6%) vs. 5 (2%)]. Of the 38 studies that conducted a cost analysis, only 17 included a team member in the field of business, economics, or health care administration (determined by author’s listed professional designation or affiliation); however, the number of teams that conduced cost analysis with such expertise increased in 2009 [5 (3%) vs. 11 (5%)].
The majority of reviewed studies tested an intervention to improve health care processes or outcomes [93 (58%) vs. 141 (62%)]. The number of studies conducted with only 1 interventionist decreased slightly from 2004 to 2009 [22 (24%) vs. 18 (13%)]. Furthermore, studies that reported on the intervention training for nurses increased [34 (37%) vs. 50 (35%)].
Measurement domains were summarized as follows: care delivery processes (eg, medication error rates), patient experiences (eg, patient satisfaction), and patient outcomes (eg, health status). Patient outcomes were further divided into subcategories of health status (eg, blood pressure, lipid levels), quality of life (eg, self-report quality of life measures), and costs (eg, hospital readmissions, cost of health care services).
Care processes were measured frequently [55 (34%) vs. 110 (48%)]. Patient experiences were measured in about one third of the studies [55 (34%) vs. 66 (29%)]. The following studies measured the subcategories of patient outcomes: health status [88 (55%) vs. 105 (46%)], quality of life [12 (7%) vs. 18 (8%)], and costs [30 (19%) vs. 41 (18%)]. The measurement of quality also became more comprehensive, as more studies measured at least 3 domains [12 (7%) vs. 21 (9%)].
Overall, the majority of nonexperimental studies in both years found a positive association between nursing and quality [33 (46%) vs. 45 (46%)]. Overall, there were few studies that reported an inverse association between nursing and quality [3 (4%) vs. 3 (3%)], or no difference [2 (3%) vs. 7 (7%)]. Specifically, the primary finding in such studies was a positive association between nurse staffing and/or work environment and the quality of patient care [23 (32%) vs. 19 (20%)].
Among quasi-experimental studies, there was an increase in the number but decrease in proportion of studies that demonstrated a positive association between nursing and quality in 2009 compared with 2004 [51 (93%) vs. 62 (78%)]. No studies demonstrated an inverse association. In general, nurse-administered interventions resulted in improved quality as well [28 (51%) vs. 21 (26%)]; furthermore, interdisciplinary implementation teams that included nurses demonstrated positive linkages to quality [13 (25%) vs.15 (19%)].
Experimental studies or RCTs typically demonstrating the positive effects of nursing on patient care quality increased in 2009 [28 (82%) vs. 43 (84%)]. Only 1 RCT in each year reported a negative impact. The number of studies that found no difference decreased [8 (24%) vs. 5 (10%)]. Specifically, RCTs that evaluated nurse-administered interventions also demonstrated nursing’s positive effects on patient outcomes [22 (65%) vs. 35 (69%)]; in contrast, a small number of such studies revealed no impact on the primary quality outcome [6 (18%) vs. 4 (8%)]. Interdisciplinary teams that included at least 1 nurse demonstrated improvements in patient outcomes [14 (41%) vs. 4 (8%)].
Notably, very few [1 (0.6%) vs. 2 (0.9%)] studies identified cost savings generated by interventions. A single study in each respective year calculated a return on investment of the described intervention ratio (2.21:1 vs. 3.81:1). A few studies cited challenges in obtaining exact cost and revenue figures and estimated the potential financial impact of their study for their respective sites [9 (6%) vs. 11 (5%)]. These studies also provided estimates of the cost savings incurred nationally utilizing previously established cost estimates. The majority of studies that conducted cost analyses found that nursing care improved patient outcomes while reducing or adding no additional costs [10 (6%) vs. 18 (8%)].
Dissemination of Findings
Table 2 describes the dissemination findings including the target audience, authorship by discipline, and impact factor as reported in 2010. Studies published in nursing journals increased [58 (36%) vs. 89 (39%)], as did the number of studies published in multidisciplinary journals [105 (65%) vs. 141 (62%)], but proportions remained relatively consistent. The number of peer reviewed journals that published the studies on nursing’s contributions to quality nearly doubled in 2009 compared with 2004 (80 in 2004; 148 in 2009). Nurses as first authors increased by 7% [75 (47%) vs. 123 (54%)]. However, studies related to nursing and quality in which nursing was not represented in authorship also increased [34 (21%) vs. 60 (26%)]. Interdisciplinary authorship with nurses increased in numbers [85 (53%) vs. 95 (42%)]. The mean impact factors of publishing journals, reflecting potential for dissemination influence of these articles, were consistent [2.999 (SD, 3.192) vs. 2.912 (SD, 4.149)]; however, the range of impact factors increased in 2009 compared with 2004 [(0.304–18.970) vs. (0.304–30.11)].
Findings from this comprehensive review and analysis support the first assumption stated in the INQRI guiding framework. Research published in both 2004 and 2009 demonstrated positive linkages between nursing and patient care quality. Nonexperimental studies in both years supported the association between nursing and nursing workforce characteristics, care processes, and outcomes. This association was revealed in studies that assessed nurses’ unique contributions but also measured multidisciplinary team-delivered patient care. Quasi-experimental studies, which used a comparison group and multiple measurement time points, demonstrated that interventions delivered by nurses and multidisciplinary teams (including nursing) most frequently had a positive effect on quality outcomes. Interventions that targeted improving nurse care processes also showed promise in improving the delivery of patient care, through reported improvements in areas such as knowledge improvement, assessments, and adherence to evidence-based guidelines. Furthermore, RCTs generally demonstrated the positive effects between nurse-administered interventions and quality. RCTs often tested an expansion of the nurses’ role in both chronic disease management and health promotion (eg, case management for diabetes and asthma, smoking cessation counseling). Such studies also evaluated interventions conducted with nurses’ use of innovative technology (eg, telecare for insulin therapy support, or internet portal-based coaching).
Gains within lines of inquiry examining linkages between nursing and patient care quality are illustrated by the increase of the number, rigor, and reach of studies. Compared with 2004, the quantity of peer reviewed publications increased by 40% in 2009. The results of this analysis offer evidence of increased action in response to the call to clearly delineate nursing’s contributions to the quality of patient care across diverse settings.14 However, quantifying attention to an issue does not alone reflect scientific advances; high-quality investigations are needed to illustrate progression and growth.
Evidence of quality is demonstrated in the increase of methodological rigor from 2004 to 2009. Scientific rigor is established through study conceptualization, design, implementation, and analyses. For example, the number of RCTs increased by 50%. Furthermore, compared with 2004, there were more longitudinal studies in 2009, which is associated with greater precision in interpreting causality. Power analyses were reported with greater frequency in 2009 (compared with 2004), lending greater strength to the findings’ validity.
The measurement of quality has become more robust, which allows for a comprehensive assessment of nurses’ influence on patient care quality. Comparing 2009 to 2004, more studies included additional measures of patient care processes, experience, and/or outcomes. Patients’ experience with care has received more attention as engagement has emerged as a key factor in health outcomes.15 There was a 20% increase in the number of studies that included a measure of patient experience. Although comprehensive measurements of quality are on the rise, additional work is needed to establish standards for comparison.
The rise in numbers of interdisciplinary team collaborations in 2009, as compared with 2004, evidences another pillar of rigor. The enhanced emphasis on interdisciplinary collaboration in the conceptualization, design, and conduct of studies, and in the nature of interventions developed to improve patient care was a major finding of this review. Previous evidence has demonstrated that interdisciplinary teams lend strength to the study design by increasing access to methodological expertise and expanding the range of ideas.15
Notably, the science underpinning nurse and quality linkages has expanded as evidenced by the breadth of dissemination efforts, the range of disciplines involved in publications, and the implementation of evidence-based findings. The scope of a science is reflected in publications that are widely circulated and highly regarded. Studies examining linkages of nurses and patient care quality were published in a greater number of unique journals, and increasingly, in higher tiered journals in 2009 compared with 2004. Hence, evidence suggests other health care professionals and stakeholders are increasingly exposed to nursing’s integral role in providing and improving the quality of patient care.
In addition to establishing advances in the quantity, rigor, and reach of the science of nurse and quality linkages, this review reveals other important issues such as increased numbers of interdisciplinary teams and health equity studies. Overall, nurse-administered interventions were the most common, but in 2009 there was a shift to interdisciplinary interventions that included nurses of various professional designations, including RNs, licensed practical nurses, and nurse practitioners. For example, Ma et al11 evaluated an interdisciplinary team approach to case management of cardiovascular disease in a low-income population. Specifically, nurses and registered dieticians collaborated to implement a multicomponent, case management program in partnership with a primary care physician. This interdisciplinary team intervention resulted in clinically significant improvement in patients’ cardiovascular health based on a strong research design.
Compared with 2004, the greater number of studies published in 2009 with no nurse on the authorship team may suggest that there is an increased interest in the work and influence of nurses that extends beyond the discipline. However, it is important to determine if a nurses’ active participation on these study teams would accelerate and strengthen advances in science linking nursing to quality. Studies with nurses as first author also increased during this period, highlighting the evolution of nurses as research team leaders.
National achievement of high-quality care requires the equitable distribution of health care access, services, and outcomes.2,16 In light of such a priority, another important trend seen in this review is the increased attention to health care equity. In comparison to 2004, more studies published in 2009 explored health disparities or examined the implementation of intervention studies targeting vulnerable populations, demonstrating nursing’s commitment to resolving disparities and their impact on achieving health equity. For example, Krieger et al13 designed a nurse-led asthma self-support intervention and found an improvement in disease exacerbations and quality of life outcomes, and decreases in urgent care usage in low-income communities.
The final discussion point is the cost issue as it relates to quality. As defined in the Affordable Care Act,17 high-value health care is a national priority aim, encompassing the evaluation of quality care in the context of resource allocation. Yet, there are few studies that reported on the impact of nursing on health care costs. Available findings suggest that nursing may contribute to lower priced health care but, overall, the body of evidence identified in this cross-year comparison is not sufficiently robust to support this assertion. In light of this, findings from this review support an increased commitment to rigorously capture and report this essential measure of health care value.
The measurement of cost in relation to resource requirements increases the ability of key stakeholders to make informed implementation decisions on published interventions, provides information for funding agencies, and enhances the ability for stakeholders to make informed care decisions. An example of an organization that champions high-quality health care is the Leapfrog Group. Since its formation, the Leapfrog Group, which is comprised of a consortium of large corporations and public agencies, has emphasized the importance of improving quality while reducing costs. Without rigorous cost analyses, it will be difficult to convincingly make the business case for adoption of innovation(s).
This comprehensive review broadly searched published literature in 8 electronic databases based on variations of keywords “nurse” and “quality.” Publications that did not include these terms in the title, abstract, keywords, or subject heading may have been unintentionally excluded from evaluation; however, the scope of the key words, the quantity of search engines targeting diverse fields and consistency in the application of inclusion criteria in both years, were measures taken to provide confidence in adequate representation of the state of the science and its progression. Another limitation was the focus on direct patient care that may minimize the influence of nursing on patient care quality, given nurses’ roles in science and academia were not evaluated. Beyond the scope of this paper is the contribution of nurses in leading or contributing to programs of research or scholarship that may not be specific to nurses’ impact on patient care.
Furthermore, recognizing the complexity often observed in multicomponent, interdisciplinary experimental studies, authors often reference another publication for more information on specific intervention protocol or cost analysis details. However, in this review, the papers included did provide at least an overview of the protocol and analysis of cost. Thus, the review may underestimate advances regarding these dimensions of the nurse and quality linkages.
Finally, there is a general publication bias for studies reporting positive results. Methods to address bias were not applicable to this review due to broad endpoints, methods, and rigor that were unable to be standardized. Nevertheless, well-designed studies demonstrating how nurses contribute to the delivery and improvement of high-quality care have the greatest potential for dissemination and translation. Because the search was consistently conducted for the 2 years, biases discussed would be comparable within the 2 years.
This review was intended to capture potential changes in the state of the science between 2 periods, before the launch of the INQRI program and 5 years into the program, as one of multiple strategies to evaluate the potential impact of the program. Although we are unable to establish any causal link between INQRI and increased attention to this area of inquiry, the INQRI launch was part of a call to establish evidence in this area. Furthermore, important work in high-tiered journals may have brought further attention to this need for evidence. Longitudinal evidence on the advancement of the science will need to be conducted to provide increased understanding of this program’s impact.
Despite limitations, this review adds to the body of literature indicating positive linkages between nursing and patient care quality, the patient experience, and patient outcomes. Trends found in this review suggest that this link may be strengthened within the context of interdisciplinary teams that design or implement interventions to improve the value of health care. Therefore, lines of inquiry exploring nurses’ unique contributions within a team-based care approach are needed so that nurses can be appropriately targeted and reimbursed.
This review also highlights gaps and identifies research areas to be further developed. To make a substantial impact on the quality of health care, interventions to improve health care delivery need to be successfully implemented. Intervention studies that have established protocols, detailed training (or referenced a published resource), were conducted with a greater number of interventionists and, in a variety of contexts, and therefore have greater potential for dissemination. Furthermore, more research needs to include comprehensive cost analyses in conjunction with nurse-sensitive quality measures. This review suggests that inclusion of economic or health services researchers will enhance the business case for high-quality care through nursing. With rigorous cost analyses integrated into studies that link nurses and quality, leaders in health care and policy, as well as national and local stakeholders, will increase their attention to the nursing workforce, environment, care processes, and skills.
This comprehensive review conducted in 2 benchmark years, 2004 (baseline year, pre-INQRI) and 2009 (5 y post-INQRI’s launch), has described an expansive body of literature reflecting the state of the science. Findings reveal that nursing is central and essential to the delivery of high-quality care. In this cross-year comparison, investigations of nursing’s contributions to quality have had notable improvements in quantity, quality, and scope of publications. Although INQRI’s level of influence in spurring these important changes may become clearer over time, continued investment in the area of inquiry is essential to accelerate knowledge development and translate this knowledge for timely, positive impact on the quality of patient care. With initiatives such as the INQRI program, the field of research can be enriched with the further development of scientific rigor and emphasis on nursing science by including standardized quality outcomes, interdisciplinary perspectives, comprehensive cost analyses, and ongoing partnerships with health care leaders—who can capitalize on rigorous findings to transform health care practice and policy. Interdisciplinary and national interest in improving health care quality through nursing is important to maintain and increase rigor in the field.
The authors appreciate the assistance of Shelly Fischer, RN, MS, NE-BC (University of Colorado College of Nursing); Heather M. Gilmartin, MSN, RN, FNP-BC, CIC (University of Colorado College of Nursing); Monica Rochman, PhD, RN (University of Pennsylvania School of Nursing); Robert Lee Slaughter, MSN, RN (University of North Carolina Greensboro School of Nursing); and Dulce Mia Warren, MS, RNC, WHNP-BC (University of Colorado College of Nursing).
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quality; nursing; quality care; evidence; care processes
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