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Diane K. Boyle, PhD, RN; Peggy A. Miller, PhD, RN; & Nancy Dunton, PhD University of Kansas School of Nursing Kansas City, KS. Consensus standards for Nursing-sensitive care and implications for certification. ABNS Spring Conference March 5, 2010 Costa Mesa, CA. Objectives.

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Consensus standards for nursing sensitive care and implications for certification

Diane K. Boyle, PhD, RN;

Peggy A. Miller, PhD, RN; & Nancy Dunton, PhD

University of Kansas School of Nursing

Kansas City, KS

Consensus standards for Nursing-sensitive care and implications for certification

ABNS Spring Conference

March 5, 2010

Costa Mesa, CA


  • Describe the evolution of nursing-sensitive indicators.

  • Discuss the National Quality Forum’s development & maintenance of the National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set.

  • Describe a model for linking nursing specialty certification with process & outcome indicators.

  • Indentify research linking nursing specialty certification with process & outcome measures.

Consensus standards for nursing sensitive care and implications for certification

Historical Context

(Dawn of Nursing-Sensitive Indicators)

Genesis of nursing sensitive indicators
Genesis ofNursing-Sensitive Indicators

  • Late 1980s — New payment/reimbursement structures and expansion of managed care

    • RN jobs at risk, care compromised

  • 1994 — American Nurses Association (ANA) launched Patient Safety and Quality of Care Initiative

    • Established Panel of Experts

    • Commissioned a literature review to identify valid and reliable nursing-sensitive indicators

Expert panel findings
Expert Panel Findings

  • 1995 ANA’s Nursing Report Card for Acute Care Settings identified 21 indicators likely related to availability and quality of nurses

  • 10 indicators selected for development

    • TNHPPD*, Skill Mix, RN Satisfaction with work environment

    • Injury Falls, Pressure Ulcers, Nosocomial Infections,

    • Patient Satisfaction (nursing care, pain management, educational information, care)

  • *TNHPPD = total nursing hours per patient day

    Next steps
    Next Steps

    • 1996 — ANA funded pilot studies in 7 states to assess feasibility of data collection by nurses in hospitals:

      • CA, AZ, TX, ND, VA, MN, OH

    • 1996 – IOM released report stating there was a paucity of scientific evidence linking nursing with hospital patient outcomes (other than mortality).

    • 1998 — ANA issued request for proposals to develop and manage the National Database of Nursing Quality Indicators® (NDNQI®).

      • Provide hospitals with comparative data for quality improvement activities

      • Develop a national data resource for investigating the relationship between nursing and patient outcomes

    Ndnqi development
    NDNQI Development

    • 1998 — Contract awarded to Midwest Research Institute and University of Kansas School of Nursing

    • 1999 — First reports Issued to ~30 hospitals, almost all of whom were pilot study participants

    • 2010 — ~ 1570 hospitals and 15 indicators

    Other healthcare measurement initiatives
    Other HealthcareMeasurement Initiatives

    • CMS — Centers for Medicare and Medicaid Services (CMS), Long history of quality measurement: Care Measures

    • 1986 — The Joint Commission began to plan for performance measurement

      • 2002 Hospitals begin collecting core measures and hospital quality measures

    • 1993 — National Committee for Quality Assurance, HEDIS measures

    • 1996 – CalNOC – One of the original state pilot projects for ANA

    Measurement initiatives
    Measurement Initiatives

    • 1998-2002 — Agency for Healthcare Research & Quality (AHRQ): developed Quality Indicators & Patient Safety Measures

      • National Quality Measures Clearinghouse (

    • 1999 – National Quality Forum founded

    • 2007 — AHRQ launched HCAHPS (Consumer Assessment of Healthcare Providers & Systems) which includes questions on nursing

      • 2008, public reporting began

    Quality measurement
    Quality Measurement Nursing-Sensitive Care

    • What is a quality indicator?

    • How are measures developed and endorsed?

    Key definitions
    Key Definitions Nursing-Sensitive Care


    “…nursing-sensitive performance measures are processes and outcomes— and structural proxies for these processes and outcomes (e.g., skill mix, nurse staffing hours)—that are affected, provided, and/or influenced by nursing personnel, but for which nursing is not exclusively responsible. Nursing-sensitive measures must be quantifiably influenced by nursing personnel, but the relationship is not necessarily causal

    National Quality Forum: National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC: 2004

    Key definitions1
    Key Definitions Nursing-Sensitive Care

    • Quality of Care: Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine)

    • Indicator: Valid and reliable quantitative process or outcome measure related to one or more dimensions of performance, such as effectiveness or appropriateness (The Joint Commission)

    Quality assessment
    Quality Assessment Nursing-Sensitive Care

    Donabedian’s Structure – Process - Outcome

    Antecedents Structure Process Outcome

    • Factors that can influence structure, process:

    • Environmental factors

    • Patient factors (also influence outcomes)

    Interactions between

    healthcare practitioner & patient

    Changes (desirable or undesirable) in individuals & populations

    Organiza-tional character-istics

    Types of quality indicators measures
    Types of Quality Indicators/Measures Nursing-Sensitive Care

    • Structure

    • Process

    • Outcome

    • Use of services (used as proxy for outcome)

    • Efficiency/cost

    • Patient experience

    National quality forum nqf
    National Quality Forum Nursing-Sensitive Care(NQF)

    • Private, non-profit voluntary consensus standards-setting organization

    • Multi-stakeholder member organization

    • Three-part mission to improve quality of American healthcare:

      • Setting national priorities and goals for improvement

      • Endorsing national consensus standards for measuring and publicly reporting on performance

      • Promoting attainment of national goals through education and outreach programs

    Nqf consensus development process
    NQF Consensus Nursing-Sensitive CareDevelopment Process

    • Nine Steps

      • Call for Intent to Submit Candidate Standards

      • Call for Nominations

      • Call for Candidate Standards

      • Candidate consensus standard review

      • Public and member voting

      • Consensus Standards Approval Committee (CSAC) Decision

      • Board Ratification

      • Appeals

    Original nqf consensus standards for nursing sensitive care 2004
    Original NQF Consensus Standards Nursing-Sensitive Carefor Nursing-Sensitive Care (2004)

    Patient-Centered Outcome Measures

    Nursing-Centered Intervention Measures

    Smoking cessation*** counseling for

    Acute myocardial infarction

    Heart failure


    • “Failure to rescue”*

    • Pressure ulcer prevalence

    • Falls prevalence**

    • Falls with injury

    • Restraint prevalence (vest & limb only)

    • Urinary catheter-associated UTI rate (ICU)**

    • Central line catheter-associated blood stream infection rate (ICU & HRN)**

    • Ventilator-associated pneumonia rate (ICU & HRN)**

    System-Centered Measures

    • Skill mix

    • Nursing care hours per patient day

    • Practice Environment Scale - NWI

    • Voluntary Turnover

    * Death among surgical inpatients with treatable serious complications

    **Also an NQF-endorsed voluntary consensus standard for hospital care

    *** The smoking cessation standards were not re-endorsed

    Nqf measure maintenance
    NQF Measure Maintenance Nursing-Sensitive Care

    • Annual updates provided by measure steward

    • Ad hoc review for evolving evidence or identified problems with measure

    • Routine full reviews

      • Moving to 3-year cycles by topic area

      • Meet evaluation criteria with focus on data from implementation

      • Harmonization with other NQF-endorsed measures

      • Best-in-class

      • Publicly reported

    Nqf measure maintenance1
    NQF Measure Maintenance Nursing-Sensitive Care

    • Notice of topic with notice of maintenance review and call for new measures

    • Stewards submit information demonstrating criteria are met

    • Reviewed by Steering Committee

    • Steering Committee make recommendations

      • If competing measures, recommend best-in-class

    • Public comment

    • NQF member voting

    • CSAC approval

    • Board ratification

    Measure evaluation criteria
    Measure Evaluation Criteria Nursing-Sensitive Care

    • Importance to measure & report

      • Important to make gains in quality (e.g., safety, effectiveness, efficiency, patient-centeredness)

      • Evidence supports measure focus

    • Scientific acceptability

      • Specifications, reliability, validity, risk-adjustment is evidence-based, clinically meaningful differences in practice

    • Usability

      • Are results understandable and usable in decision making?

      • Useful for public reporting

    • Feasibility

      • By-product of care processes

      • Unintended consequences

    Consensus standards for nursing sensitive care and implications for certification

    Issues to Ponder Nursing-Sensitive Care

    Outcome or process measures
    Outcome or Process Measures? Nursing-Sensitive Care

    • Most medical indicators are process measures.

      • Critics say that we should measure outcomes not process

    • Many nursing measures are outcomes

      • Falls, pressure ulcers, nosocomial infections, PIV infiltrations

    • NQF recently suggested that outcomes should be accompanied by best practice process measures

      • e. g., along with fall rate: fall risk assessment and prevention protocol implementation

    Absolute or relative measure
    Absolute or Relative Measure? Nursing-Sensitive Care

    • Sentinel event (Absolute)

      • Serious, undesirable, and largely avoidable outcome

      • Utility of a measure that is Yes/No as opposed to a rate?

    • Rate-based indicators (Relative)

      • Patient care events expressed as a proportion or ratio

    Risk adjustment issue
    Risk Adjustment Issue Nursing-Sensitive Care

    • Considerations:

      • Adjust for differences in patient populations?

      • Evaluation based on providing care for population you have?

      • Are data available to make effective adjustment?

      • Is adjusted measure interpretable by users?

    • Risk stratification—looking within

    Desirable indicator qualities
    Desirable Nursing-Sensitive CareIndicator Qualities

    • Covers a large segment of the patient population—a typical patient experience

    • Related to a costly or serious condition

    • Fosters quality improvement

      • Should not create incentive for providers to game the system (improve measures without improving quality)

      • Focus on interventions, not documentation

      • Does not focus on what’s being measured to detriment of aspects of care

    Measuring quality is difficult
    Measuring Quality Nursing-Sensitive CareIs Difficult

    • How do we isolate nursing’s impact or contribution?

      • Strongly related to nursing (workforce or processes)

    • Many confounding factors

      • Characteristics or actions of the patients

      • Influence of other healthcare providers

      • Organization and environment of hospital

    Nurse sensitive quality care ndnqi conceptual model
    Nurse-Sensitive Quality Care with processes and outcomes? (NDNQI Conceptual Model)




    of Care

    Nursing Care


    Donabedian Model

    Example measures for nursing sensitive care
    Example Measures with processes and outcomes?for Nursing-Sensitive Care

    Structure Process Outcome

    • Size

    • Teaching status

    • Payer mix

    • Magnet status

    • CNO/manager

    • Practice environment (e.g., autonomy)

    • NHPPD

    • Staff mix

    • Use of agency staff

    • Education

    • Specialty Certification

    • Other credentials

    • Turnover

    • Risk assessment

    • Implementation of prevention protocols

    • Pain management

    • Medication administration

    • Counseling

    • Communication, teamwork, decision making

    • Injury falls

    • HAPUs

    • Nosocomial infections

    • “Failure to rescue”

    • Mobility

    • Satisfaction with care

    • Unplanned readmissions

    Certification and patient outcomes
    Certification and improved processes and outcomes?Patient Outcomes

    • Nelson et al. (2007), in a study of 54 randomly selected rehabilitation units in the US found:

      • For every 6% increase in certified rehabilitation nurses (CRRN) on a unit, mean case-mix adjusted patient length of stay decreased by one day.

      • Conversely, more years experience as a rehabilitation nurse corresponded with a longer length of stay.

    • Lange et al. (2009) found that on units staffed with 2 or more certified nurses, there was a significantly lower fall rate than on units with one or no certified nurses.

      • Results were confounded by a 3-month education program on care of geriatric patients.

    Certification and patient outcomes1
    Certification and improved processes and outcomes?Patient Outcomes

    • Hiser et al. (2006) implemented a quality improvement program that specifically enhanced utilization of Certified Wound Ostomy Continence Nurses (CWOCN) in one medical intensive care unit and found that pressure ulcer prevalence dropped from 29% to near 0%.

    • Both Frank-Stromborg et al. (2002) and Coleman et al. (2009) found no difference in outcomes (e.g., management of pain & nausea) between certified and noncertified nurses.

    Certification and nursing processes
    Certification and improved processes and outcomes?Nursing Processes

    • Critical care certification was found to be associated significantly with the correct use of a pulmonary artery catheter (Iberti et al., 1994) and decision-making regarding the withholding of digitalis (Walthall et al., 1993).

      • In both studies certification was confounded with years of experience.

    • Kendall-Gallagher (2009) found the proportion of certified nurses and the rates of medication errors had no significant association via correlation or hierarchical linear model analysis.

    Certification and nursing processes1
    Certification and improved processes and outcomes?Nursing Processes

    • Zulkowski, Ayello, and Wexler (2007) reported that certified wound care nurses scored wounds significantly more accurately than nurses certified in other specialties or non-certified nurses.

    • Using a national sample of hospitals and hierarchical linear modeling, NDNQI investigators found that nurses with wound, continence and/or ostomy certifications were significantly better at identifying (B=0.12, SE=0.03, p<0.001) and staging (B=0.13, SE=0.04, p<0.001) pressure ulcers than other nurses (Gajewski et al., 2007; Hart et al., 2006).

    Research critique
    Research Critique improved processes and outcomes?

    • Some studies have small sample sizes and weak research designs.

    • Education and experience often confound the results.

    • Experience as certified nurse may confound the results.

      • RNs certified < 5 years report more autonomy, confidence, & collaboration (Cary, 2001).

    • Much of the research on specialty certified nurses and clinical performance is based on self-report or manager-report data.

      • Lacks quantitative measurement of performance

      • No patient outcome data

    • Research may been conducted in environments where few differences exist between the autonomy of certified and non-certified nurses.

    Issues questions
    Issues/Questions improved processes and outcomes?

    • Need to specify measureable processes and outcomes that each specialty certification is expected to impact, for example:

      • Wound, ostomy, continence: pressure ulcer assessment, pressure ulcer rate, urinary tract infections, etc.

      • Lactation consultants: exclusive breast milk feeding, etc.

      • Critical care: ventilator associated pneumonia, etc.

    • Are there measures that an RN with any specialty certification would impact?

      • Pain assessment, fall risk assessment

    • Many processes and outcomes need measure development

    Issues questions1
    Issues/ Questions improved processes and outcomes?

    • Is certification a skill level net of education and experience or as a proxy for education & experience (they are confounded)?

      • Is there a combination of education and certification that effects processes and outcomes?

      • Example: BSN + Certification

    • Does certification ‘wear off’ over time?

    • Is there a critical prevalence of certified nurses (unit, workgroup, hospital, clinic) needed to make an impact?

    Issues questions2
    Issues/Questions improved processes and outcomes?

    • The impact of specialty certification may be more difficult to capture when certified nurses:

      • Exist outside the usual workgroups

      • Are poorly utilized

      • Employed in units/workgroups outside their specialty certification

      • Have not reached a critical prevalence

    • RN vs ARPN certification – What are outcomes?

    • Level of analysis – Individual? Unit/Workgroup? Organization? Multi-level?

    Consensus standards for nursing sensitive care and implications for certification

    Snapshot of Specialty Certified Nurses from the improved processes and outcomes?

    2009 NDNQI RN Survey

    Ndnqi rn survey
    NDNQI RN Survey improved processes and outcomes?

    • RN inclusion criteria:

      • Full or part-time, regardless of job title

      • >50% of time in direct patient care

      • Employed a minimum of 3 months on unit

      • Unit based PRN or per-diem nurses employed by the hospital (agency or contract nurses are excluded)

    Survey certification question
    Survey Certification Question improved processes and outcomes?

    • Specialty certification inclusion criteria:

      • Standards have been verified by either the American Board of Nursing Specialties or the National Organization for Competency Assessment

      • Are direct-care related

      • Are nursing certifications

    • 2009 data are collected on 64 specialty certifications from 18 different specialty entities

    Ndnqi certification question
    NDNQI Certification Question improved processes and outcomes?

    Ndnqi certification question1
    NDNQI Certification Question improved processes and outcomes?

    2009 rn survey respondents
    2009 RN Survey Respondents improved processes and outcomes?

    270,423 US total survey respondents

    Where do certified rns work
    Where Do Certified RNs Work? improved processes and outcomes?

    Certifications by specialty entity
    Certifications by improved processes and outcomes?Specialty Entity



    Consensus standards for nursing sensitive care and implications for certification
    Q & A improved processes and outcomes?

    References improved processes and outcomes?

    • American Nurses Association (ANA). (2004). Measures and indicators that reflect the impact of nursing actions on outcomes. Scope and Standards for Nurse Administrators, 2nd Ed., Washington, DC.

  • Davies SM, Geppert J, McClellan M, et al. (May 2001). Refinement of the HCUP Quality Indicators. Technical Review Number 4 (Prepared by UCSF-Stanford Evidence-based Practice Center under Contract No. 290-97-0013). AHRQ Publication No. 01-0035. Rockville, MD: Agency for Healthcare Research and Quality.

  •  Donabedian A. (1988). The quality of care: How can it be assessed? JAMA, 260,1743-1748.

  • Donabedian, A. (1992). The role of outcomes in quality assessment and assurance.Quality Review Bulletin, 11, 356-60.

  • National Quality Forum. (2004). National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC. Available at:

    • Wunderlich GS, Sloan FA, Davis CK, eds. (1996). Nursing staff in hospitals and nursing homes: Is it adequate? Institute of Medicine, National Academy Press, Washington, DC.

  • Research references
    Research References improved processes and outcomes?

    • Cary, A.H. (2001). Certified registered nurses: Results of the study of the certified workforce. American Journal of Nursing, 101(1), 44-52.

    • Coleman, E., Coon, S., Lockhart, K., Kennedy, R., Montgomery, R., Copeland, N., et al. (2009). Effect of certification in oncology nursing on nursing-sensitive outcomes. Clinical Journal of Oncology Nursing, 13(2), 165-172.

    • Frank-Stromborg M, Ward S, Hughes L, et al. Does certification status of oncology nurses make a difference in patient outcomes? ONF. 2002;29:665-672.

  • Gajewski B, Hart S, Bergquist S, Dunton N. Inter-rater reliability of pressure ulcer staging: ordinal probit Bayesian hierarchical model that allows for uncertain rater response. Statistics in Medicine. 2007;26:4602-4618.

  • Hart S, Bergquist S, Gajewski B, Dunton N. Reliability testing of the National Database of Nursing Quality Indicators pressure ulcer indicator. Journal of Nursing Care Quality. 2006;21:256-265.

    • Hiser B, Rochette J, Philbin S, Lowerhouse N, TerBurgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy/Wound Management. 2006;52(2):48-59.

    • Iberti TJ, Daily EK, Leibowitz, AB, Schecter, CB, Fischer EP, Silverstein JH. Assessment of critical care nurses’ knowledge of the pulmonary artery catheter. Critical Care Medicine.1994;22:1674-1678.

  • Research references1
    Research References improved processes and outcomes?

    • Kendall-Gallagher, D., & Blegen, M. A. (2009). Competence and certification of registered nurses and safety of patients in intensive care units. American Journal of Critical Care, 18(2), 106-114.

    • Lange, J., Wallace, M., Gerard, S., Lovanio, K., Fausty, N., & Rychlewicz, S. (2009). Effect of an acute care geriatric educational program on fall rates and nurse work satisfaction. The Journal of Continuing Education in Nursing, 40(8), 371-379.

    • Nelson A, Powell-Cope G, Palacios P, et al. Nurse staffing and patient outcomes in inpatient rehabilitation settings. Rehabilitation Nursing. 2007;32(5):179-202.

  • Walthall SA, Odtohan B, McCoy MA, Fromm B, Frankovich D, Lehmann MH. Routine withholding of digitalis for heart rate below 60 beats per minute: widespread nursing misconceptions. Heart & Lung.1993;22: 472-476.

  • Zulkowski K, Ayello EA, Wexler S. Certification and education: do they affect pressure ulcer knowledge in nursing? Advances in Skin & Wound Care. 2007;20(1):34-38.