nursing - mcgillis · pdf fileacknowledgements the investigators would like to acknowledge the...

Nursing

Linda McGillis Hall

Diane Doran

Heather Spence Laschinger

Claire Mallette

Linda-Lee O’Brien-Pallas

Cheryl Pedersen

ISBN 0 – 7727 – 3604 – 9

February, 2002

We gratefully acknowledge the Canadian Institute for Health Information (CIHI) for development of theoriginal cover and report design.

Layout and production by the Graphic Centre, The Hospital for Sick Children and Bytehaus Studio.

AcknowledgementsThe investigators would like to acknowledge the contribution provided by

the participants of the Nursing Report Consultation Sessions and the siteliaisons for each of these sessions in each region without whom this studywould not have been possible. As well, the support and ongoingencouragement provided by the Hospital Report Research Collaborative wasexceptional. Mr. Frank Markel and Mr. Imtiaz Daniel provided assistance onbehalf of the Joint Policy and Planning Committee. We would also like toacknowledge those that offered continuing support to the research team:Dorothy Pringle, Peggy White, Donna Thomson, Ellen Schraa, Sannie Lai, andLeah Pink. Finally, we would like to thank the participants that providedinformation on initiatives related to the present report. This study was fundedby the Ontario Hospital Association (OHA) and, the Ministry of Health & Long-Term Care.

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Table of ContentsExecutive Summary

Introduction Linda McGillis Hall

Objectives

Background

Scope of Healthcare Delivery for NursingScope of the ReportRelated Initiatives Underway

Applicability of the Balanced Scorecard Framework

MethodsLinda McGillis Hall Cheryl Pedersen

Literature Review

Consultation Process

Key Informant Interviews

Criteria for Indicator Selection

Survey

ResultsSystem Integration and Change

Claire MalletteIndicator Identification

Literature ReviewInterviews/Consultation Process

Indicator Definition and Selection

Recommendations

Clinical Utilization and Outcomes Diane Doran

Indicator Identification



Recommendations

Patient Satisfaction Heather Spence Laschinger Joan Almost




Recommendations

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Nursing

Financial Performance and Condition Linda McGillis Hall




Recommendations

Feasibility Issues Linda McGillis Hall

Data Availability

Recommendations/Directions for the FutureLinda McGillis Hall

System Integration and Change Quadrant Recommendations

Clinical Utilization and Outcomes Quadrant Recommendations

Patient Satisfaction Quadrant Recommendations

Financial Performance and Condition Quadrant Recommendations

References

Appendix A: Nursing Report Consultation Session Participants

Appendix B: Key Informants and Related Initiative Participants

Appendix C: Summary of Recommended Modifications to the SystemIntegration and Change Survey

Appendix D: Feasibility of Data Collection

Appendix E: Authors – Nursing Report, Hospital Report ResearchCollaborative

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Preliminary StudiesHospital Report

Executive SummaryThe overall purpose of the Nursing Report is to introduce and structure a

nursing perspective within the Hospital Report Series. The objectives were to:

• identify evidence-based indicators representative of nursing care;

• gain consensus from key stakeholders and leaders in nursing in Ontarioregarding the relevance of the proposed indicators for nursing;

• determine the availability of data related to nursing indicators deemedimportant to measure in order to assess feasibility; and,

• identify whether the balanced scorecard approach is congruent with theindicators identified as essential for capturing a nursing perspective in theHospital Report Series.

A critical review of the literature, including theoretical and empirical workrelevant to report cards, balanced scorecards, and specifically, nursing reportcards was undertaken for the development of this Report. Literature examiningthe concepts delineated in the four quadrants of the balanced scorecard –system integration and change, clinical utilization and outcomes, patientsatisfaction, and financial performance and condition was also examined. Thespecific objectives of the critical review of the literature were to:

• determine the state of the literature related to nursing report cards and/orbalanced scorecards;

• determine the state of the literature related to indicator development forclinical outcomes of nursing care, financial indicators of nursing care,system integration and change indicators, and indicators reflecting patientsatisfaction with nursing care;

• identify the essential characteristics or attributes defining each indicator;

• determine the extent to which each indicator had demonstrated sensitivityto nursing care;

• identify the evidence that has evolved to support the relevance of eachindicator for nursing; and

• assess the congruence of these indicators with the balanced scorecardframework.

The literature suggests that the use of a balanced scorecard framework toincorporate a nursing perspective into the Hospital Report Series is a feasibleapproach to pursue.

A consultation process involving 139 key stakeholders in the nursing field inOntario was also conducted. These consultations were designed to enable theresearch team to obtain input from relevant nursing stakeholders on theproposed indicators that emerged from the literature review. The purposes ofthe consultation process were to:

• highlight indicators identified from the literature;

• obtain stakeholder input on relevant indicators deemed important forinclusion in the Hospital Report Series;

• determine whether relevant and important indicators “fit” with thebalanced scorecard framework for hospital reporting;

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Nursing

• discuss definitions for relevant and important nursing indicators; and

• identify potential data sources for these indicators.

System Integration and ChangeFor the “System Integration and Change” quadrant, the nursing literature

relating to nursing system integration, nursing informatics, retention andrecruitment, hospital-community integration, and the attributes of magnethospitals was reviewed. This, combined with a review of the systemintegration and change indicators included in Hospital Report 2001: Acute Careand feedback from the consultations, formed the basis for the identification ofnursing-specific system integration and change indicators. The indicatorsincluded in the review were: clinical information technology, clinical data,intensity of information use, nursing databases, development and use ofclinical pathways, coordination of care, nursing-CCAC relationships, nursing-community relationships, continuity of care, strategies for managing ALCpatients, and nursing integration and management. These indicators areincluded in the existing System Integration and Change questionnaire.

Clinical Utilization and OutcomesFor the “Clinical Utilization and Outcomes” quadrant, a critical review and

analysis of the literature on clinical indicators of nursing care effectivenesswas undertaken under contract for the Expert Panel on Nursing and HealthOutcomes, Ontario Ministry of Health and Long-Term Care. That report andfeedback from the consultations formed the basis for the identification ofnursing-sensitive clinical indicators. The primary clinical outcomes included inthe review were functional status, self-care, symptom control, pain, andsecondary complications. The literature review provides evidence for arelationship between a number of patient outcomes and nurse staffing inacute care inpatient units. A three-staged approach is recommended for thedevelopment of clinical utilization and outcomes indicators that are sensitiveto nursing care. This includes: (1) for data that are currently available from theCanadian Institute for Health Information (CIHI), we recommend collecting dataon the following secondary complications found to be sensitive to nursestaffing variables: bacterial pneumonia, urinary tract infection, pressure ulcers,and falls that result in a codable injury (e.g. fracture or subdural hematoma);(2) for secondary complications where the evidence does not strongly supporta relationship to nursing, we recommend collecting data for the purpose ofevaluating the sensitivity to nurse staffing variables, specifically for uppergastrointestinal bleeding and failure to rescue; and (3) we recommend furtherresearch to establish the feasibility of collecting data on primary patientoutcomes found sensitive to nursing care, specifically for functional status,symptom control, and self-care.

Patient SatisfactionFor the “Patient Satisfaction” quadrant, an analysis of the literature and

feedback gathered from nursing stakeholders across the Province suggeststhat there is room for improvement in how patient satisfaction with nursingcare is measured in Ontario hospitals. The current measure fails to capturemany of the factors identified by nurses and patients in research ondeterminants of satisfaction with care. Based on our review, we feelcomfortable in recommending that the modified version of the Patient

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Judgments of Hospital Quality (PJHQ) be considered as a measure ofsatisfaction with nursing care for the Hospital Report Series. The indicatorsincluded in this reliable and valid instrument are: caring style, respectful manner,attention to patient concerns, participation in care, availability/timeliness of care,information sharing/interpretation of symptoms, competence/skill, pain control,physical care, communication with other providers, education/preparation fordischarge, pleasant physical environment, and overall satisfaction. Given theintegral role of nursing services in the patient care experience and the consistentlink between satisfaction with nursing care and overall patient satisfaction, it iscrucial to obtain data which can be meaningfully employed to continuouslyimprove patient care quality in today’s highly charged healthcare settings. Areliable and valid measure of patient satisfaction with nursing care isfundamental to achieving this goal.

Financial Performance and ConditionFor the “Financial Performance and Condition” quadrant, the literature on

financial indicators of nursing care was examined. As well, financial datasources such as the Ontario Hospital Reporting System (OHRS) and theOntario Case Costing Project database (OCCP) were examined for indicatorsrelevant to nursing care. The indicators identified in this process and feedbackfrom the consultations formed the basis for the identification of nursing-sensitive financial indicators. The financial indicators included in the reviewwere: total nursing hours per inpatient weighted case, individual staff mixhours per inpatient weighted case, Registered Nurse (RN) hours as apercentage of inpatient weighted cases, percent of total inpatient nursinghours utilized for direct nursing care, percent of professional nursing staffhours utilized for RNs, percent of direct nursing care hours utilized for non-professional staff, percent of nursing care hours utilized for full time, part-timeand casual nursing staff, percent of staff hours used for orientation,absenteeism, ongoing education, overtime, and agency staff. The literaturereview provides evidence that supports a relationship between financial nursestaffing indicators and patient outcomes in acute inpatient care. A two-stagedapproach is recommended for the development of indicators of FinancialPerformance and Condition. This includes: (1) for data that are currentlyavailable from the Ontario Hospital Reporting System (OHRS), we recommendcollecting data for these indicators and reporting values for each in the nextacute care scorecard; and (2) for data that are not currently available from theOHRS, we recommend that the OHRS Management Information System (MIS)database be enhanced in the future to include relevant variables.

SummaryThe Nursing Report research team has generated a list of indicators that fit

within the balanced scorecard framework utilized for the Hospital ReportSeries. The researchers recommend that these nursing indicators beintegrated into the existing Hospital Report Series for validation and testing,and analysis. We acknowledge other important and complementary initiativescurrently underway in the Province. Every effort has been made to avoidduplication of effort or overlap.

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Nursing

IntroductionOne of the most significant challenges faced by nurse executives and

healthcare leaders today is demonstrating accountability for the quality of care provided to patients. While measures of quality care were always ofimportance, even greater interest from both the consumers and providers ofcare has been generated since the emergence of the Hospital Report initiativein Ontario in 1998. The acute care Hospital Reports provide information on therelative performance of hospitals and do not focus on specific providers, suchas nursing. Given the significant role that nurses fulfill in the provision ofhealthcare, the Ontario Hospital Association and the Ontario Ministry of Healthand Long-Term Care partnered to fund several new reports in 2001 including areport on nursing. This document outlines the process and methods used bythe nursing research team to develop the Nursing Report, a component ofHospital Report 2001: Preliminary Studies.

ObjectivesThe overall purpose of the Nursing Report is to introduce and structure a

nursing perspective within the Hospital Report Series. The objectives were:

• To identify evidence-based indicators representative of nursing care;

• To gain consensus from key stakeholders and leaders in nursing;

• To determine the availability of data related to nursing indicators deemedimportant to measure in order to assess feasibility; and,

• To identify whether the balanced scorecard approach was congruent withthe indicators identified as essential for capturing a nursing perspective inthe Hospital Report Series.

BackgroundChanges in the nursing workforce resulting from hospital restructuring and

downsizing in the 1990’s prompted concern from nurses and other healthcareadministrators regarding quality of patient care. These concerns have becomemagnified with the emergence of a nursing shortage and projections ofcontinued problems with nursing resource availability.

Pressures for increased accountability have precipitated the development ofnumerous healthcare report cards in North America. However, the majority ofthese initiatives either do not include nursing, or use broad indicators that donot always reflect meaningful representations of the quality of nursing careprovided in the system. This Nursing Report provides the opportunity to buildon work completed in the broader healthcare sector, and specifically in thefield of nursing, and identifies nursing indicators considered feasible forinclusion in the next iteration of the Hospital Report Series.

Scope of Healthcare Delivery for NursingNurses represent the largest single occupational group within the healthcare

workforce in Ontario.1 Nurses are the largest contributors to patient care in allsectors of the healthcare system (e.g. acute care, long-term care, home care).2

Therefore, their contribution to the quality of patient care is an essentialelement in healthcare delivery.

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Scope of the ReportThis Report includes a review and examination of a range of indicators

describing nursing performance within the healthcare system and theevidence base to support their use. Because indicators that measure theperformance of acute care hospitals are most established, this Report focusesprimarily on acute care hospitals and presents system-level indicatorscovering all quadrants of the balanced scorecard. It is proposed that theseindicators be tested and validated next year as part of an iterative process ofindicator development. However, the indicators selected are sufficientlygeneric to be utilized in scorecards for other sectors of the Hospital ReportSeries in future years to reflect nursing care (e.g. complex continuing care andemergency care).

Related Initiatives UnderwayWithin the Ontario healthcare environment, a number of initiatives that are

complementary to this Nursing Report are currently underway. The OntarioMinistry of Health and Long-Term Care (MOHLTC) has taken the lead on aproject designed to identify nursing-sensitive patient outcomes and theirattendant nursing inputs and processes that could be entered and abstractedfrom patients’ charts or collected in other formats.2 The Nursing and HealthOutcomes Project is an initiative that evolved in an effort to produce “healthinformation systems that provide comprehensive and reliable data on nursingservices.”1 This work is expected to allow administrators and researchers todescribe the impacts of different nursing interventions and different numbersand types of nurses (Registered Nurses - RNs, Registered Practical Nurses -RPNs) on patient outcomes in the future. The project focuses on acute care,long-term care and community care (home care). To date, work on the projecthas focused on an analysis of current databases in Ontario for nursing-relevant content, nurse-sensitive patient outcomes and the structures andprocesses that are associated with these.2

A second project currently underway is The Nursing Best Practices Project,led by the Registered Nurses Association of Ontario (RNAO).3 Launched inNovember of 1999, this multi-year project is intended to develop best practiceguidelines for patient care in five clinical areas. These include gerontology,primary healthcare, home healthcare, mental healthcare, and emergency care.Designed in multiple cycles, each cycle consists of five phases: (a) planning;(b) development; (c) implementation; (d) evaluation; and (e) dissemination. Todate, 17 best practice guidelines have been developed. Four of these are beingprepared for dissemination, seven are currently being evaluated and six arebeing prepared for pilot implementation.3 Best practice guidelines beingprepared for dissemination in the fall of 2001 include: (a) promoting continenceusing prompted voiding; (b) reducing constipation; (c) risk assessment andprevention of pressure ulcers; and (d) risk assessment and prevention of fallsin the older adult population. Those currently under evaluation include: (a)enhancing healthy adolescent development; (b) client-centred care; (c) crisisintervention; (d) pain assessment and management; (e) establishing therapeuticrelationships; (f) assessment and management of Stage I to Stage IV pressureulcers; and (g) supporting/strengthening families through expected andunexpected life events. Finally, the best practice guidelines being prepared forpilot implementation include: (a) adult asthma care; (b) breastfeeding bestpractices; (c) screening for delirium, dementia and depression in older adults;(d) reducing foot complications for people with diabetes; (e) smoking

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cessation; and (f) venous leg ulcers. Indicators have been developed for theevaluation of each of the best practice guidelines. These indicators arecategorized into a structure, process and outcomes framework. Whilehealthcare organizations are not mandated to participate in this project, avariety of sites have been involved in the pilot projects and the evaluationprocess. This work has the potential to create a “gold standard” for bestpractices for nursing in the selected clinical areas.

Along with these initiatives, there are a number of individual hospitalsacross the Province involved in the development of additional balancedscorecard projects. For example, St. Michael’s Hospital in Toronto, Ontario isinvolved with the Institute for Work and Health in the development of ahealthy workplace balanced scorecard intended to complement the corporatescorecard at the site. A discussion paper has been generated that identifieshealth-related themes for assessment, potential indicators and data sources.4

In another example from Northern Ontario, the Sault Area Hospitals havedeveloped a corporate balanced scorecard for performance improvement. Thisformat is being followed by different programs within the organization tomonitor ongoing performance and improvements. These are just two examplesof the various initiatives underway in a number of hospitals across theProvince.

Applicability of the Balanced Scorecard FrameworkThe balanced scorecard framework developed by Kaplan and Norton5 has

been utilized by the Hospital Report Research Collaborative as the model forthe Hospital Report Series since 1998. The four quadrants included in thebalanced scorecard are: (a) clinical utilization and outcomes; (b) financialperformance and condition; (c) patient satisfaction; and (d) system integrationand change.6 In addition to providing information for quality improvementpurposes, these reports demonstrate the accountability of acute care hospitalsin Ontario and have been referred to by many as a form of “report card”.

To date, this framework has not been explored by nursing. In 1994, theAmerican Nurses Association (ANA) started the Patient Safety-Nursing QualityInitiative using a multi-pronged approach. A number of separate activitiesrelate to the prototype report card.7 The first of two areas of research in thisInitiative is the development, testing, storage, and evaluation of nursing-sensitive indicators. This work is currently being conducted for the ANA by theUniversity of Kansas School of Nursing and Medical Center Research Institute.8

This project pilot tests draft indicators and manages the collection,submission, evaluation, and reporting of hospital-specific data and cohortbenchmarks. Currently there are 256 hospitals in 36 states participating in theNational Database of Nursing Quality Indicators (NDNQI).8

The second area of research in this Initiative is the exploration of therelationships between nurse staffing and patient outcomes. Data for thesestudies come from state and Medicare hospital discharge databases purchasedby ANA. Potential new indicators as well as existing indicators are evaluatedusing these data. The ANA reports – Implementing Nursing’s Report Card: AStudy of Staffing, LOS, and Patient Outcomes9 and Nurse Staffing and PatientOutcomes in the In-Hospital Patient Setting were published in 1997 and 2000.10

The latter expands upon the former by adding six additional states (total=nine)and one additional year (total=three).

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The ANA developed and piloted a prototype for a nursing report card foracute care in the United States (U.S.).7 In response to changes in thehealthcare environment that resulted in decreased numbers of registerednurses, the ANA became concerned with reports of an increased number ofincidents threatening patient care quality. The aim of the nursing report cardwas to explore the nature and strength of linkages between nursing care andpatient outcomes by identifying nursing quality indicators.7 A total of 21nursing quality indicators were identified for inclusion in a nursing report cardusing Donabedian’s11 structure, process and outcome quality framework.However, difficulties with measuring and tracking many of the indicators, andan overall lack of available data, resulted in only seven of these outcomeindicators being reported in a pilot report card.9

The ANA indicators included: (a) total nursing hours per nursing intensityweight; (b) registered nurse hours as a percentage of all nursing hours; (c) length of stay; (d) pressure ulcers; (e) pneumonia; (f) urinary tractinfections; and (g) post-operative infections. The pilot study included 502hospitals from three U.S. states including California, Massachusetts, and New York. These states were selected because data were: (a) available at areasonable cost; (b) reasonably current; (c) representative of a sizeablepercentage of U.S. hospitals, patients and nurses; and (d) representative ofregional differences in patient care. Findings indicated that shorter patientlengths of stay were strongly related to higher nurse staffing per acuity-adjusted day; patient outcomes of pressure ulcers, pneumonia, post-operativeinfections, and urinary tract infections were found to have a statisticallysignificant inverse relationship with registered nurse skill mix (i.e. betteroutcomes with higher proportions of RNs), and to a lesser extent with nursestaffing per acuity-adjusted day. Finally, nursing intensity weights by DRGwere statistically significantly related to differences in nurse staffing ratios perpatient day in all three states.9 This study was conducted using the HospitalDischarge Database that is mandated for hospitals in the targeted states.

In a follow-up report released by the ANA in March 200010, that replicatedand extended this work, similar findings were reported. Higher staffing levels(licensed hours per acuity adjusted day) were associated with shorter lengthsof stay. As well, patient outcomes, including secondary bacterial pneumonia,post-operative infections, pressure ulcers, and urinary tract infections werereported to be lower in hospitals with higher registered nurse skill mixes, andwith greater staffing levels in some cases. Attempts to include additionalindicators generated no statistically significant findings. The additionalindicators explored included: (a) adverse drug reactions; (b) anoxic braindamage; (c) communicable conditions; (d) complications in the immediatepostpartum period; (e) diabetic complications; (f) joint effusion; (g) metabolicimbalances; (h) personal care complications; (i) secondary psychiatricdiagnoses; (j) transfusion reactions; (k) trauma in non-trauma patients; and (l) vascular complications. Specific reports of nursing research from theindividual states involved in the development of the ANA report cardinitiatives have been published.12-15

The ANA also funded six unique pilot projects to State Nursing Associations(SNA) in Arizona, California, Virginia, Minnesota, North Dakota, and Texas toprovide a basis for developing a National Database of Nursing QualityIndicators (NDNQI)8. Staff in those projects served as advisors to the MidwestResearch Institute and the University of Kansas School of Nursing indeveloping the National Database, and hospitals participating in the SNAprojects were the first members of the database. The aim was to permit

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hospitals to benchmark themselves against others across the U.S. inevaluating the relationship between nursing staffing levels and quality of care.Six state nursing associations compiled data on nursing-sensitive qualityindicators. These indicators included: (a) nursing hours per patient day; (b) nursing skill mix; (c) pressure ulcers; (d) falls; (e) nosocomial infections; (f) patient satisfaction with pain management; (g) patient satisfaction witheducational information; (h) patient satisfaction with nursing care; (i) patientsatisfaction with overall care; and (j) nurse staff satisfaction.9

There have been other nursing report cards developed, beyond thoseproduced by the ANA. A number of authors have described the developmentand implementation of report cards measuring quality of care by divisions ofnursing or multi-institutional groups of nurses, patterned after the work of theANA.16-20

While much of the work on report cards in nursing has utilized the structure,process and outcomes framework, alternatives to this model have also beenexamined. For example, one of the states involved in the ANA report cardused Holzemer’s Outcomes Model incorporating the constituents of patient,provider and setting to guide their research.13 As well, the use of the clinicalvalue compass is described for the development of a report card for outcomesmanagement in a Michigan hospital.21

The use of a balanced scorecard framework to incorporate a nursingperspective into the Hospital Report Series is a feasible approach to pursue.Although the majority of work in nursing, to date, has utilized Donabedian’s11

framework, both it and the balanced scorecard approach are oriented towardsimproving the quality of patient care. The indicators used in the ANA NursingReport Card can be categorized within the four quadrants of the balancedscorecard. Specifically, the system integration and change quadrant couldinclude nurse staff satisfaction. The clinical utilization and outcomes quadrantcould include: pressure ulcers, falls, and nosocomial infections. The patientsatisfaction quadrant could include: patient satisfaction with educationalinformation, with nursing care, with pain management, and with overall care.Finally, the financial performance and condition quadrant could includenursing hours per patient day and nursing skill mix. The advantage of thebalanced scorecard is its underlying objective to facilitate continuous qualityimprovement through response to the results.

During the development of this Report, consultations were held with nursingrepresentatives from across the Province. Participants in the ConsultationSessions provided support for the use of the balanced scorecard approach fornursing. First, they supported the integration of nursing indicators into varioussector reports within the Hospital Report Series, since nursing practice takesplace in all sectors of care. Second, participants indicated that Donabedian’s11

structure, process, and outcomes approach provides limited information on“processes” of care. It was suggested that this gap could be addressed using abalanced scorecard framework, specifically through the system integration andchange quadrant.

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MethodsA descriptive analytical methodology was used for the development of the

Nursing Report. The research underlying this Nursing Report was conductedin three phases extending over 12 months. The objective of phase one was to conduct a critical review and analysis of the literature on nursing reportcards, balanced scorecards in nursing, and the concepts delineated in the fourquadrants of the balanced scorecard. As part of this process, we conducted areview of the indicators included in each quadrant of Hospital Report ’99 andHospital Report 2001: Acute Care to determine their relevance to nursing care.Phase two objectives included consultations with stakeholders and leaders in nursing in Ontario. The third and final phase focused on determining theavailability of data for the proposed nursing indicators to enable measurementof the indicators at a system level in the next iteration of the Hospital ReportSeries.

Literature ReviewA comprehensive literature review examined theoretical and empirical work

relevant to report cards, balanced scorecards, and specifically, nursing reportcards. Literature examining the concepts delineated in the four quadrants ofthe balanced scorecard were examined.

The objectives of the literature review were:

1. To determine the state of the literature related to nursing report cardsand/or balanced scorecards;

2. To determine the state of the literature related to indicator developmentfor clinical outcomes of nursing care, financial indicators of nursing care,system integration and change indicators, and indicators reflectingpatient satisfaction with nursing care;

3. To identify the essential characteristics or attributes defining eachindicator;

4. To determine the extent to which each indicator haddemonstrated sensitivity to nursing care;

5. To identify the evidence that has evolved to support therelevance of each indicator for nursing; and

6. To assess the congruence of these indicators with thebalanced scorecard framework.

The literature review was based on searches of the followingdatabases: CINAHL (1982-2001), MEDLINE (1966-2001),PubMed (1976-2001), PREMEDLINE (1966-2001), HealthStar(1975-2001), CancerLit (1975-2000), EMBASE (1980-2001), andPsycInfo (1966-2001).

Consultation ProcessThe consultation process was designed to enable the

research team to obtain input from key stakeholders in thenursing field in Ontario on the proposed indicators thatemerged from the literature review. The objectives of theconsultation process were to: (a) highlight indicators identifiedfrom the literature; (b) obtain stakeholder input on relevant

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Consultation Sessions were held in Hamilton,Kingston, London, Ottawa, Sudbury, andToronto. Each of the geographic regions definedby the Ontario Hospital Association receivedrepresentation. Nurse stakeholders across theProvince were sent an information letter and aninvitation to attend the Consultation Session inclosest proximity to them. Of the 181 nursestakeholders invited, 139 attended in thefollowing cities:

• Hamilton 24

• Kingston 14

• London 18

• Ottawa 23

• Sudbury 23

• Toronto 37

139

indicators deemed important for inclusion in the Hospital Report Series; (c)determine whether relevant and important indicators “fit” with the balancedscorecard framework for hospital reporting; (d) discuss definitions for relevantand important nursing indicators; and (e) identify potential data sources forthese indicators.

Since the northern region of the Province encompasses a large geographicarea, it was difficult for many of the invitees to attend the ConsultationSession in person. To ensure sufficient representation from this group,participants were given the option of participating via teleconference. Fourteen (14) of the 23 contributors at the Sudbury session elected toparticipate via telephone. Included in the extensive list of participants fromacross the Province were representatives from Ontario hospitals and otherhealthcare organizations, professional nursing organizations and unions,Community Care Access Centres, community nursing organizations,universities and colleges, the Ontario Joint Policy and Planning Committee,the Canadian Institute for Health Information, the Ontario Ministry of Healthand Long-Term Care, and Health Canada (see Appendix A).

During the three-hour Consultation Sessions, stakeholders were given anoverview of report cards and balanced scorecards including the emergence,purpose, and state of their development in Ontario. After receivingbackground information on nursing indicators identified in the literature, thesessions provided a unique opportunity for participants to collaborate andassist in the identification of relevant indicators for inclusion in this Report.

Key Informant InterviewsA number of key informant interviews were also conducted by individual

members of the research team related to the specific quadrants. As well, theprincipal investigator met with the project leaders of related initiativescurrently underway to determine the focus of these initiatives and todetermine whether there was any overlap in objectives (see Appendix B).

Proposed indicators for the clinical utilization and outcomesquadrant and the financial performance and conditionquadrant were reviewed by key members of the HospitalReport Research Collaborative. As well, input from arecognized expert in the field of nursing who has beenresponsible for developing the nursing methodology for thenursing component of the Ontario Hospital Reporting System(OHRS) was also obtained.

For the patient satisfaction quadrant, a preliminary analysisof concerns identified by nursing administrators with regard tocurrent patient satisfaction instruments was also undertaken.Nine key informants, comprising nursing leaders withextensive knowledge of patient issues related to nursing carefrom Ontario hospitals and nursing organizations, providedinput via personal telephone interviews. Participants wereasked to comment on the adequacy of the current PatientSatisfaction tool, the Parkside Quality of Care Monitor, as ameasure of satisfaction with nursing care. The same group ofexperts was also given the opportunity to offer suggestions forimproving the measurement of patient satisfaction withnursing care for Ontario hospitals.

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Criteria for IndicatorSelectionValid quality indicators are based on outcomesof care. The outcomes of nursing care includethose experienced by the patient, the hospitalstaff (nursing personnel), the informalcaregivers (family, friends, volunteers), andthe provider agencies (hospitals). Theindicators of interest to consumers, healthcareproviders and policy makers demonstrate threecharacteristics: (a) they can be evaluated usingefficient, valid, and reliable methods; (b) theyare relevant to the patient, informal or formalcare provider, provider agency, consumer orgovernment; and (c) they represent intendedor unintended effects of hospital nursing care.These criteria are consistent with thoseemployed in the Hospital Report Series.

SurveyA survey was developed to assess the feasibility of data collection for

selected clinical utilization and outcome indicators. Included in the ‘ClinicalUtilization and Outcomes Survey’ were questions relating to the followingprimary outcomes: (a) functional status; (b) self-care status; and (c) symptomcontrol; and the following secondary outcomes: (d) patient falls; and (e) hospital-acquired pressure ulcers. In the interest of limiting responseburden, the remaining secondary outcomes proposed in this Report (bacterialpneumonia and urinary tract infections) were excluded from the survey sincethese indicators have been previously measured in the acute care reports ofthe Hospital Report Series. The questions comprised simple “yes/no”responses indicating: (a) whether the organization could provide informationon the occurrence of each specified indicator for the past year; and (b) whetherthe information could be provided in an electronic format. One short answerresponse required respondents to indicate the primary source for informationon each of the specified indicators.

Representatives from acute care hospitals in Ontario who attended or wereinvited to the Nursing Consultation Sessions received the survey. Duplicaterepresentatives from each hospital were excluded. Some participants from theConsultation Sessions could not be reached for various reasons.

Results

System Integration and Change

Indicator IdentificationA critical review and analysis of the nursing literature was performed

examining system integration and change, nursing informatics, retention andrecruitment, hospital-community integration, and the attributes of magnethospitals (hospitals that have been evaluated as demonstrating good practicein human resource management and report lower than average rates ofnursing turnover22). This, combined with a review of the system integrationand change indicators included in Hospital Report 2001: Acute Care, formedthe basis for the identification of nursing-specific system integration andchange indicators for this Report. The indicators included in the review were:clinical information technology, clinical data, intensity of information use,nursing databases, development and use of clinical pathways, coordination ofcare, nursing-CCAC (Community Care Access Centre) relationships, nursing-community relationships, continuity of care, strategies for managing AlternateLevel of Care (ALC) patients, and nursing integration and management. Thework that follows is a summary of the literature and evidence on each of theindicators and how each relates to nursing.

Literature ReviewIt was a challenge to identify indicators that are feasible, relevant to nursing

and scientifically sound for inclusion in the system integration and changequadrant of the Hospital Report Series. This is a result of there being fewstandardized measures applicable to this area that are routinely collected byorganizations.

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Information Use

1) Clinical Information TechnologyAs well as delivering and monitoring patient care, nurses generate, integrate

and coordinate information.23 There are estimations that nurses generate over50% of patient care information primarily using paper documentation takingup approximately 30% of nursing time.23 However, paper documentation isoften inconsistent, and the ability to extract information from paperdocumentation for evaluation and research purposes is difficult.24

Most information systems focus on financial and administrative aspects ofhealthcare with much less focus on automating the clinical side.25 Presently,nursing is essentially invisible in clinical and administrative databases.2,26

Existing information systems do not contain data that reflects the delivery andmagnitude of nursing practice and the evaluation of nursing care.27 As healthpolicy is being made based on data originating from comprehensive andadvanced health information systems, it is imperative that information relatedto nurses’ contributions to patient care be collected, stored and easilyretrieved.28,29

Graves and Corcoran30 indicate that a nursing information system should: (a) serve as a repository for both demographic and clinical data; (b) allow fordocumentation of nursing action and patient/client outcomes of care; (c) organize data into information structures for retrieval in different waysdepending on the needs of the practitioner; (d) provide access to the body ofrelevant knowledge; and (e) provide a technology for continuous building ofknowledge of the discipline. The availability of nursing data will increaseknowledge of the effectiveness of nursing practice and will influence healthpolicy and enable the study of health problems across populations, settingsand caregivers.29,31 Nurses also require access to multi-sectoral information andinformation on resources specific to their profession because of their scope ofpractice.32 Organizational policies and environments are critical in promotingthe proficient use of information systems and evidence-based practice.32

2) Clinical Data - Collection, Dissemination, and BenchmarkingTo measure and evaluate clinical outcomes and the nursing profession’s

impact on them, there is a need to access nursing information from theorganization’s databases. The collection of primary and secondary outcomedata sensitive to nursing care reflects the impact of nursing practice on thequality of patient care, the organization and the healthcare system. Nursingsensitive patient outcomes are defined as “a general patient state, behaviouror perception resulting from nursing interventions.”33 The literature on nursingclinical indicators was reviewed for this Report and primary and secondaryoutcomes reflecting nursing practice are recommended in the clinicalutilization and outcomes quadrant of this Report. If these measures are to bereported, it will be important for hospitals to collect and disseminateinformation on these indicators on an ongoing basis.

Benchmarking is a process improvement technique that provides data fororganizations to compare performance on specific variables to achieve bestperformance practices.34 The addition of primary and secondary patientoutcomes related to nursing practice, nursing financial data, and informationrelated to nursing health human resources will facilitate the development ofimprovement strategies and benchmarking of nursing practice.

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3) Nursing Databases and Intensity of Use of InformationThe challenge for any nursing database is identifying relevant information

that should be included and determining how best to enter the data.35

Schlehofer36 identified that nursing clinical databases should collect and recordhemodynamic values, document interventions, collect data for qualitymonitoring, facilitate the daily administrative aspects of nursing, and providetools to reduce repetitive documentation.

There is a wide body of literature recommending a standardized languagefor nursing and collection of a minimum data set of uniform indicators thatreflects nursing practice and its impact on patient care. Without a standardizedlanguage, it will be difficult to compare nursing information data and identifytrends within and among organizations. There are classification systems in theUnited States such as the North American Nursing Diagnoses Association, theOmaha System, the Home Healthcare Classification and the NursingIntervention/Outcome Classification that have been developed and used fordocumentation of nursing practice.27 The Canadian Nurses Association issupporting the International Classification of Nursing Practice (ICNP) as astarting point for classifying and coding nursing data.37 The three primaryelements of ICNP are nursing phenomena (sometimes stated as nursingdiagnoses), nursing interventions, and nursing outcomes.37

Primary and secondary nursing data need to be collected to reflect themagnitude of nursing practice, allocate nursing resources, create newprograms and policies, develop benchmarks and identify improvementstrategies within the organization.6 In Canada, the debate continues regardingthe use of standardized language and minimum data sets to document theamount and nature of nursing interventions as well as the quality and theeffectiveness of nursing care. Presently, there is minimal and inconsistentnursing data being collected in organizations. Before nursing data can beroutinely collected, it is important to gain an understanding of the type ofnursing information available within organizations. An assessment of theelectronic availability of nursing history, notes and flow sheets isrecommended to identify the type and availability of nursing data acrossOntario.

Internal Coordination of Care

4) Development and Use of Clinical PathwaysClinical pathways are developed to improve the quality and efficiency of care for

select patient populations, standardize care and reduce costs.38 Multidisciplinaryteams should formulate clinical pathways that emphasize enhanced communicationand the coordination of care across health disciplines.39 A multidisciplinary team alsoensures that pathways are evidence-based, comprehensive, practical and usedacross the organization.40 Once the pathway has been established, this team shouldcontinue to monitor its effectiveness and relevance and make revisions whennecessary.38

Clinical pathway implementation will not succeed unless the value is evidentto members of the healthcare team.41 As nurses are primarily involved inimplementing the clinical pathways, it is imperative that they are part of thedevelopment and evaluation team. Nurses also need to champion pathwaydevelopment and implementation within the organization. Presently, theHospital Report only measures the participation of physicians in the clinical

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pathway process. Nursing participation should also be assessed throughnursing indicators.

5) Coordination of CareWith changes in the healthcare system, there is an increased need for the

coordination of care across the healthcare continuum among healthcareprofessionals of different clinical backgrounds and expertise.42 Coordination hasbeen defined as “the conscious activity of assembling and synchronizingdifferentiated work efforts so that they function harmoniously in the attainment oforganizational objectives”.43 Research findings indicate that patient outcomes arerelated to how effectively healthcare organizations coordinate work responsibilitiesamong their staff.42 Changes in the complexity and diversity of the healthcaresystem create barriers for individuals accessing and moving through the system.44

Nurses play a key role in the coordination of care as they are with patients 24hours a day in acute care organizations, as well as being the primary caregiverswho implement care in community settings. While there is recognition of theimportance of coordination of care for positive patient outcomes, there is limitedresearch on how to implement and achieve effective coordination.42

In some healthcare coordination studies, a coordination typology has beenused. They identify two major types of coordination: programming andfeedback.43 Programming coordination approaches attempt to clarify workresponsibilities and activities prior to performing the work and include the useof rules, regulations, schedules, plans, procedures, policies, and protocols tocomplete specific activities.43 Coordination by feedback involves the exchangeof information verbally and in written form amongst staff. 43 In healthcarewhere there is relatively unpredictable and uncertain work that requiresflexibility of staff and interdependence among healthcare professionals, Younget al’s43 findings indicate that utilizing both programming and feedbackcoordination facilitates the implementation of quality care.

Nurse case management has also been identified as a system to providecoordination of care across the health continuum.45 Case management hasbeen defined as “a systematic approach to identify high risk, high costpatients, assess opportunities to coordinate care, assess and choose treatmentoptions, develop treatment plans to improve quality and efficiency, controlcosts and manage a patient’s total care to ensure optimum outcomes”.46 Basedon the literature, it is recommended that items be included in the HospitalReport to examine nurses’ participation in programming and the coordinationof feedback, and the prevalence of nurses in case management roles.

Hospital-Community Integration

6) Hospital-Community RelationshipsIndividuals, particularly those with chronic conditions, often receive care

from multiple providers and from multiple sites and services.47 However, few organizations have developed a method to assess healthcare needs andimprove services and hospital-community integration to meet the needs of individuals, families and communities across the healthcare continuum.Inter-organizational relationships can be defined as the level of coordination,integration and partnership among nurses and healthcare personnel inhospitals, CCACs, and the community in meeting the needs of the individual,as well as assessing and responding to the health needs of the community.48

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One of the challenges to coordinating care across the healthcare continuum isthat the focus of care is very different. In acute care institutions, the care ishigh tech, episodic, short term and focuses on illness and cure, while in thecommunity and long-term care sectors, the emphasis is on such factors aspromoting health, functional status and well-being.47 The nurse should be anactive participant in joint initiatives with organizations in the hospital and thecommunity to ensure coordination and continuity of patient care andcommunity needs.

One of the key healthcare reforms has been the shift from institutions tocommunity-based care.49 With shorter hospital stays and the aging population,many patients require assistance from home care programs followingdischarge.50,51 The nursing role in implementing community-based caresupports ability, preserves function and meets the needs of the patient, familyand the community.47 In order to achieve this, it is important for nurses toparticipate in activities such as developing clinical pathways and initiativesthat span patient care in the hospital and the community, and improving thetransfer of information across organizations.

7) Continuity of CareContinuity of care across the healthcare continuum can be defined as a

series of connected patient care events within a healthcare institution andamong a number of organizations.52 This process occurs over time, requirescoordination, involves a variety of people and settings and includes a transferof information.52 Sparbel and Anderson53 performed a qualitative integratedliterature review of 38 continuity of care nursing articles and identified thatcontinuity of care is a multi-factorial concept affected by environmentalinfluences.

System issues were identified as impacting on continuity of care. Theseissues, such as lack of coordination or networking processes; lack oforganizational commitment toward continuity; financial considerations such aslength of stay, staff availability, and support of staff to promote continuity;professional role differentiation; and assessment of patient needs allinfluenced the continuity of care.53

Patient factors such as physical status, psychosocial situations, andpreferences of patients and family also influenced how continuity of care wasperceived and implemented. Imperative for satisfactory patient outcomes arethe involvement of the patient and their families in the different phases ofhospitalization, as well as communication of timely and accurate informationand the availability and coordination of community services. More patients arerecuperating at home after early discharges from hospital. Families requiresupport as estimations have been made that up to 80% of care is provided byinformal caregivers.54

Communication between organizations, providers and family/patients, andsystem issues were identified as key factors that influence continuity of care.The written transfer of information was explored, and while substantialdemographic information was provided, there was limited nursing andpsychosocial data included.53 The information provided to patients when being discharged home was found to be characterized by informationoverload about medications, and inadequacies in relation to the writtendischarge instructions and orders, reaching agreement on a discharge plan,and physician communication with the patient and family in relation to issuesof care.

A limited number of established instruments has been used to examine the24


continuity of care.53 Sparbel and Anderson53 indicate that the measurement ofcontinuity of care is usually achieved through measuring a related conceptsuch as hospital length of stay, reimbursement, client satisfaction, and patient,family and provider perceptions of discharge planning. The review of theliterature suggests that the measurement of continuity of care, and hospitaland community integration is complex and ambiguous. Presently, patients aresurveyed with eight questions asking for their assessment of the coordinationof care while in hospital and during their preparation and discharge fromhospital. Based on the literature and the fact that nurses primarily perform thedischarge teaching and the care at home, it is recommended that items beincluded to examine patients’ perceptions of the type of communicationtransferred and the support they received prior to and after discharge fromhospital.

8) Strategies for Managing Alternate Level of Care PatientsThe needs of patients designated as “Alternate Level of Care (ALC)” are a

challenge for the system and for hospital-community integration. The ALCpatient is one who is medically ready to be discharged from hospital, butremains in hospital as she/he is in need of complex continuing care, homecare, nursing home care or rehabilitative care but none is available.6,55

One strategy for managing ALC patients is to have a clinical nurse specialistwho acts as a liaison between the acute care organization and thecommunity.56 Patients are identified on admission for their potential need forALC and the appropriate measures are implemented to minimize their lengthof stay in acute care institutions. The nurse can assist the patient and family incoping with the illness, assist them in identifying ways to deal with theirillness, provide linkage between systems and settings, and decrease thedevelopment of negative outcomes as a result of lack of continuity of care.

Health Human Resources

9) Nurse Integration and ManagementThe generic definition of integration is the extent to which functions and

activities are appropriately coordinated across operating units.57 Three types ofintegration were identified in the Integration Delivery System Theorydeveloped by Shortell and colleagues.58 They are clinical integration, provideror physician-system integration, and administrative or functional integration.Clinical integration is defined as the extent to which patient care services arecoordinated across the various functions, activities and operating units of asystem.57 Physician-system integration is defined as the physician’sidentification with the system; and how they use the facilities and services andactively participate in its planning, management and governance.57,59 Functionalintegration is the extent to which key support functions and activities such asfinancial management, human resources, and information management arecoordinated across the operating units.57

Gillies et al57 argue that the extent to which physicians and functionalactivities are integrated into the system will facilitate clinical integration. Whilethere is recognized importance for the integration of physicians within theorganization, nurse integration and involvement in planning, management andgovernance are equally important for clinical integration. Nurses make up two-thirds of all health professionals in Canada and are a key resource for meeting

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the increased and evolving demands of the changing healthcare system whilemaintaining quality care and decreasing costs.44,60

In the past decade, the healthcare systems in Ontario and Canada haveundergone dramatic changes with technological advances, restructuring andeconomic demands.61 Research indicates that Canada is entering into a severenursing shortage. By the year 2011, it has been predicted there will be ashortage ranging from approximately 59,000 to 113,000 nurses.62 In Ontario,researchers from the Nursing Effectiveness, Utilization and OutcomesResearch Unit (NEUORU), in examining the impact of losses due toretirements and deaths, estimate, that by the year 2004, there will be a totalloss of 9,114 RNs from the approximately 82,000 nurses currently in theworkforce (based on College of Nurses of Ontario 2000 supply data). Sincehospitals are still the major employers of nurses, the loss for this sector aloneis estimated at 4,096 RNs.63

Nursing associations and unions across Canada are also reporting adeterioration in the quality of work life for nurses.60 A recent policy synthesisexamining the health of the workplace for nurses identified that key issues fornurses include work pressures, job insecurity, violence and safety in theworkplace, lack of support from managers and colleagues, no control overpractice and scheduling, and lack of leadership roles for nurses withinorganizations.64 Quality of work life has been identified as one of the mostimportant components in recruitment and retention strategies.60 Continuity andquality of care are highly dependent on the retention of experienced nurses aswell as the recruitment of new nurses.65 The magnet hospital literatureidentified that organizations that promoted and sustained professionalnursing, provided satisfying work environments, recognized clinical expertise,and had accessibility and visibility for nursing leaders were able to attract andretain nurses, and provide exceptional patient care.22,66

The nursing health human resources indicator explores the components ofan organization focused on promoting nursing involvement in planning,management and governance. Pinkerton67 identifies that while Shortell’s workwas based on physicians, the principles could be applied to other healthcarepractitioners in the system. The items in this indicator are based on theattributes identified in the magnet hospital and recruitment and retentionliterature. Nurse integration within an organization is dependent on a numberof factors such as the supply of nurses, their competency and ability toprovide quality care, and a supportive work environment. Other factors thatinfluence nursing integration include nursing leadership, professionalautonomy, participation in decision-making, entry-to practice standards,support for new graduates, continuing education opportunities, andmeaningful careers.60,62,64,65,68-70 Nursing research within organizations is alsoimportant as valid and reliable data are needed to track changes and guide thedevelopment of workforce policies.71 Job satisfaction is a key component ofnursing integration. Nurses’ job satisfaction is important as it has beenidentified as an important correlate of nurse performance, quality patient care,turnover, and cost savings.72,73

Interviews/Consultation Process During the Consultation Sessions, several participants indicated that

outcomes from many studies lack meaningful results from a qualityimprovement perspective. Participants agreed that the collection of data onnursing information use is a necessity, but identified concern that the nurse’s

26


perspective of what this actually means is important and has not beencaptured in the past. The need for standardized collection of clinical data wasstressed as well.

Concerns with currentmethods for internalcoordination of care were alsoidentified in the ConsultationSessions. It was suggestedthat nurses play the largestrole in the development ofclinical pathways, although itis difficult to find evidence ofnursing involvement in thecare process when reviewingthe completed documents.Since the development ofclinical pathways is timeconsuming and may requirethe involvement of advancedpractice nurses, some hospitalnursing representativesadmitted that they do not havethe resources to create orupdate these tools. The valueof clinical pathways in theacute care system wasquestioned, noting that someare not sufficiently flexible orspecific. In one session, it wasnoted that “the process ofdeveloping clinical pathways isprobably the most importantpart of the whole thing.”

Participants agreed thatcapturing the role of nurseintegration and managementin healthcare was importantfor the Hospital Report Series.The group acknowledged aneed for measurement of thefollowing items: (a) thepresence of supports fornursing (infrastructure, accessto managers); (b) nursingresearch; (c) nursingeducators; (d) nursingcouncils; (e) sharedgovernance; (f) recruitmentand retention of nurses; (g) theavailability of technology; and(h) training issues.

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Indicator Definition and SelectionClinical Information Technology: The extent to which nurses have access toclinical information (patient admission history, discharge and transferinformation, imaging results, lab results, drug profiles, care maps, progressnotes) electronically at the bedside and nursing unit.

Collection of Clinical Data: The collection of primary and secondary outcomedata that reflect the impact of nursing practice on the quality of patient careand on the system.

Benchmarking of Outcomes: The extent to which organizations are comparingnursing performance on specific variables within the organization and settingrealistic goals for improvement by comparing results from hospitals consideredto be good performers.38

Intensity of Information Use: The extent to which nursing information, basedon data obtained through a variety of sources such as patient and nursingsurveys, clinical outcome data, and financial data, is shared and utilizedinternally and externally to allocate resources, create new programs andpolicies, and identify improvement strategies.6

Nursing Databases: The extent to which the nursing history, notes, and flowsheets, as well as nurses’ activities in clinical pathway documentation, areavailable electronically to healthcare providers within the organization andoutside the organization.

Development and Use of Clinical Pathways: The level of nurses’ participation inthe development, implementation and evaluation of clinical pathways topromote optimal patient outcomes while controlling and reducing care costs.74

Coordination of Care: The nurse’s role within the organization as thecoordinator of care to promote positive patient outcomes across the healthcarecontinuum.

Hospital-Community Integration: The level of coordination, integration andpartnership between nurses and healthcare personnel in hospitals, CCACs andthe community in meeting the needs of the individual across the healthcarecontinuum as well as assessing and responding to the health needs of thecommunity.

Continuity of Care: The extent to which internal and external system issuesand nurses’ communication with the patient/family and allied healthprofessionals impact on continuity of care.52

Strategies for Managing Alternate Level of Care (ALC) Patients: The role ofadvanced practice nurses and staff nurses in implementing strategies tomanage the care of ALC patients and minimize the length of stay in hospitals.

Health Human Resources: Nurse Integration and Management: Nurses’identification with the organization and how they actively participate in itsplanning, management and governance.57

Considerable discussionthroughout the meetings focusedon the topics of workload, nursesatisfaction, and nurses’ quality ofwork life. Some discussion focusedon the number of hours that nursesspend doing ‘non-nursing’ relatedduties. The importance of capturingnurses’ job satisfaction was evidentthroughout the consultationprocess, specifically the notion thatnurse satisfaction is likely toinfluence patient satisfaction.

The participants acknowledgedthat continuity of care can play animportant role in patient satisfaction.Shorter patient lengths of stay andthe lack of consistency in careproviders during a patient’s staywere identified as potentialproblems to the quality of caremade available to patients. It wasalso noted that filtering ALCpatients for research purposes is achallenge. However, it was felt thatthe reportedly large number of ALCpatients in Ontario hospitals merits the segregation. The ConsultationSessions also provided an opportunity for the researchers to prioritize andsynthesize the information from the literature review into two key areas forfuture work.

Clinical Utilization and Outcomes

Indicator IdentificationA critical review and analysis of the literature on clinical indicators of nursing

care effectiveness was undertaken under contract for the Expert Panel onNursing and Health Outcomes, Ontario Ministry of Health and Long-Term Care.The report75 formed the basis for the identification of nursing-sensitive clinicalindicators. The primary clinical outcomes included in the review were functionalstatus, self-care, symptom control, pain, and secondary complications. Whatfollows is a synopsis of the evidence for each outcome.

Literature Review

Functional StatusFunctional status has been suggested as an outcome of care for staff

nurses76,77 and advanced practice nurses.78 Several studies have documentedthe effect of nursing interventions on functional status outcomes.76,79 Thesefindings are supported by a meta-analysis of the literature.80

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RecommendationsThere are few standard measures applicable to system integration and change thatare routinely collected by organizations. Based on relevant literature, keyinformants and work from previous reports on system integration and changeindicators, the following recommendations are made:

• That a survey methodology be utilized to obtain information from hospitals inrelation to system integration and change indicators specific to nursing. Theseitems should be included in the current system integration and changequestionnaires in the following sections: clinical information technology,clinical pathways, and alternate levels of care (see Appendix C).

• That a new indicator – nurse integration and management – be included inthe existing health human resources indicator of the Hospital Report, tocapture human resource issues specific to nursing. This indicator should bebased on the work of Shortell and colleagues58, integration and managementtheory, and literature on health human resources, magnet hospitals, retentionand recruitment.

• In the future, when nursing data are routinely collected and examined, werecommend that items be developed and included in the Hospital Report Seriesto assess internal and external benchmarking of nursing practices. Continuityand coordination of care, specific to the role of nurses, should also bedeveloped and included in the patient satisfaction survey.

In the early literature, discussion of functional status focused on anindividual’s ability to engage in activities of daily living (ADL), such as bathing,dressing, feeding, and motor performance.81 In the middle to late 1980s, asproviders became more focused on shorter hospital stays and outcomeswhich reflected an individual’s ability to be at home, measures began toemerge addressing instrumental activities of daily living.81

Sensitivity to Nursing CareThirty empirical studies were reviewed that included functional status as an

outcome variable, of which there were seven randomized controlled trials.75,82-87

The weight of the evidence from the clinical trials did not support functionalstatus as an outcome of nursing care; however, there are several reasons fornot dismissing it as a possible quality indicator at this time. First, the nursinginterventions in these trials varied considerably in design, dose, setting, andpatient populations. It is possible that the nursing intervention was notsufficiently strong or properly designed and implemented, to test the impact ofnursing on patients’ functional health status. Second, there is evidence fromnon-experimental studies to suggest a relationship between nursing variablesand functional health outcomes that warrants consideration. Six studiesemploying quasi-experimental designs reported significant relationshipsbetween a nursing intervention and functional health outcomes.88-93 Three ofthese demonstrated an improvement in functional health outcomes followingtraining for unit nursing staff directed to improving their practice89,90 orsupporting nursing practice through the introduction of an advanced practicenurse.88 Two studies demonstrated a relationship between improved functionalhealth outcomes for patients on units where there was evidence of qualitynursing practice92,93 and where there was a dedicated geriatric unit.91 Anotherset of studies examined the relationship between patients’ functional statusand nursing inputs, such as nursing diagnoses/ nursing intensity94-96, theamount of care received from registered nurses96,97 and nurse staffing.98

Approaches to MeasurementThe majority of studies reviewed utilized a standardized instrument, based

on patients’ self-report, to measure functional status outcomes. The mostfrequently used instruments in order of magnitude were the Katz Activities ofDaily Living Scale, the Medical Outcome Study Short Form (SF-36), the OlderAmericans Resource and Services Questionnaire, the Barthel Index, and theFunctional Independence Measure (FIM instrument).93,98 Of the studiesemploying the SF-36, only one found a significant relationship between theSF-36 and nursing variables.96 All five studies that used the Katz Activities ofDaily Living scale found sensitivity to nursing practice variables. None of thestudies using the Older Americans Resource and Services Questionnairedemonstrated sensitivity to nursing variables, and only one of the studiesusing the Barthel Index88 demonstrated sensitivity to nursing care. The twostudies that used the FIM instrument found a significant relationship betweenFIM instrument scores and nurse staffing variables.93,98

Two interesting measures have recently been developed that are specificallydesigned to assess patients’ functional status outcomes following nursing carewithin a hospital setting. Both measures are based on data collection byobservation and/or chart extraction. These are the Quality Audit Marker(QAM)99 and the Health Status Outcomes Dimensions (HSOD).97 Thedevelopment of the HSOD was based on the QAM.

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Based on this empirical evidence, it would appear that the studies that usedthe Katz Activities of Daily Living scale found stronger relationships withnursing care variables than the studies that used measures that assessedbroader dimensions of functioning. The Katz Activities of Daily Living scaleand the FIM instrument assess patients’ engagement in activities of dailyliving, such as self-care. These types of functional activities have been foundto be associated with nursing interventions, nursing care effectiveness, andcoordination of care in acute care hospital settings.93 Several important issuesconcerning the assessment of functional status emerged from the literaturereview. These are summarized below based on the report by Irvine Doran etal.75

• Nurses’ and patients’ perspectives on the patients’ levels of functioningare incongruent; nurses tend to underestimate the functional status ofpatients.100,101

• While for many patient populations, improvements in functional statusconstitute a good outcome, this is not the case for all patient populations.It may be more appropriate to focus on the prevention of decline for somepatient populations for whom restoration of complete independence is notpossible.102

• Kaufert103 noted that when assessing functional status, it is important toaccount for the fact that someone may successfully use an assistive deviceor helper.

• It is important to account for the possibility that “subjects being assessedby clinicians who are directly involved in their treatment may attempt tomaximize secondary gains by over- or under-representing their level ofdisability”.103

• It is important to consider cultural expectations about the roles of men andwomen when assessing functional status.103

• Instruments measuring instrumental activities of daily living may be lesssensitive to change than instruments measuring activities of daily living,when assessing functional status in institutional settings.91,101

• Burns, Moskowitz, Ash, Kane, Finch, and Bak104 evaluated the congruencebetween self-report and medical record functional status and found theamount of missing medical record functional status data varied byfunction, from 20% for bathing to 50% for dressing.

Based on the analysis of the empirical and theoretical literature, Irvine Doranrecommended that functional status be explored as a patient outcomeindicator for nursing practice but that research is needed to evaluate the mostreliable, valid, and practical approach for assessing functional status outcomesfor hospitalized patient populations.

Self-CareSidani reviewed the literature on self-care for the Expert Panel on Nursing

and Health Outcomes.75 Self-care is viewed as a philosophical orientationunderlying nursing that distinguishes it from other disciplines.105,106 Self-care hasbeen conceptualized as a process variable.107 Simultaneously, self-care has beenconceptualized as an outcome of nursing care.108 This dual conceptualization ofself-care as a process and an outcome variable has led to some confusion inresearch studies that examined the contribution of nursing care to self-care.

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A total of 23 studies were reviewed that investigated engagement in self-care practices as an outcome of nursing care.75 Almost all studies aimed atevaluating the effectiveness of educational/psychoeducational interventionsprovided by nurses. The specific actions measured varied across the studies,depending on the focus of the intervention and on the target population.

When reviewing only methodologically sound studies (i.e. no or limitedthreats to validity), the results indicated that educational/psychoeducationalinterventions are effective in improving the individual’s performance of self-care activities.75,109-113 This conclusion was supported by the results of meta-analyses.114,115

The instruments used to measure self-care in the literature differed. Mostwere developed for the particular study, addressing the specific self-carebehaviours of concern.116-120 The literature and clinical experience suggest thatthe expected self-care behaviours vary across client/patient populations, andacross healthcare settings. This variability in the expected self-care behavioursaccounts for the large number of instruments found.

The following recommendations were proposed by Sidani75 for themeasurement of self-care:

• It is important to assess self-care behaviours comprehensively butdifferently, based on the target population.

• To be consistent with the conceptualization of self-care behaviourspresented in the theoretical literature, the following domains of self-carebehaviours should be addressed: health promotion/maintenance,recognition and monitoring of changes in functioning, selection andapplication of appropriate strategies for managing these changes, andcoping with/adjusting to long-term changes. All these domains could beassessed in patients presenting with an illness, whether chronic or acute.

• The assessment of self-care behaviours could be confined to thosereflective of health promotion/maintenance for healthy persons. Whilenone of the reviewed instruments adequately reflects all these domains,there were some that seemed to fit closely.

Sidani concluded the literature review with recommendations for continuedmeasurement work to evaluate how self-care might be assessed forhospitalized patients and its potential usefulness as an indicator of qualitynursing care.75

Symptom ControlThe literature on symptom control as an outcome of nursing care was

reviewed by Sidani.75 The following findings were summarized from the reportprepared for the Expert Panel on Nursing and Health Outcomes.75 Symptomsrepresent the reason most frequently cited by persons to seek healthcare.121

They are experienced by patients with various acute and chronic medical andsurgical conditions. Effective symptom management is viewed as an essentialrole of nurses in different clinical settings, but has taken precedence inoncology and palliative care nursing practice.122

Several researchers have used individual items to assess symptoms ofinterest in a particular study. Most often, the participants were asked to reporton the presence of the symptomse.g. 89 and to rate the severity or intensity of thesymptoms experienced. Different rating scales were used, such as the VisualAnalogue Scalee.g. 123 or numeric rating scales. Fatigue, nausea, vomiting, and

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dyspnea were often measured with single-items incorporated in multi-itemscales. The psychometric properties of single items are very difficult toestablish; however, using one item reduces the response burden for patients.Therefore, single items are clinically useful if the terms used to describe thesubjective sensation are accurate and relevant to different patient populations.

The effectiveness of various nursing interventions in relieving the symptomsof fatigue, nausea and vomiting, and dyspnea, was examined.e.g.86,124-133

Educational or psychoeducational interventions have been designed toprovide patients with the knowledge and skills for recognizing and managingsymptoms they may experience.e.g.89,134-136 Relaxation and guided imagery have been investigated, primarily in patients with cancer receivingchemotherapy. e.g.124-126,137-139 Systematic reviews of the effectiveness of theseinterventions were also conducted, offering evidence that nursinginterventions can affect patients’ symptom control.140

The studies used different designs ranging from experimental to pre-experimental. They included rather small sample sizes. The symptoms weremeasured with reliable and valid instruments. In general, the results supportedthe favourable effects of these specific interventions in relieving the severity ofsymptoms.

The symptoms experienced differ across patient populations, based on thenature of the pathophysiological mechanisms underlying the illness conditionand on the type of treatment given. Consequently, the measurement ofsymptoms presents some challenges. These are associated with:

• Identifying the subjective sensation characterizing the symptom to bemeasured, and stating it in terms that accurately describe it.

• Finding a criterion for determining the validity of the symptom measure,because of the subjective, unique, and private nature of symptoms.Objective indicators of some symptoms did not correlate or converge withthe subjective indicators.

• Holzemer et al141 report that nurses’ ratings of symptoms were consistentlyshown to underestimate the frequency and intensity of symptomsexperienced by patients with HIV disease. They recommended that “thepatient is the gold standard for understanding the symptom experience”,as “the meaning of the symptoms experience can only be captured fromthe patient’s perspective”.

Pain as a SymptomWatt-Watson reviewed the literature on pain as an outcome of nursing care

for the Expert Panel on Nursing and Health Outcomes.75 She noted that pain isa symptom that has been documented as an indicator of inadequate painmanagement for almost 30 years, particularly since Marks and Sachar’sseminal work in 1973.142 More recently, the question of whether nursinginitiatives actually change pain management practices stimulated anexamination of patients’ pain as a critical outcome measure. Studies havebegun to measure pain as a symptom outcome to determine the effect ofinterventions, such as education for both nurses141,143,144 and patients145-149 andnon-pharmacological strategies.150-153

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The following measurement issues arose from the review of the literature75:

Issues in Measurement• Pain assessment has not been a routine component of nursing practice,

and patients have not perceived nurses as resources in assessing andmanaging their pain.149 Nurses have underestimated the pain experiencedby their patients although they believed that mild pain or less was ideal.

• Nurses’ experience and personal beliefs influence their painassessment.154,155

• Pain is multi-dimensional and not directly proportional to tissue damage.156

While sensation is important, other dimensions such as the quality andimpact of pain also need to be assessed. Only two trials reviewed usedmeasures to determine the impact of pain on everyday relationships andactivities along with pain intensity.157,158

The measures reviewed had well-established reliability and validity innursing studies that examine pain and/or its impact with patients in a varietyof clinical settings. As well, many of these measures have been translated intoseveral languages and are useful for nurses working with multiculturalpatients. The shorter versions of the McGill Pain Questionnaire (MPQ) andBrief Pain Inventory (BPI) have greater clinical utility than the other forms.However, the Numerical Rating Scale (NRS) has demonstrated the mostclinical utility of all measures, particularly with people having less education.The BPI is unique in that it examines broader issues of the impact of pain thatwould be important to assess, particularly for people with persistent pain. Aswell, the BPI can be used as a long, short, or interference subscale version, allwith established reliability and validity.

Only recently have nurses begun to examine systematically the influence ofinterventions on patient outcomes related to pain management usingrandomized controlled trials. In most of the studies included in the review,75

the primary outcome was operationalized as pain intensity and measured by aVisual Analogue Scale (VAS) or NRS. Fewer researchers used the MPQ or theBPI. While change in some studies was reported, responses to these painmeasures are equivocal, which may relate more to issues such as theindividuality of pain, complexity of the pain management context, and/ormethodological issues such as uncontrolled designs, rather than the measuresthemselves.

Watt-Watson concluded that the literature provides considerable evidencethat pain assessment and related management are problematic, but that painmanagement is an important component of nursing practice and theassessment of pain outcomes within the clinical setting might beaccomplished with a simple linear or visual analogue scale.75

Secondary Complications/ Adverse OccurrencesWhite75 reviewed the literature on secondary complications and adverse

occurrences for the Expert Panel on Nursing and Health Outcomes. Whatfollows is a summary of the review and recommendations.75

Thomas and Brennan159 defined an adverse event as “any injury caused bymedical management (rather than disease process) that results in either aprolonged hospital stay or disability at discharge”. Adverse events can includethe following: falls, decubitus ulcers, medication errors, nosocomial infections,

33

Nursing

treatment errors and mortality.75 There is mounting evidence that certain typesof adverse events can be linked to nurse staffing, particularly certain types ofnosocomial infections. The evidence is less conclusive in relation tomedication errors and patient falls.

Flood and Diers160 found that inadequate staffing was associated with theoccurrence of adverse events such as nosocomial infections. Taunton,Kleinbeck, Stafford, Woods, and Bott161 found a relationship between nurseabsenteeism and unit rates of nosocomial infections. Aiken et al.162 found thatmortality rates were lower in hospitals with higher ratios of registered nursesrelative to licensed practical nurses or unlicensed personnel. Kovner andGergen163 found a strong inverse relationship between full-time equivalentRegistered Nurses (RNs) per adjusted inpatient day and urinary tract infectionsafter major surgery as well as pneumonia after major surgery. A significantbut less robust inverse relationship was found between full-time equivalentRNs per adjusted inpatient day and thrombosis after major surgery. Blegen,Goode and Reed164 found the proportion of hours of care delivered byregistered nurses was associated with unit rates of medication errors, decubiti,and patient complaints. A recent study by the American Nurses Association10,involving 12.9 million patients in approximately 2,500 hospitals, found thatsecondary bacterial pneumonia, post-operative infections, pressure ulcers, andurinary tract infections were lower in hospitals with higher nurse skill mix, andin some instances, nurse staffing. The ANA’s10 study demonstrated theimportance of controlling for patient acuity through nursing intensity weights(NIWs) when examining the impact of nursing practice on adverse occurrences.Most recently, Needleman, Buerhaus, Mattke, Stewart, and Zelevinsky165 foundstrong and consistent relationships between nurse staffing variables and fivepatient outcomes: (a) urinary tract infections; (b) pneumonia; (c) length of stay;(d) upper gastrointestinal bleeding; and (e) shock in medical patients. In majorsurgical patients, they found a strong relationship between nurse staffing andfailure to rescue.165

Failure to rescue is a new outcome variable first conceptualized by Silber,Williams, Krakauer, & Schwartz.166 It is defined as mortality of patients whoexperience a hospital-acquired complication.

Needham and Buerhaus167 noted the difficulties in obtaining reliable data onmedication errors, with the vast majority of medication errors not beingrecorded on the patient chart.10 These challenges, coupled with the equivocalevidence concerning the relationship between nurse staffing variables andmedication errors2 suggest that medication errors are not a good measure ofnursing care quality at this time.

There is evidence to suggest a relationship between patient falls andorganizational factors; however, not all patient falls are predictable orpreventable.168 The reporting structure within the hospital impacts on the typeand number of falls that get reported.75 The most reliable data are for falls thatresult in a patient injury.

White concluded that the evidence linking adverse outcomes to nursing careis stronger for certain types of nosocomial infections than the evidence formedication errors and patients falls and that there are more problemsassociated with collecting data on falls and medication errors because ofdifferences in reporting formats than for nosocomial infections.75

34


Interviews/Consultation ProcessDuring the Consultation Sessions, nurse stakeholders agreed that it would

be useful to measure the functional status of patients at discharge butidentified some concerns and recommendations related to its measurement. Itis difficult to gauge functional status in the acute care setting as it may only bereported for patients who have long lengths of stay. They suggested that forthe purpose of a scorecard, measurement of functional status should: (a) bedirectly related to nursing care; (b) include the patient’s perception of his/herfunctional status; and (c) provide a focused rather than a broad approach.

With regard to symptom control,participants highlighted the need for aconsistent method of data collection,noting that the assessment ofsymptoms by a patient would mostlikely differ from an assessment by acaregiver.

Pain management wasacknowledged by participants as animportant symptom that nursing canimpact. Since hospitals across Ontarioare presently using a variety of painassessment tools, nurse stakeholdersrecognized the need for standardizedmeasurement tools and practices to beimplemented. It was acknowledgedthat since not all pain can be improvedby nursing interventions, an indicatorselected to measure pain must besensitive to nursing care.

The obstacles associated withobtaining data on medication errorswere referred to repeatedly throughoutthe consultation process. The concernsincluded inconsistency in the reportingof medication errors and difficultyassociated with segregating errorssolely attributable to nursing.

A number of issues with themeasurement of fall rates wereidentified by Consultation Sessionparticipants. The identified concernsincluded: challenges with comparingfall rates across different hospitals,diagnoses and age groups; and aninconsistency in the frequency andquality of reporting. It was suggestedthat an important factor to considerwhen measuring patient fall rates isthe degree of injury incurred as aresult of the incident.

There were numerous commentsmade by the participants pertaining to

35

Nursing

Indicator Definition and SelectionThe outcome indicators selected for inclusion in the Nursing Report weredetermined based on empirical evidence of their sensitivity to nursing care fromthe literature and based on confirmation of their importance to decision makers.

Functional Status: The level at which a person is functioning in a variety ofdifferent areas, such as physical health, quality of self-maintenance, quality ofrole activities, intellectual status, social activity, attitude toward the world andtoward self, and emotional status.81

Self-Care Status: The practice of activities that maturing and mature personsinitiate and perform, within timeframes, on their own behalf, in the interests ofmaintaining life, healthful functioning, continuing personal development, and well-being.106

Symptom Control: The subjective experience of an individual, in reference to: (a) sensations or experiences reflecting changes in a person’s biopsychosocialfunctions; (b) a patient’s perception of an abnormal physical, emotional, orcognitive state; or (c) the perceived indicators of change in normal functioning asexperienced by patients.121,141

Patient Falls: An event which results in a person coming to rest inadvertently onthe ground/floor or the lower level which results in a fracture, subduralhematoma, head injury, or death.3

Urinary Tract Infections: Bacterial infections of the bladder, urethra and/orkidneys acquired after major surgery. A hospital-acquired urinary tract infectionis defined as one that is noted to have occurred when there was nodocumentation of the existence of a urinary tract infection within the first 24 hours following the patient’s admission.

Pneumonia: The rate at which patients develop inflammation of the lungs withexudation and consolidation during the course of their hospitalization.7 Hospital-acquired pneumonia is defined as pneumonia that is noted to have occurred whenthere was no documentation of the existence of pneumonia within the first 24 hours following the patient’s admission.

Pressure Ulcers: Any lesion that results in damage to underlying tissue.3 Ahospital-acquired pressure ulcer is defined as one that is noted to have occurredwhen there was no documentation of the existence of a pressure ulcer within thefirst 24 hours following the patient’s admission.

Failure to Rescue: Mortality of patients who experience a hospital-acquiredcomplication.166

secondary complications. Overall, they agreedthat the analysis of these indicators would providevaluable information but identified concerns with:(a) the need for specific definitions, especially forpneumonia, urinary tract infections and falls; (b) the relatively low frequency of occurrence ofsome of the indicators as hospital-acquiredcomplications in the acute care setting; and (c) linking adverse occurrences with nursing asthey are not solely accountable for many of these,and more specifically, that interventions withinthe scope of nursing are not necessarily the mosteffective in improving the outcomes. On thecontrary, it was also recognized that manyadverse occurrences are related to the amount ofattention given to patients by nursing staff.

Patient Satisfaction

Indicator IdentificationA critical review and analysis of the literature on

patient satisfaction with nursing care was undertakento identify indicators of patient satisfaction withnursing care for use in the nursing component of theHospital Report Series. The proposed indicators areincluded in a reliable and valid instrument thatmeasures patient satisfaction with nursing care. Theindicators include: caring style, respectful manner,attention to patient concerns, participation in care, availability/timeliness of care,information sharing/interpretation of symptoms, competence/skill, pain control,physical care, communication with other providers, education/preparation fordischarge, pleasant physical environment, and overall satisfaction. An overview ofthe evidence to support these indicators and the relevant instruments follows.

Literature ReviewPatient satisfaction with nursing care has been shown to be the most crucial

determinant of overall satisfaction with hospital care.169-178 Indeed, Mahon179

claims that this strong relationship is due to the fact that ‘most healthcare isnursing care’ since nursing care is the major service provided to hospitalizedpatients. Several factors have led to an intensified interest in the measurementof patient satisfaction with nursing and healthcare. These include: (a) thedemand for public accountability for healthcare outcomes and the need toprovide evidence of quality; (b) incentives to tie government funding tostandards of quality in healthcare delivery; (c) the managed competitionapproach to healthcare delivery in the US with its associated market shareimplications; (d) the total quality management movement to monitor efforts toreduce costs and maintain quality; (e) a shift from the notion of patients aspassive recipients of care to that of informed consumers of healthcare andtheir willingness and ability to choose healthcare services based on theirperceptions of quality provided; and (f) the changing mix of healthcareworkers in acute care settings. As a result of these changes, patient

36


RecommendationsThe literature review provides evidence for a relationshipbetween a number of patient outcomes and nurse staffingin acute care inpatient units. A three-staged approach isrecommended for the development of clinical utilization andoutcomes indicators that are sensitive to nursing care. Thisincludes:

• For data that are currently available from theCanadian Institute for Health Information (CIHI), we recommend collecting data on the followingsecondary complications found to be sensitive to nursestaffing variables: bacterial pneumonia, urinary tractinfections, pressure ulcers, and falls that result in acodable injury (e.g. fracture or subdural hematoma).

• For secondary complications where the evidence doesnot strongly support a relationship to nursing, werecommend collecting data for the purpose ofevaluating the sensitivity to nurse staffing variables,specifically for upper gastrointestinal bleeding andfailure to rescue.

• We recommend further research to establish thefeasibility of collecting data on primary patientoutcomes found sensitive to nursing care, specificallyfor functional status, symptom control, and self-care.

satisfaction has emerged as an important indicator of healthcare quality thathas implications for the survival of healthcare organizations and the well-beingof patients under their care.

The concept of patient satisfaction, although widely used, is poorlyunderstood with no consistent definition found in numerous sources in theliterature.180,181 Consequently, research on patient satisfaction has beenhampered by a lack of consistent conceptualization, resulting in variability inthe way it is operationalized and until recently, a lack of well-established,reliable, and valid instruments to measure the phenomenon accurately andcomprehensively. Many instruments have been developed for local use inspecific institutions that vary in scope and quality, many with littledocumented psychometric properties.

The most consistent definition of patient satisfaction found in the literature isthe extent to which patients’ expectations of care matched the actual carereceived.169,182-188 Eriksen187 defined patient satisfaction with nursing care as ‘thepatient’s subjective evaluation of the cognitive-emotional response that resultsfrom the interaction of the patient’s expectations of nursing care and theirperception of actual nurse behaviours/characteristics’. This is consistent withthe definition proposed by Cleary and McNeil189 in the health services researchliterature. However, Williams190 notes that few studies have actually foundempirical support for this conception of satisfaction. Several researchers haveshown that when both expectations and perceptions of actual care receivedare included in the analysis, the latter is consistently the stronger predictor ofintent to reuse the service or recommend it to family and friends.191-193

Many argue that patient satisfaction is a general affective response to theoverall healthcare experience rather than a focused assessment of distinctaspects of the care episode.190,194,195 In the health services marketing literature,researchers distinguish between the concepts of patient satisfaction andpatient perceptions of care quality. Taylor195 claims that perception of quality isa long-term attitude developed over time, whereas, patient satisfaction is ashort-term response to a specific experience. Patient satisfaction is viewed asa mediator between patient perception of quality and future intentions toreuse the service or recommend the service to others.196

Consistent differences in importance ratings of aspects of care by nurses andpatients have been found by several researchers, suggesting that nurses’ andpatients’ definitions of satisfaction with patient care quality differ. In severalstudies, nurses consistently overestimated the importance of emotional carefor patients.197-200 On the other hand, patients gave higher ratings to theimportance of technical care, such as monitoring and following through andthe provision of explanations regarding their condition and care. Thesefindings are consistent with those of Larson201 and Kovner.202 Kovner’s202 resultsare important since she found that the less patients and nurses disagreed ondesirability of outcomes, the more satisfied patients were with their care.These results led to a concern that what was being measured in these surveysreflected provider perspectives and spawned a variety of qualitative studies toascertain patients’ perspectives of high quality care.203-205 Researchers havebegun to determine patient expectations of care and incorporate theseperspectives into measures of patient satisfaction.206 Given the popularity ofusing patient satisfaction as a patient care quality outcome and the pre-eminent role of nursing in the patient care experience, it is extremelyimportant to ensure that patients are asked to evaluate aspects of their carethat are amenable to nursing intervention.

37

Nursing

Determinants of Patient SatisfactionA variety of factors has been found to influence patient satisfaction in a variety

of studies. Individual patient factors, such as cultural background, degree ofsocial support and demographic variables, such as age, sex, and education havebeen found to influence patient satisfaction ratings in some studies207 but notothers.208 The nature of the nurse-patient interaction or relationship has beenidentified as important in numerous studies. Patient involvement in caredecisions and being able to express their opinions189,194,202,209-211, informationsharing and interpretation of symptoms179,189,212-214, a caring, humane style189,211,213-215,and sense of being treated fairly185 are among the many interpersonal factorsidentified. Promptness and timeliness of care are other important factors.213,216,217

Structural variables, such as patients’ perceptions of the competence ofnurses209,213,218 and type of nursing care delivery system, including primarynursing, use of critical paths, case managers, professional/non-professionalpartner models of care, have also been associated with higher levels of patientsatisfaction.173,179,219-221 Nurse job satisfaction has been shown to be related topatient satisfaction in a few studies222-225, but these studies have limitedgeneralizability. Niedz177 however, in a well-designed study, was not able to establish a significant relationship. According to Kangas, Kee, and McKee-Waddle226, the empirical evidence linking nurse job satisfaction topatient satisfaction remains elusive due to methodological challenges and themulti-dimensional nature of patient care quality.

Consequences of Patient Satisfaction with Nursing CareThere have been a few studies of the consequences of patient satisfaction

with nursing care, particularly in health services research. Numerous studieshave shown patient satisfaction with nursing care to be strongly related tooverall satisfaction with the healthcare encounter.169,170,172,227 Swan and Carroll228

and Weisman and Nathanson225 found satisfaction with nursing care to be astrong predictor of adherence to medically prescribed regimens. Davidow andUttal229 suggest that more satisfied patients are more cooperative with theircaregivers although no data are provided to support this contention. Finally,patient satisfaction with nursing care has been linked to intention to use theservice at a later date and to recommend the service to others.169,230

Methodological Issues in Patient Satisfaction ResearchThere are several issues associated with the assessment of patient

satisfaction. Despite the fact that patient satisfaction with nursing care hasbeen shown to be the most critical determinant of patients’ overall satisfactionwith hospital care, Chang231 maintains that many instruments commonly usedin large patient satisfaction surveys do not adequately capture importantnursing activities, limiting their utility as valid nurse-sensitive outcomemeasures. This is a problem when researchers attempt to link nursingactivities and other factors, such as redesign of nursing care delivery systems(e.g. changes in staff mix and staffing ratios) to patient satisfaction. The widerange of healthcare personnel in hospital settings also makes it difficult forpatients to differentiate nurses from non-nurses and thus threatens thereliability and validity of measurements of satisfaction with nursing care.232

Another issue relates to the positive skewness and lack of variability of mostpatient satisfaction ratings. This creates problems in determining the trueeffects of the phenomenon and can have a negative impact on statisticalcomparisons and relationships being studied. As a result, policy changes are

38


difficult to justify based onempirical evidence. Finally,there is no standardization ofmeasures of satisfaction withnursing care, making itimpossible to compare acrosssettings.

Increased interest in patientsatisfaction as a qualityindicator in the managed careenvironments in the U.S. hasstimulated greater attention todeveloping standardizedmeasures of the concept withadequate psychometricproperties. Healthcaremarketers and consultingfirms have become involved inthe development andadministration of patientsatisfaction measures. Thesetools have been exported toCanada and other countries,

such as the United Kingdom and other European countries. Many of thesemeasures have been developed without the input of healthcare professionalsand have been criticized, in particular, for not capturing the essence of nursingactivities related to patient care.

Indicators of Patient Satisfaction with Nursing Care: Existing Patient Satisfaction Tools For this Report, 29 instruments available in the nursing and health services

literature were evaluated. These instruments have varying degrees of datareported on their psychometric characteristics.

Although none of the instrumentsmet all of the criteria found in theliterature, several appeared to beadequate. Since these tools wereexamined in relation to the existingpatient satisfaction measure used inthe acute care scorecard for Ontariohospitals (Quality of Care Monitor,developed by Parkside Associates),the other instruments are describedfollowing a discussion of the Parksidetool.

The Parkside Quality of CareMonitor was used to measure patientsatisfaction in Hospital Report ’99and Hospital Report 2001: AcuteCare. This tool taps eight dimensionsof patient care and contains nineitems specifically related to nursingcare quality. Some of these items

39

Nursing

Lin233 summarized methodological factors shown to have an influence on patientsatisfaction ratings:

1. Timing of the survey: ratings are higher when obtained several months as opposed toseveral weeks post-discharge; at discharge, ratings are lower but the return isbetter.

2. Response format: an excellent/poor scale rather than agree/disagree or satisfactionlevels increase variability; as does a neutral point on the scale.

3. Non response: 30% response rate is typical; more satisfied patients are less likely toreturn questionnaires.

4. Demographic variables: gender, age, education and race are inconsistently associatedwith satisfaction.

5. Expectations: patients with lower expectations and less knowledge of services aremore satisfied.185

6. General health status: patients in better health are more satisfied.

7. Care received: perceived competence of the nurses is associated with increasedsatisfaction; also the manner in which care was delivered, such as, interpersonalmanner, communication skills, friendliness, and attentiveness, are associated withhigher satisfaction.

Criteria used to assess the relative value ofthese tools included:

• The comprehensiveness of the tool withregard to factors identified in theliterature as determinants of patientsatisfaction with nursing care quality;

• Acceptable psychometric properties;

• Readability of items;

• Length of the tool;

• Ease of scoring;

• Sensitivity to nursing activities/responsibilities that are consideredactual nursing duties; and

• The potential to yield results that can beacted upon to improve quality.

have been identified by nurse researchers in previous research (e.g. competence,interpersonal relationships and information sharing). The nursing sub-scale hasshown high internal consistency (0.88) and to be correlated with overall patientcare ratings.234 However, when the scorecard results were published in 1999, therewere concerns expressed by the nursing community about the validity of theParkside measure.

Initially, four of the 29 instruments reviewed were determined to havepotential for use in the Hospital Report Series, based on their inclusion offactors demonstrated to be associated with patient satisfaction and the criteriadescribed above. They were then compared to the nine items in the Parksideinstrument related to nursing care quality. As can be seen in the followingtables, these instruments were more comprehensive than the Parksideinstrument. The Patient Judgments of Hospital Quality (PJHQ)235 and the PickerSatisfaction Survey were the most comprehensive. However, the Pickerquestionnaire was considerably longer than the PJHQ.

Based on recommendations in the literature that measures of patientsatisfaction should reflect both nurse and patient perspectives, these toolswere further evaluated to determine the extent to which quality indicatorsidentified by patients in the literature were included. Again, the PJHQ and thePicker questionnaire were superior to the others.

40


Identified Quality Indicators(From Literature)

Met expectations

Caring style

Friendliness/courtesy

Attention to patient concerns

Information sharing

Communication andinterpersonal skills

Competence/skill

Goal achievement

Professional practice/caredelivery models

Organizational factors

Overall healthcare experience

Patient Perception ofCare Quality

(Cronenwett & Batalden,

1999)

✓

✓

✓✓

✓✓

✓✓

✓

✓

✓✓

✓✓

✓

Patient Judgments ofHospital Quality

(Meterko et al., 1990)

✓

✓

✓✓✓✓

✓✓✓

✓✓

✓

✓✓

✓

✓✓

✓

Parkside PatientSatisfaction Survey(Parkside Associates Inc.,

1999)

✓

✓✓

✓✓

✓

✓

✓

✓

Picker InstitutePatient Satisfaction

Survey (Picker Institute, 1991)

✓✓✓

✓✓✓✓

✓✓✓✓

✓✓✓

✓

✓✓✓

✓✓

✓

✓✓

Press Ganey PatientSatisfaction Survey

(Press, Ganey

Associates Inc.)

✓✓

✓

✓✓

✓

✓

✓

✓✓

✓

Comparison of Patient Satisfaction Instruments with Quality Indicators Identified in theLiterature

Note: Each check mark represents an item on the questionnaire.

Following this analysis, two instruments were selected based on the criteriaoutlined in the literature and feedback from nurse stakeholders – the PatientJudgments of Hospital Quality questionnaire (PJHQ) by Meterko et al.235 andthe Patient Perception of Care Quality (PPCQ) - developed in 1999 byCronenwett and Batalden.236 With some modification, the PJHQ was deemedpotentially useful. However, the PPCQ, in particular, seemed to address salientaspects of nursing care quality from both the provider and patientperspectives. The following table provides a comparison of items in these twomeasures. Items in the table columns are aligned according to item similarity.

41

Nursing

Patient Identified QualityIndicators (From Literature)

Caring style

Respectful manner

Attention to patient concerns

Participation in care

Availability/timeliness of care

Information sharing/interpretation of symptoms

Competence/skill

Pain control

Physical care

Communication with otherproviders

Education/preparation fordischarge

Pleasant physical environment

Overall

Patient Perception ofCare Quality (PPCQ)(Cronenwett & Batalden,

1999)

✓

✓✓

✓✓

✓

✓

✓✓

✓✓

✓

✓

✓

✓✓

✓

✓

Patient Judgments ofHospital Quality

(PJHQ)(Meterko et al., 1990)

✓

✓

✓✓✓✓

✓✓

✓✓

✓✓✓

✓

✓

✓✓

✓✓

✓

✓

Parkside PatientSatisfaction Survey(Parkside Associates Inc.,

1999)

✓

✓✓

✓✓

✓

✓

✓

✓

✓

Picker InstitutePatient Satisfaction

Survey (Picker Institute, 1991)

✓✓✓

✓✓✓✓

✓✓

✓✓✓✓

✓✓✓✓

✓

✓✓

✓

✓✓✓

✓✓✓✓

✓✓

Press Ganey PatientSatisfaction Survey

(Press, Ganey

Associates Inc.)

✓✓

✓

✓

✓✓

✓

✓

✓

✓

Comparison of Patient Satisfaction Instruments Using Patient Identified Quality Indicators

Note: Each check mark represents an item on the questionnaire.

42


PATIENT JUDGMENTS OF HOSPITAL QUALITY (PJHQ)

1. INFORMATION YOU WERE GIVEN: Howclear and complete were the nurses’explanations about tests, treatments, and,what to expect.

2. INSTRUCTIONS: How well nurses explainedhow to prepare for tests and operations.

3. EASE OF GETTING INFORMATION:Willingness of nurses to answer yourquestions.

4. INFORMATION GIVEN BY NURSES: Howwell nurses communicated with patients,families, and doctors.

5. INFORMING FAMILY OR FRIENDS: How wellthe nurses kept them informed about yourcondition and needs.

6. INVOLVING FAMILY OR FRIENDS IN YOURCARE: How much they were allowed to helpin your care.

7. CONCERN AND CARING BY NURSES:Courtesy and respect you were given;friendliness and kindness.

8. ATTENTION OF NURSES TO YOURCONDITION: How often nurses checked onyou and how well they kept track of howyou were doing.

9. RECOGNITION OF YOUR OPINIONS: Howmuch nurses ask you what you think isimportant and give you choices.

10. CONSIDERATION OF YOUR NEEDS:Willingness of the nurses to be flexible inmeeting your needs.

11. THE DAILY ROUTINE OF THE NURSES: Howwell they adjusted the schedules to yourneeds.

12. HELPFULNESS: Ability of the nurses to makeyou comfortable and reassure you.

13. NURSING STAFF RESPONSE TO YOURCALLS: How quick they were to help.

PATIENT PERCEPTION OF CARE QUALITY (PPCQ)

1. Helpfulness of information that you and yourfamily receive from the nurses about yourillness, surgery, or care.

2. Extent to which the nurses clearly explain toyou the purposes of your care and activities.

3. Nurses’ collaboration with physicians.

4. Consistency with which the nurses approachyou and your visitors with warmth,courtesy, and personal attention.

5. Degree to which the nurses communicate asense of caring for you and your family.

6. Extent to which the nurses who care for youknow about your condition and what needsto be done for you.

7. Extent to which nurses let you participate indeciding how to accomplish things.

8. Consistency with which the nurses met yourbasic needs, such as cleanliness and hygiene.

9. Attentiveness of the nurses to helping yourelieve any discomfort, such as pain, nausea,trouble breathing or trouble sleeping.

10. Accessibility of the nurses for promptattention when you request help.

Comparison of PJHQ235 and PPCQ236

43

Nursing

14. SKILL AND COMPETENCE OF NURSES: Howwell things were done, like giving medicineand handling IV’s.

15. COORDINATION OF CARE: The teamworkbetween nurses and other hospital staffwho took care of you.

16. RESTFUL ATMOSPHERE PROVIDED BYNURSES: Amount of peace and quiet.

17. PRIVACY: Provisions for your privacy bynurses.

18. DISCHARGE INSTRUCTIONS: How clearlyand completely you were told by the nurseswhat to do and what to expect when youleft the hospital.

19. COORDINATION OF CARE AFTERDISCHARGE: Nurses’ efforts to provide foryour needs after you left the hospital.

20. Overall quality of care and services youreceived.

21. Overall quality of nursing care.

11. Ability of the nurses to observe changes inyour condition and deal with problems asthey arise.

12. Ability of the nurses to manageunpredictable events and times when theunit is busy.

13. Teamwork, respect, and trust among unitstaff.

14. Consistency with which your caregivers andtheir roles were clearly identified.

15. Sensitivity of the nurses to managingvisitors, noise, and other disturbances sothat you and other patients have anenvironment that supports rest and healing.

16. Consistency with which the nurses respectand protect your confidentiality.

17. Helpfulness during preparation for yourdischarge.

18. Considering all the factors that influenceyour perceptions of quality of care, howwould you rate the quality of care on thisunit?

PATIENT JUDGMENTS OF HOSPITAL QUALITY PATIENT PERCEPTION OF CARE QUALITY

The Patient Judgments of Hospital Quality questionnaire (PJHQ) has beenused in a variety of studies in tertiary hospital settings. The PJHQ235 wasdeveloped by a multidisciplinary research team at the Hospital Corporation ofAmerica. Items for the instrument were derived from an extensive literaturereview, focus groups, and content analysis of patients’ verbatim answers toquestions about hospital quality. The goal was to develop a questionnaire thatwould represent patients. The original tool contained nine scales: nursing anddaily care, ancillary staff and hospital environment, medical care, information,admissions, discharge and billing, overall quality of care and services,recommendations and intentions, and overall health outcomes. Each itemconsists of a “sign-post” label followed by a “descriptor” phrase. Theinclusion of this “sign-post” label was praised many times throughout theConsultation Sessions with nurses across Ontario. Questions are presented ona five-point Likert-type scale ranging from ‘excellent’ to ‘poor’. Cronbach’salpha coefficients for the subscales have ranged from 0.66 to 0.94. Completion

usually takes about 30 minutes when administered by telephone and 20 minutes when self-administered. Several short forms are available: 10, 14, 20, and 24-item versions. The modified version suggested for inclusionwith the acute care scorecard contains 21 items, including two overallquestions regarding quality of care in general and nursing care in particular.

The PJHQ nursing subscale has been shown to be related to importantaspects of hospital service delivery. Atkins, Marshall, and Javalgi222 found thatscores on the PJHQ nursing subscale (skill and competence of nurses,attention of nurses to patient’s condition, nursing staff response to calls,nurses demonstrating a concerned and caring attitude, and informationprovided by nursing) were related to overall perceptions of hospital quality(r=0.75, p<0.005). Two items, “concern and caring attitude” and “informationprovided by nurses” were strongly related to overall quality (r=0.69 and r=0.71, p<0.005, respectively). Leiter, Harvie, and Frizzell223 found that patients’perceptions of the overall quality of care were significantly related to thedegree of emotional exhaustion experienced by nurses. Patients on unitswhere nurses found their work meaningful were more satisfied with allaspects of their hospital stay (r=0.79, p<0.01). Likewise, patients were lesssatisfied with their care on units where nursing staff more frequentlyexpressed the intention to quit (r=-0.53, p<0.05) or tended to be more cynical(r=-0.53, p<0.05). McNeese-Smith176 found a positive relationship between thePJHQ nursing subscale and patient perception that one nurse was in charge ofhis/her care (r=0.15, p=0.03) and the patient’s acquaintance with the nursemanager (r=0.17, p=0.01). Larrabee, Engle, and Tolley237 found thatachievement of patient-identified goals was a strong predictor of patientsatisfaction with nursing care.

A newly developed tool, the Patient Perception of Care Quality (PPCQ)236 wasexamined for its comprehensiveness and potential as an instrument forsatisfaction with nursing care quality. The tool was developed by the QualityImprovement Department at the Dartmouth-Hitchcock Medical Center basedon focus groups comprised of both providers and patient representatives.There is a commensurate measure of provider evaluation of patient carequality. These tools are intended to be used at the unit level to monitor qualityacross time and to serve as a basis for quality improvement initiatives. Thisinstrument has 17 items that are rated on a Likert scale ranging from poor tooutstanding quality. A global quality item which asks respondents to rateoverall quality of care on the unit on a 10-point scale, where 10 is the highestquality of care they can imagine, is included at the end of the questionnaire.The content validity was assessed by a panel of four experts (patients) anddetermined to be adequate (CVI= 0.96). Although there is no supportingpsychometrics for this scale at this time, it looks particularly promising as apotential instrument for assessing nursing care quality. It contains all of thefactors identified by patients as important to their satisfaction with nursingcare and includes many of the items included in other tools. The wording ofthe items is particularly appealing in comparison to others. Items seem to be‘actionable’, a desirable characteristic for quality improvement purposes.Several hospitals have expressed interest in piloting this questionnaire in thenear future, which would provide valuable information on its psychometricproperties.

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Interviews/Consultation ProcessA two-staged approach was utilized to obtain input related to patient

satisfaction with nursing care. This included gaining feedback from selectnurse executives across the Province regarding the Parkside patientsatisfaction instrument to frame the context for the literature review. As well,input on the proposed measures was also obtained during the ConsultationSessions.

Several senior nursing administrators provided key informant feedbackregarding the adequacy of the Parkside Quality of Care Monitor as a measureof satisfaction with nursing care. Their feedback was predominantly negativeas they saw the tool as:

• not providing information that can be used to make meaningful change;

• being very service-oriented, focusing on ‘hotel’ aspects of the patientexperience;

• creating the image of nurses as hostesses, with an orientation towardsservice hospitality;

• trivializing nursing’s contribution to meeting patient needs;

• containing items that are vague and unclear; and

• measuring patients‘ ‘happiness index’, rather than satisfaction with care.

The same nursing administrators were asked to offer suggestions for itemsthat would provide a more meaningful measure of patient satisfaction withnursing care. Their suggestions included items that would ask about the extentto which:

• nurses provide patients with timely, clear, and accurate information;

• families are involved in care;

• nurses assess and understand the patients’ conditions;

• nurses respond to and meet the patients’ needs;

• nurses demonstrate knowledge and skill;

• comfort measures are provided by nurses;

• nurses help patients prepare for discharge; and

• nurses demonstrate a caring attitude, respect and approachability.

In the Consultation Sessions, participants from across the Province werealso asked to share their views of the Parkside instrument. The resultsrevealed somewhat contradictory responses. Many participants felt that theParkside instrument does not accurately reflect the nurse’s role in the hospitalenvironment, while others felt that the instrument is very specific to nursing. Aconsistent comment was that the Parkside tool does not produce results thatcan be acted upon for quality improvement purposes. Some were concernedthat since the Parkside tool has been used throughout Ontario hospitals for thepast two years, comparative data will be lost if a new tool is introduced. Theyfelt that vast resources would be required to create a psychometrically soundmeasure that is relevant to Canadian healthcare settings.

Participants in the Consultation Sessions identified some general concernsrelated to the measurement of patient satisfaction with nursing care.Specifically, they verified the findings from the literature indicating thatdifferences exist between nurses’ and patients’ expectations of patient care

45

Nursing

quality. As well, they agreedthat individual patient factors,such as demographics andcultural background, mayinfluence patient satisfaction,as well as specific salientnegative events that may occurduring the patient’s hospitalstay. Finally, some participantssuggested that most patientshave difficulty distinguishingthe registered nurse fromother hospital personnel whoperform similar duties. Theyfelt that this problem isintensified if measures ofpatient satisfaction withnursing care do not reflectwhat nurses actually do, or donot relate to variables thatnurses can control. Thisfeedback was considered inour analysis of existing tools.

When asked to comparethese two instruments (PJHQ235

and PPCQ236), the ConsultationSession participants indicatedthat both instruments capturedthe realm of what nurses do.Although many wereenthusiastic about Cronenwettand Batalden’s236 choice ofitems in the PPCQ, severalwere concerned with thelanguage and wording of theinstrument. They felt thatpatients would have difficultyunderstanding the context ofthe questions and that severalitems were unnecessarilyverbose. In contrast, thelanguage used in the PJHQinstrument was repeatedlycommended for its clarity. Inthe interest of time andresources, many felt that thePJHQ had an advantage overthe PPCQ because it has beentested for reliability andvalidity and has been used ona smaller scale in severalOntario hospitals.

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Patient Judgments of Hospital Quality Questionnaire (PJHQ)235

Information You Were Given: How clear and complete were thenurses’ explanations about tests, treatments, and what to expect.

Instructions: How well nurses explained how to prepare for tests andoperations.

Ease of Getting Information: Willingness of nurses to answer yourquestions.

Information Given by Nurses: How well nurses communicated withpatients, families, and doctors.

Informing Family or Friends: How well the nurses kept them informedabout your condition and needs.

Involving Family or Friends in Your Care: How much they wereallowed to help in your care.

Concern and Caring by Nurses: Courtesy and respect you were given;friendliness and kindness.

Attention of Nurses to Your Condition: How often nurses checked onyou and how well they kept track of how you were doing.

Recognition of Your Opinions: How much nurses ask you what youthink is important and give you choices.

Consideration of Your Needs: Willingness of the nurses to be flexiblein meeting your needs.

The Daily Routine of the Nurses: How well they adjusted theschedules to your needs.

Helpfulness: Ability of the nurses to make you comfortable andreassure you.

Nursing Staff Response to Your Calls: How quick they were to help.

Skill and Competence of Nurses: How well things were done, likegiving medicine and handling IV’s.

Coordination of Care: The teamwork between nurses and otherhospital staff who took care of you.

Restful Atmosphere Provided by Nurses: Amount of peace and quiet.

Privacy: Provisions for your privacy by nurses.

Discharge Instructions: How clearly and completely you were told bythe nurses what to do and what to expect when you left the hospital.

Coordination of Care After Discharge: Nurses’ efforts to provide foryour needs after you left the hospital.

Overall quality of care and services you received.

Overall quality of nursing care.

Financial Performance and Condition

Indicator IdentificationA critical review and analysis of the literature on financial indicators of nursing

care was undertaken for this Report. As well, financial data sources such as theOntario Hospital Reporting System (OHRS) and the Ontario Case Costing Projectdatabase (OCCP) were examined for indicators relevant to nursing care. Theindicators identified in this process formed the basis for the identification ofnursing-sensitive financial indicators for this Report. The financial indicatorsincluded in the review were: total nursing hours per inpatient weighted case,individual staff mix hours per inpatient weighted case, Registered Nurse (RN)hours as a percentage of inpatient weighted cases, percent of total inpatientnursing hours utilized for direct nursing care, percent of professional nursingstaff hours utilized for RNs, percent of direct nursing care hours utilized for non-professional staff, percent of nursing care hours utilized for full time, part-timeand casual nursing staff, percent of staff hours used for orientation,absenteeism, ongoing education, overtime, and for agency staff. A synopsis ofevidence from the literature follows for each indicator.

Literature ReviewWithin the nursing literature, the primary financial variables of interest relate

to nursing staff-mix models and the hours and costs associated with thesemodels. This is true both for nursing report card projects, as well as individualempirical nursing research studies that link outcomes to nurse staffingmodels.

Traditional Financial Nurse Staffing IndicatorsAmong the indicators proposed by the American Nurses Association (ANA),

the nursing financial indicators included: (a) the ratio of RNs to total nursingstaff; (b) the mix of RNs, licensed practical nurses (LPNs) and unlicensedworkers; (c) RN experience; (d) RN education; (e) the ratio of nursing staff topatients; (f) total nursing care hours provided to patients for each category of

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Nursing

RecommendationsOur analysis of the literature and of feedback gathered from nursing stakeholders across theProvince suggests that there is room for improvement in how patient satisfaction with nursingcare is measured in Ontario hospitals. The current measure fails to capture many of the factorsidentified by nurses and patients in research on determinants of satisfaction with care. Based onour review, we feel comfortable in recommending that the modified 20-item version of the PatientJudgments of Hospital Quality (PJHQ) be considered as a measure of satisfaction with nursingcare for the Hospital Report Series. Although the PCCQ has potential, it is probably premature torecommend this tool without further testing.

Given the integral role of nursing services in the patient care experience and the consistent linkbetween satisfaction with nursing care and overall patient satisfaction, it is crucial to obtain datawhich can be meaningfully employed to continuously improve patient care quality in today’s highlycharged healthcare settings. A reliable and valid measure of patient satisfaction with nursing careis fundamental to achieving this goal.

staff mix; (g) use of agency nurses; (h) use of float nurses; (i) unsafeassignment rates; (j) nurse staff turnover rates; (k) full-time to part-time staffratio; (l) overtime rates; and (m) nurse staff injury rates.7 In the pilot workcompleted for the ANA Nursing Report Card9, two nurse staffing variableswere explored. These were: (a) total nursing hours per Nursing IntensityWeight (NIW); and (b) RN hours as a percentage of all nursing hours.9 Thus,the researchers were interested in overall nursing costs in relation to patientacuity. As well, they were interested in examining the unique costs associatedwith RN staffing, within overall nursing hours and costs.

The report generated from the pilot work by the ANA provides both system-level comparative hospital data within and among three states as well asindividual-level comparisons between all of the participating hospitals. Forexample, NIW acuity, total nurse staffing per patient day, and RN mix as apercentage of total nursing hours were compared. Not surprisingly, the skillmix was greater in hospitals with the highest degree of teaching and thosethat were the least urbanized.9

In their follow-up report10, nurse staffing data were obtained from theHealthcare Financing Association (HCFA) Provider of Services (POS) file. Theresearchers measured two indicators for nurse staffing: (a) staffing level (theamount of nursing time provided to patients) using NIW adjusted patient days;and (b) the skill mix of the nurses (RN hours as a percentage of total licensedhours). Findings indicated that shorter lengths of stay were related to higherlevels of overall staffing per NIW adjusted day. As well, lower complicationrates were associated with a higher mix of RNs for each of the four patientcomplications examined.10

In ongoing work underway by the ANA to develop the National Database forNursing Quality Indicators (NDNQI), the two nurse staffing variables thatcontinue to be included are: (a) mix of RNs, LPNs, and unlicensed staff caringfor patients in acute care settings; and (b) total nursing care hours providedper patient day. The purpose of the Costing of Quality Indicators project is todevelop and demonstrate a methodology for costing which can be used toassess the contributions of nurses to patient care and clinical costs. The focusof this project is on relationships between nurse structure of care indicatorsand patient adverse outcomes, length of stay and total charges.238

A similar project has been undertaken by the California Nursing OutcomesCoalition that aims to create a statewide nursing outcomes database that linkspatient outcomes to hospital nursing care. In a preliminary descriptive reportreleased in January 2000239, data from 257 units within 38 acute care hospitalswere presented. The aim of future reports is to examine the associationamong nursing skill mix, intensity of nursing hours and outcomes of care.

Several independent research teams have also explored financial indicatorsof nurse staffing in relation to patient and nurse outcomes. In the majority ofthese studies, staff mix and nursing care hours per patient day are thefinancial nursing variables examined. In a program of research led byBlegen164, nurse staffing variables included: (a) all hours of care per patientday; and (b) the proportion of those hours of care delivered by RNs. Mark,Salyer & Wan240 explored nurse staffing as the ratio of filled RN positions tototal filled positions on the unit. Lichtig, Knauf & Milholland241 examined: (a) RN hours as a percentage of total nursing hours; and (b) total nursinghours per NIW adjusted patient day. Whitman et al20 examined worked hoursper patient day/case mix index for their nurse staffing variable.

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Additional Financial Indicators of Nurse StaffingA number of researchers have moved beyond these traditional financial

variables for nurse staffing to develop additional indicators that capture abroader perspective of the financial impact of nurse staffing on patient care.Along with nursing report cards, the need for a nurse executive database toprovide information that may be more synonymous with the balancedscorecard approach has also been identified. The Nursing ManagementMinimum Data Set (NMMDS), developed in the U.S., was initiated to identify,define, and measure a set of valid management data elements.242 The NMMDSevolved using a participative approach with stakeholders, starting with a list ofindicators developed by a focus group that comprised management andadministrative experts. The indicators were initially pilot-tested and thenvalidated by a random sample of nurse executives surveyed from across theU.S.243 Seventeen indicators were categorized according to three dimensions:(a) nursing resources; (b) financial resources; and (c) the environment ofnursing practice.244 The nursing resources category describes the nursinghuman resources required for care delivery and includes a description of themanagement demographic profile, support personnel, nursing staff and theirsatisfaction.244 The financial resources category describes the monetaryresources of the organization and includes nursing unit/service budget,expenses, payer types and reimbursement. Finally, the environment categorydescribes the context of the nursing care delivery environment including typeof nursing unit/service, patient/client population(s) served, volume of nursingdelivery, accreditation, complexity of the environment, geographicalaccessibility of patients/clients, centralization of the environment of caredelivery, method of care delivery employed, and the complexity of clinicaldecision-making.244 The pilot test of the NMMDS supported collection ofinformation for the 17 indicators, although much of the data retrieval wasmanual.242

In Ontario, the Toronto teaching hospital initiative (TAHSC) to benchmarkhospital performance included a separate Nursing Management PracticeAtlas.245,246 The TAHSC Nursing Management Practice Atlas was a pilot studythat used an approach similar to that outlined by Huber et al.243 The Atlasreported variations in nursing and financial resource utilization over a three-year period. Nurse executives from each of the hospital sites identifiedindicators of interest for inclusion in the Atlas. These indicators were refinedover several months through an iterative process that included individualmeetings with nursing leaders from each of the TAHSC hospitals involved inthe study, as well as validation by hospital financial staff. Following thiscomprehensive data verification process, a total of 10 nursing managementindicators, related to nursing paid hours and compensation in relation toweighted cases, were developed for examination in the pilot study. Theseindicators included: (a) inpatient nursing paid hours per inpatient weightedcase; (b) RN paid hours per inpatient weighted case; (c) percent of professionalnursing staff hours utilized for RNs; (d) percent of direct nursing care hoursutilized for RNs; (e) percent of direct nursing care hours utilized for non-professional staff; (f) inpatient nursing paid dollars per inpatient weightedcase; (g) RN paid dollars per inpatient weighted case; (h) percent ofprofessional nursing staff dollars utilized for RNs; (i) percent of direct nursingcare dollars utilized for RNs; and (j) percent of direct nursing care dollarsutilized for non-professional staff. Little variation in nursing and financialresource utilization was found among the sites, although trends in downsizingof nursing resources were noted along with an increase in the utilization ofnon-professional nursing staff.245,246

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In a large national study recently released in the U.S., Needleman et al247

examined public and private sources of nurse staffing data and concludedstate hospital financial reports to be the best source of data for their study.These researchers encountered a number of challenges in developingvariables for nurse staffing. These included: (a) data sources did not use auniform set of categories in which nursing personnel were assigned resultingin the researchers assigning nursing personnel to the stated categories in thestudy; (b) variations existed in how hospitals define full-time equivalentsmaking it necessary to standardize the data to produce comparable estimatesof nurse staffing; and (c) data were reported for the total hospital, requiringallocation to either inpatient or outpatient areas by the research team.247 Oncethese adjustments were completed, the indicators developed for nurse staffingwere: (a) total hours per day; (b) RN hours per day; (c) LPN hours per day; (d) aide hours per day; (e) RN share of total hours (RN hours/total hours); (f) LPN share of total hours (LPN hours/total hours); (g) aide share of totalhours (aide hours/total hours); (h) licensed hours per patient day; (i) RN hours/licensed hours; (j) non-RN hours per day; and (k) aide hours/non-RN hours.

Several independent nursing report card initiatives also demonstrate themove beyond traditional indicators reflecting nursing financial resource use.Lowe and Baker248 describe the development of an institutional nursing reportcard that expands on nurse staffing financial indicators to examine broadernursing costs. They include: (a) total direct hours staffed excluding benefit,orientation, or education hours; (b) RN percentage of total staff; (c) LPNpercentage of total staff; (d) unlicensed worker percentage of total staff; (e) total salary costs per unit including overtime and agency costs; (f) benefitsas a percentage of salaries; (g) total agency fees; (h) average agency hourlyrate; (i) absenteeism hours; (j) vacancy hours; and (k) turnover rate. Similarly,Lancaster and King16 identify the following fiscal indicators for nursing: (a) staffmix; (b) RN turnover rate; (c) overtime; and (d) agency use. These indicatorsmay reflect the trend towards monitoring the efficiency of nursing care as wellas the quality.

Interviews/Consultation ProcessDuring the Consultation Sessions, participants agreed, for the most part,

with the list of proposed financial indicators. Specifically, numerousstakeholders addressed the need to consider nursing hours in a number ofways including the separate and combined measurement of RN, RPN, andnon-professional paid hours; and full-time, part-time and casual nurse paidhours. Some felt that the relationship between professional and non-professional staff, as well as regulated and unregulated staff, would provideuseful information. The percentage of staff employed in temporary andfloating positions was also suggested to be an important indicator to measure.Some representatives identified the importance of segregating the number ofnursing care hours spent by nurses performing non-nursing related dutiessuch as clerical work. Participants also indicated the importance of filtering outthe number of paid hours allocated for sick time or absentee replacement.

Some unique features related to nurse staffing in rural areas of the Provincewere also noted to be of importance. For example, participants from RegionOne (encompassing northern Ontario) identified that small rural hospitals arerequired to maintain a baseline or “minimum staffing level” regardless ofpatient volume. Thus, these hospitals may appear inefficient when comparingnursing hours per patient day across hospitals or regions. Similar concerns

50


with measures of efficiency were acknowledged during the consultationprocess in other regions. Some participants were concerned that financialmeasures of efficiency would conflict with other quadrants in the balancedscorecard, especially where the issue of workload is involved. It was felt thatto achieve what is considered to be financial efficiency, nursing workload willbe compromised.

Many participants stressed that they would like to see the inclusion ofindicators that capture orientation costs, absenteeism, vacancy, and turnoverrates. Specifically, it was identified that “where you have high turnover, youtend to have the most absenteeism”. Absenteeism was also reportedly linkedto overtime, although overtime was recognized as a complex issue as manycentres have individual protocols regarding overtime utilization. As well, oneparticipant argued that turnover is so frequent that orientation hours are oftenwasted. It was also suggested that vacancy and turnover rates may be relatedto patient satisfaction. Since it was reported that the accessibility of data onthese indicators is presently insufficient, the need for their measurement washighlighted repeatedly.

The discussion on absenteeism led to suggestions that this Report shouldcapture data on the number of nurses requiring compensation for injuriessustained while on duty. Participants identified the importance of trackinginjuries associated with the delivery of patient care, the number of hours beingcompensated, and whether employees absent due to injury had beenreplaced.

There were numerous suggestions that data be collected on ongoingnursing education. Ongoing education was identified as an important yetcomplex issue; however, some participants reported that they have specificbudgets for education making it easy to measure. Nonetheless, measuring thecost of replacing nurses absent while taking courses was felt to be morecomplicated.

In summary, feedback from the Consultation Sessions underscored theimportance of collecting nursing cost performance and productivity measures.

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Indicator

1) Inpatient nursing earned hours perinpatient weighted case

2) UPP (RN, RPN, and non-professionalstaff) earned hours per inpatientweighted case

3) RN staff earned hours per inpatientweighted case

4) Percent of total inpatient nursing earnedhours utilized for direct nursing care

5) Percent professional nursing staff hoursutilized for RNs

6) Percent of direct nursing care earnedhours utilized for non-professional staff

7) Percent of nursing care earned hoursutilized for full time RNs

8) Percent of nursing care earned hoursutilized for full time RPNs

9) Percent of nursing care earned hoursutilized for full time non-professionalstaff

10) Percent of nursing care earned hoursutilized for part time RNs

11) Percent of nursing care earned hoursutilized for part time RPNs

12) Percent of nursing care earned hoursutilized for part time non-professionalstaff

13) Percent of nursing care earned hoursutilized for casual RNs

14) Percent of nursing care earned hoursutilized for casual time RPNs

Indicator Definition

Nursing Cost Performance Measures

All earned hours for inpatient functional centres (including administrative and clinical resources)Inpatient weighted cases

Note: Earned hours=worked hours + benefit hours + purchased service hours. Earned hour statisticsmeasure the use of labour in fulfilling the mandate of the service [of the functional centre].

UPP (RN, RPN & non-professional staff) earned hours in inpatient functional centresInpatient weighted cases

RN staff earned hours in inpatient functional centresInpatient weighted cases

Utilization Measures

RN + RPN + non-professional patient care staff earned hoursTotal inpatient nursing earned hours

RN staff earned hoursRN & RPN earned hours

Non-professional staff earned hoursRN + RPN + non-professional patient care staff earned hours

Full time RNs earned hoursTotal inpatient nursing earned hours

Full time RPNs earned hoursTotal inpatient nursing earned hours

Full time non-professional staff earned hoursTotal inpatient nursing earned hours

Part time RNs earned hoursTotal inpatient nursing earned hours

Part time RPNs earned hoursTotal inpatient nursing earned hours

Part time non-professional staff earned hoursTotal inpatient nursing earned hours

Casual RNs earned hoursTotal inpatient nursing earned hours

Casual RPNs earned hoursTotal inpatient nursing earned hours

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15) Percent of nursing care earned hoursutilized for casual non-professional staff

16) Percent nursing staff hours utilized fororientation

17) Percent nursing staff hours utilized forabsenteeism

18) Percent nursing staff hours utilized forongoing education

19) Percent nursing staff hours utilized forovertime

20) Percent nursing staff hours utilized foragency staff

Casual non-professional staff earned hoursTotal inpatient nursing earned hours

Efficiency Measures

Orientation hours for RN + RPN + non-professional patient care staffTotal inpatient nursing earned hours

Sick time hours for RN + RPN + non-professional patient care staffTotal inpatient nursing earned hours

Ongoing education hours for RN + RPN + non-professional patient care staffTotal inpatient nursing earned hours

Overtime hours for RN + RPN + non-professional patient care staffTotal inpatient nursing earned hours

Agency staff hours for RN + RPN + non-professional patient care staffTotal inpatient nursing earned hours

Feasibility Issues

Data AvailabilityThe availability and quality of patient outcomes data are perhaps the

greatest concerns for the development of nursing indicators. For the mostpart, data sources are comprised of administrative or secondary databases.Mark & Burleson249 developed and tested an instrument to determine theavailability and consistency of five patient outcome indicators for nursing: (a)medication administration errors; (b) patient falls; (c) occurrence of decubitusulcers; (d) nosocomial infections; and (e) unplanned readmissions to the hospital in arandom sample of 20 U.S. hospitals. Results indicated that data were collectedconsistently for medication errors and patient falls only.249 The authors suggest

RecommendationsThe literature review provides evidence that supports a relationship between financial nursestaffing indicators and patient outcomes in acute inpatient care. A two-staged approach isrecommended for the development of indicators of financial performance and condition. Thisincludes:

• For data that are currently available from the OHRS (indicators 1 – 15, 20), we recommendcollecting data for these indicators and reporting values for each in the next acute carescorecard.

• For data that are not currently available from the OHRS (indicators 16 -19), we recommendthat the OHRS MIS database be enhanced in the future to include relevant variables.

the need for a standardized minimum data set for nursing administration toensure that comparisons such as these are possible for decision-making in thefuture. The importance of understanding administrative data, and itsusefulness for practice and management within healthcare institutions hasbeen underscored by other researchers.250,251

In light of this evidence, we conducted a telephone survey to determine thefeasibility of collecting data on the proposed nursing indicators for the clinicalutilization and outcomes quadrant. In total, we received 42 completed surveysfrom acute care hospitals representing each of the five geographic regionsdefined by the Ontario Hospital Association. The surveys revealed that manyacute care hospitals in Ontario do not collect data on the primary outcomes offunctional status, self-care status and symptom control. However, data areavailable on the secondary outcomes of patient falls and hospital-acquiredpressure ulcers at the majority of the hospitals surveyed. Of the hospitals thatdo collect data on each of the recommended indicators, most would be able toprovide the information in an electronic format, with the exception of datacollected on symptom control. The results of the survey are summarized in thetable below.

A few representatives indicated that it would be possible to provideinformation on the specified indicators for patients in complex continuing careor rehabilitation but these data are not collected in acute care at theirhospitals.

The integration of nursing indicators into the existing Hospital Report Seriesprovides the opportunity for testing the reliability and validity of the nursingindicators, using an established methodology. The results of the literaturereview and Consultation Sessions have provided confirmation that data on thefollowing nursing indicators should be collected:

System Integration and Change: 1. Clinical information technology2. Clinical data 3. Intensity of information use 4. Nursing databases5. Development and use of clinical pathways6. Coordination of care 7. Nursing-community integration 8. Continuity of care 9. Strategies for managing ALC patients

10. Nursing health human resources

Collection of data on each of these indicators is currently feasible for measurement.

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Can you provide informationon the [indicator] of patientswho have visited yourhospital in the past year?

Can these data be provided inan electronic format?

Functional Status

Yes - 8No - 28

Unsure - 2

Yes - 4

No - 4

Self-Care Status

Yes - 7No - 30

Unsure - 1

Yes - 4

No - 3

Symptom Control

Yes - 17No - 23

Unsure - 1

Yes - 3

No - 14

Patient Falls

Yes - 42No - 0

Unsure - 0

Yes - 35

No - 6

Pressure Ulcers

Yes - 25No - 15

Unsure - 0

Yes - 15

No - 10

Summary of Responses from Clinical Utilization and Outcomes DataFeasibility Survey

Clinical Utilization and Outcomes:1. Functional status 2. Self-care status3. Symptom control 4. Patient falls 5. Urinary tract infections 6. Pneumonia 7. Pressure ulcers8. Upper gastrointestinal bleeding9. Failure to rescue

Collection of data on patient falls, urinary tract infections, pneumonia and pressureulcers is currently feasible; however, data on functional status, self-care status andsymptom control may not be readily available.

Patient Satisfaction:1. Information you were given2. Instructions 3. Ease of getting information 4. Information given by nurses5. Informing family or friends6. Involving family or friends in your care 7. Concern and caring by nurses8. Attention of nurses to your condition9. Recognition of your opinion

10. Consideration of your needs11. The daily routine of nurses12. Helpfulness 13. Nursing staff response to your calls14. Skill and competence of nurses15. Coordination of care16. Restful atmosphere provided by nurses17. Privacy18. Discharge instructions19. Coordination of care after discharge20. Overall quality of care and services you received21. Overall quality of nursing care

Collection of data on each of these indicators is feasible with the implementationof the Patient Judgment of Hospital Quality Survey.235

Financial Performance and Condition:1. Inpatient nursing earned hours per inpatient weighted case2. UPP (RN, RPN, and non-professional staff) earned hours per inpatient

weighted case3. RN staff earned hours per inpatient weighted case4. Percent of total inpatient nursing earned hours utilized for direct nursing care5. Percent professional nursing staff hours utilized for RNs6. Percent of direct nursing care earned hours utilized for non-professional staff7. Percent of nursing care earned hours utilized for full time RNs8. Percent of nursing care earned hours utilized for full time RPNs9. Percent of nursing care earned hours utilized for full time non-professional

staff

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Nursing

10. Percent of nursing care earned hours utilized for part time RNs11. Percent of nursing care earned hours utilized for part time RPNs12. Percent of nursing care earned hours utilized for part time non-professional

staff13. Percent of nursing care earned hours utilized for casual RNs14. Percent of nursing care earned hours utilized for casual time RPNs15. Percent of nursing care earned hours utilized for casual non-professional

staff16. Percent nursing staff hours utilized for agency staff17. Percent nursing staff hours utilized for orientation18. Percent nursing staff hours utilized for absenteeism19. Percent nursing staff hours utilized for ongoing education20. Percent nursing staff hours utilized for overtime

Collection of data on the first 16 indicators is currently feasible; however,data on the remaining indicators is not readily available.

A substantial amount of evidence has been presented in this Report tosupport the inclusion of these indicators as measures that capture the practiceof nursing in each quadrant of the balanced scorecard. While all of theindicators are theoretically important to consider, the plausibility of measuringall of them must be examined. The availability of comparable data for some ofthe indicators is problematic. An overview of the availability of each of thenursing indicators and the data source for each is provided in Appendix D.

Recommendations and Future DirectionsThe nursing team has generated a list of indicators that fit within the

balanced scorecard framework utilized for the Hospital Report Series. Theseindicators are supported by evidence in the literature and by nursestakeholders from across the Province. The researchers recommend that thesenursing indicators be integrated into the existing Hospital Report Series forvalidation and testing, and analysis. We acknowledge other important andcomplementary initiatives currently underway in the Province. Every effort hasbeen made to avoid duplication of effort or overlap. For example, the MOHLTCNursing and Health Outcomes Study is working towards the development ofvariables for inclusion in healthcare databases about nursing and nursing-sensitive outcomes. Attempts to measure several of the clinical outcomesacknowledged as important in this Report (e.g. functional status, self-care,symptom control) are not recommended for this year as we await progress onthe Nursing and Health Outcomes Project. Similarly, the Best PracticeGuidelines being developed by the RNAO support the indicators included inthis Report, those identified in the Nursing and Health Outcomes Project andthe Hospital Report Series. Thus, the potential to create a guideline orframework for the ongoing evaluation of these indicators is evident.

System Integration and Change Quadrant RecommendationsBased on relevant literature, key informants and previous work on the

development of system integration and change indicators, we recommend:

• That a survey methodology be utilized to obtain information fromorganizations in relation to system integration and change indicators fornursing care. Items representing nursing should be included in the

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sections on clinical information technology, nursing databases, clinicalpathways, and alternate levels of care.

• We recommend that a new indicator – nurse integration and management –be included in the existing human resources indicator of the HospitalReport, to capture the nursing human resource challenges that exist withinorganizations. This indicator is based on the work of Shortell andcolleagues58, integration and management theory, and literature on healthhuman resources, magnet hospitals, retention and recruitment.

• In the future, when nursing data are routinely collected and examined, werecommend that items be developed to assess internal and externalbenchmarking of nursing practices.

• Continuity and coordination of care items should also be developed andincluded in the Hospital Report, to augment the patient’s assessment ofthese indicators.

Clinical Utilization and Outcomes Quadrant RecommendationsA three-staged approach is recommended for the development of the clinical

utilization and outcomes indicators. This includes:

• For data that are currently available from CIHI, we recommend collectingdata on the following secondary complications found to be sensitive tonurse staffing variables: bacterial pneumonia, urinary tract infection, skinpressure ulcers, and falls that result in a codable injury (e.g. fracture orsubdural hematoma).

• For secondary complications where the evidence is unclear in regard tosupport for a relationship with nursing interventions at this time, werecommend collecting data for the purpose of evaluating sensitivity tonurse staffing variables, specifically for upper gastrointestinal bleedingand failure to rescue.

• We recommend further research to establish the feasibility of collectingdata on primary patient outcomes found sensitive to nursing care,specifically for functional status, symptom control, and self-care.

Patient Satisfaction Quadrant RecommendationsOur analysis of the literature and of feedback gathered from nursing

stakeholders across the Province suggests that there is room for improvementin how patient satisfaction with nursing care is measured in Ontario hospitals.The current measure fails to capture many of the factors identified by nursesand patients in research on determinants of satisfaction with care. Based onour review, we feel comfortable in recommending that the modified 20-itemversion of the Patient Judgments of Hospital Quality (PJHQ)235 be consideredas a measure of satisfaction with nursing care.

Financial Performance and Condition Quadrant RecommendationsA two-staged approach is recommended for the development of financial

performance and condition indicators. This includes:

• For data that are currently available from the OHRS, we recommendcollecting data and analyzing it for inclusion within the next series ofHospital Reports.

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• For data that are not currently available from the OHRS, we recommendthat the OHRS MIS database be enhanced in the future to include variablesrelevant to these indicators.

58


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177. Niedz BA. Correlates of hospitalized patients’ perceptions of servicequality. Res Nurs Health 1998; 21:339-349.

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179. Mahon PY. An analysis of the concept ‘patient satisfaction’ as itrelates to contemporary nursing. J Adv Nurs 1996; 24:1243.

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184. Petersen MB. Measuring patient satisfaction: Collecting useful data. J Nurs Qual Assur 1988; 2(3):25-35.

185. Swan J. Deepening the understanding of hospital patient satisfaction:Fulfillment and equity of effects. J healthcare Mark 1985; 5(3):14.

186. Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med1982; 16:577-582.

187. Eriksen LR. Patient satisfaction with nursing care: Conceptsatisfaction. J Nurs Meas 1995; 3:59-76.

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188. Hill J. Patient satisfaction in a nurse-led rheumatology clinic. J AdvNurs 1997; 25:347-354.

189. Cleary PD, McNeil BJ. Patient satisfaction as an indicator of qualitycare. Inquiry 1988; 25:25-36.

190. Williams B. Patient satisfaction: A valid concept? Soc Sci Med 1994;38(4):509-516.

191. Pascoe GC. Patient satisfaction in primary healthcare: A literaturereview and analysis. Eval Prog Plan 1983; 6:185-210.

192. Babakus E, Mangold WG. Adapting the SERVQUAL scale to hospitalservices: An empirical investigation. Health Serv Res 1992; 26:767-786.

193. Taylor SA, Cronin JJ. Modeling patient satisfaction and servicequality. J healthcare Mark 1994; 14(1):34.

194. Chang BL, Uman GC, Lawrence LS, Ware JE, Kane RL. The effect ofsystematically varying components of nursing care satisfaction inelderly ambulatory women. West J Nurs Res 1984; 6:366-379.

195. Taylor SA. Distinguishing service quality from patient satisfaction indeveloping healthcare marketing strategies. Hosp Health Serv Adm1994; 39(2):221-236.

196. Woodside AG, Frey LL, Daly RT. Linking service quality, customersatisfaction, and behavioral intention. J healthcare Mark 1989; 9(4):5-17.

197. von Essen L, Sjoden P-O. Perceived occurrence and importance ofcaring behaviours among patients and staff in psychiatric, medicaland surgical care. J Adv Nurs 1995; 21:266-276.

198. von Essen L, Sjoden P-O. Patient and staff perceptions of caring:Review and replication. J Adv Nurs 1991; 16:1363-1.

199. Farrell GA. How accurately do nurses perceive patients’ needs? Acomparison of general and psychiatric settings. J Adv Nurs 1991;16:1062-1070.

200. Young WB, Minnick AF, Marcantonio R. How wide is the gap indefining quality care? Comparison of patient and nurse perceptions ofimportant aspects of patient care. J Nurs Adm 1996; 26:15-20.

201. Larson PJ. Comparison of cancer patients’ and professional nurses’perceptions of important nurse caring behaviors. Heart Lung 1987;16:187-193.

202. Kovner C. Nurse-patient agreement and outcomes after surgery. WestJ Nurs Res 1989; 11(1):7-17.

203. Bond S, Thomas L. Measuring patient’s satisfaction with nursing care.J Adv Nurs 1992; 17:52-63.

204. Lynn MR, Moore K. Relationship between traditional quality indicatorsand perceptions of care. Semin Nurse Manag 1997; 5(4):187-193.

205. Webb C, Hope K. What kind of nurses do patients want? J Clin Nurs1995; 4:101-108.

206. Lynn MR, McMillen BJ. Do nurses know what patients think isimportant in nursing care? J Nurs Care Qual 1999; 13(5):65-74.

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207. Conbere PC, McGovern P, Kochevar L, Widtfeldt A. Measuringsatisfaction with medical case management: a quality improvementtool. AAOHN J 1992; 40(7):333-41, 358-60.

208. Rubin HR, Ware JE, Hays RD. The PJHQ questionnaire. Exploratoryfactor analysis and empirical scale construction. Med Care 1990; 28(9 Suppl):S22-9.

209. Andaleeb SS. Determinants of customer satisfaction with hospitals: A managerial model. Int J healthcare Qual Assur 1998; 11(6):181-187.

210. Krouse H, Roberts S. Nurse-patient interactive styles: Power, controland satisfaction. West J Nurs Res 1989; 11:717-725.

211. Forbes DA. Clarification of the constructs of satisfaction anddissatisfaction with home care. Public Health Nurs 1996; 13:377-385.

212. Bowling A. Assessing health needs and measuring patientsatisfaction. Nurs Times 1992; 88(31):31-33.

213. Cottle DW. Client-centred service: How to keep them coming back formore. New York: John Wiley & Sons; 1989.

214. Fosbinder D. Patient perceptions of nursing care: An emerging theoryof interpersonal competence. J Adv Nurs 1994; 20:1085-1093.

215. Lewis K, Woodside R. Patient satisfaction with care in the emergencydepartment. J Adv Nurs 1992; 17:959-964.

216. Denton DK. Quality service. Houston, TX: Gulf Publishing; 1989.

217. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actualwaiting time, perceived waiting time, information delivery andexpressive quality on patient satisfaction in the emergencydepartment. Ann Emerg Med 1996; 28:657-665.

218. Hanan M, Karp P. Customer satisfaction. New York: AmericanManagement Association; 1989.

219. Heinemann D, Lengacher CA, VanCott ML, Mabe P, Swymer S.Partners in patient care: Measuring the effects on patient satisfactionand other quality indicators. Nurs Econ 1996; 14:276-285.

220. Goode CJ. Impact of a CareMap and case management on patientsatisfaction and staff satisfaction, collaboration and autonomy. NursEcon 1995; 13(6):337-348.

221. Twardon C, Gartner M. Empowering nurses: Patient satisfaction withprimary nursing in home health. J Nurs Adm 1991; 21(11):39-43.

222. Atkins PM, Marshall BS, Javalgi RG. Happy employees lead to loyalpatients. J healthcare Mark 1996; 16(4):15-23.

223. Leiter MP, Harvie P, Frizzel C. The correspondence of patientsatisfaction and nurse burnout. Soc Sci Med 1998; 47(10):1611-1617.

224. Kaldenberg DO, Regrut BA. Do satisfied patients depend on satisfiedemployees? Or, do satisfied employees depend on satisfied patients?The Satisfaction Report, Volume III. South Bend, IN: Press, GaneyAssociates, Inc; 1998.

225. Weisman CS, Nathanson CA. Professional satisfaction and clientoutcomes: A comparative organizational analysis. Med Care 1985;23(10):1179-1192.

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226. Kangas S, Kee CC, McKee-Waddle R. Organizational factors, nurses’job satisfaction, and patient satisfaction with nursing care. J NursAdm 1999; 29:32-42.

227. Batalden PB, Nelson EC. Hospital quality: Patient, physician, andemployee judgments. Int J healthcare Qual Assur 1990; 3:7-17.

228. Swan JE & Carroll MG. Patient satisfaction and overview of research-1965 to 1978. In H.K. Hunt & R.L. Day (Eds.), Refining concepts andmeasures of consumer satisfaction and complaining behavior (pp.112-118). Bloomington, IN: Foundation for the School of Business,Indiana University; 1980.

229. Davidow WA, Uttal B. Total customer service. New York: Harper &Row Publishers; 1989.

230. Rubin HR, Gandeck B, Rogers WH, Kosinski M, McHorney CA, WareJE. Patients' ratings of outpatient visits in different practice settings,results from the medical outcomes study. JAMA 1988; 270:835-840.

231. Chang K. Dimensions and indicators of patients’ perceived nursingcare quality in the hospital setting. J Nurs Care Qual 1997; 11(6):26-37.

232. Moritz P. Innovative nursing practice models and patient outcomes.Nurs Outlook 1991; 39(3):111-114.

233. Lin C. Patient satisfaction with nursing care as an outcome variable:Dilemmas for nursing evaluation researchers. J Prof Nurs 1996;12(4):207-216.

234. Carey RG, Seibert JH. A patient survey system to measure qualityimprovement: questionnaire reliability and validity. Med Care 1993Sept; 31(9):834-45.

235. Meterko M, Nelson EC, Rubin HR, Batalden P, Berwick DM, Hays RD,Ware JE. Patients’ judgment of hospital quality: A report on a pilotstudy. Med Care 1990; 28(supp):S1-S56.

236. Cronenwett L, Batalden P. Perceptions of Care Quality. Working Paper; 1999.

237. Larrabee JH, Engle VF, Tolley EA. Predictors of patient-perceivedquality. Scandinavian Journal of Caring Science 1995; 9:153-164.

238. American Nurses Association. Costing of Nursing Quality Indicators.Washington, DC:Author; 2001 [cited 2001 Sept 21]. Available from:URL: http://www.nursingworld.org/quality/costing.htm

239. California Nursing Outcomes Coalition. [Title]: Descriptive Report. San Francisco, CA:Author; 2000 Jan.

240. Mark BA, Salyer J, Wan TTH. Market, hospital and nursing unitcharacteristics as predictors of nursing unit skill mix. J Nurs Adm2000; 30(11):552-560.

241. Lichtig LK, Knauf RA, Milholland DK. Some impacts of nursing onacute care hospital outcomes. J Nurs Adm 1999; 29(2):25-33.

242. Huber DG, Delaney C. Nursing management minimum data set. ApplNurs Res 1997; 10(3): 164-165.

243. Huber DG, Delaney C, Crossley J, Mehmert M, Ellerbe S. A nursingmanagement minimum data set: significance and development. J Nurs Adm 1992; 22(7/8):35-40.

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244. Huber DG, Schumacher L, Delaney C. Nursing management minimumdata set (NMMDS). J Nurs Adm 1997; 27(4):42-48.

245. McGillis Hall L, Pink GH, Johnson LM, Schraa EG. Developing anursing management practice atlas: Part 1, methodologicalapproaches to ensure data consistency. J Nurs Adm 2000 Jul/Aug;30(7/8):364-372.

246. McGillis Hall L, Pink GH, Johnson LM, Schraa EG. Development of anursing management practice atlas: Part 2, variation in use of nursingand financial resources. J Nurs Adm 2000 Sept; 30(9):440-448.

247. Needleman J, Buerhaus PI, Mattke S, Stewart M, Zelevinsky K. NurseStaffing and Patient Outcomes in Hospitals: Final Report. Boston, Ma:Harvard School of Public Health, Health Resources and ServicesAdministration, US Department of Health and Human Services; 2001Feb 28. Contract No. 230-99-0021 [cited 2001 Sept 21]. Available from:URL: http://bhpr.hrsa.gov/dn/staffstudy.htm

248. Lowe A, Baker JK. Measuring outcomes: A nursing report card. NursManage 1997; 28(11):38,40-41.

249. Mark BA, Burleson DL. Measurement of patient outcomes: dataavailability and consistency. J Nurs Adm 1995; 25(4):52-59.

250. Czaplinski C, Diers D. The effect of staff nursing on length of stay andmortality. Med Care 1998 Dec; 36(12):1626-38.

251. Diers D, Bozzo J. Using administrative data for practice andmanagement. Nurs Econ 1999 Jul-Aug; 17(4):233-7.

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Appendix A: Nursing Report ConsultationSession Participants

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Eileen Bain

Gloria Cardoso

Nancy Sinclair

Kathleen Heslin

Sylvia Scott

Irene Pasel

Myrna Cooper

Kim Alvarado

Petra Cooke

Karen Eddy

Bernice King

Barbara MacKinnon

Tricia Stiles

Larry Stewart

Michelle Butt

Diane Cameron

Cindy Bates

Marion Bramwell

Program Manager

Corporate Project Specialist

Professional PracticeRepresentative

Vice President, ClinicalPrograms

Director, ProfessionalPractice

Vice President, PatientServices & Chief NursingOfficer

Chief Nursing Officer

Profession Leader

Registered Nurse

Registered Nurse

Registered Nurse

Manager, External Quality

Clinical Nurse Specialist

Vice President, Patient CareServices

Senior Research Associate

Health Programs Director

Nurse Manager

Vice President, PatientServices & Chief NursingOfficer

Cambridge MemorialHospital



Grand River Hospital

Grand River Hospital

Guelph General Hospital

Haldimand War Memorial &West Haldimand GeneralHospitals

Hamilton Health SciencesCorporation




Hamilton WentworthCommunity Care AccessCentre

Homewood Health Centre

Joseph Brant MemorialHospital

McMaster UniversityMedical Centre

Niagara Health System

St. Joseph’s Hospital &Home

St. Mary’s General Hospital

HAMILTON CONSULTATION SESSION

76


Wendy Cuthbert

Eleanor Plain

Trudy Freeman

Linda Hofman

Eleanor Rivoire

Joan Tranmer

Sue Wilson

Gail Beatty

Velma Desjardins

Maureen McGinn

Marianne Lamb

Catherine Kirk

June Nalon

Director, Clinical Services

Director of CommunityServices

Director of Nursing

Coordinator, QualityManagement & NursingPractice

Program Director

Director, Nursing Research

Program Director

Nurse Manager, Outpatients

Patient Care Unit Manager

Director, PhysiotherapyServices

Director, School of Nursing

Director, Medicine & CriticalCare

Coordinator of NursingProgram

Brockville General Hospital

Kingston Community CareAccess Centre

Kingston General Hospital





Lennox and AddingtonCounty General Hospital

Perth & Smiths FallsDistrict Hospital

Providence Centre

Queen’s University

Quinte HealthcareCorporation

St. Lawrence College

KINGSTON CONSULTATION SESSION

Connie Courtney

Linda Goldsmith

Pat Kirkby

Alfretta Vanderheyden

Roberta Ament

Glenda Hayward

Nancy Hilborn

Kathleen Ledoux

Barb Willis

Carol Wong

Site Director


Chair of Health Sciences

Integration Leader

Assistant Executive Director,Patient Services

Professional PracticeSpecialist

Intensive Care Unit Nurse

Manager, Surgical Care

Vice President, OperationalPerformance

Professional Practice Leader

Charlotte Eleanor EnglehartHospital

Chatham-Kent HealthAlliance

Fanshawe College

Huron-Perth HospitalsPartnership

Leamington DistrictMemorial Hospital

London Health SciencesCentre





LONDON CONSULTATION SESSION

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Sandra Letton

Karen Perkin

Joan Almost

Kinga Kluska

Anne Snowdon

Janis Shkilnyk

Vice President

Professional Practice Leader

Fourth Year Coordinator &Lecturer

Graduate Student


Coordinator

St. Joseph’s HealthcareLondon

St. Joseph’s HealthcareLondon

University of WesternOntario

University of WesternOntario

Windsor Regional Hospital

Woodstock General Hospital

Francine Anne Roy

Sharon Nield

Carole Presseault

Christine Kouri

Ruth Pollock

Christine Fitzgerald

Jane L. MacDonald

Diane G. Plante

Sheila Bauer

Nicki Sims-Jones

Mary Carson

Nancy Kelly

Nancy Brookes

Susan Draper

Marlene Mackey

Donna Kettyle

Betty Cragg

Barbara Davies

Joan Garrow

Consultant, NursingDatabases

Manager, Nursing Policy &Regulatory Support

Manager, Health Policy

Patient FamilyRepresentative

Patient Care AdministrativeAssistant

Consultant

Field Epidemiologist

Clinical Services Leader

Assistant Director, ClientServices

Family Health Manager

Director of Nursing

Assistant Executive Director

Nursing PracticeCoordinator

Coordinator, NursingQuality and Improvement

Coordinator, NursingQuality

Discipline Leader, Nursing

Director, School of Nursing

Director


Canadian Institute forHealth Information

Canadian NursesAssociation

Canadian NursesAssociation

Children’s Hospital ofEastern Ontario

Cornwall General Hospital

Fitzgerald and Associates

Health Canada

Montfort Hospital

Ottawa Community CareAccess Centre

Ottawa-Carleton HealthDepartment

Queensway CarletonHospital

Renfrew Victoria Hospital

Royal Ottawa Hospital

The Ottawa Hospital

The Ottawa Hospital

The Rehabilitation Centre

University of Ottawa

University of Ottawa

Winchester DistrictMemorial Hospital

OTTAWA CONSULTATION SESSION

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Lois Kozak

Monique Berger

Beverley McFarlane

Anne K. Weiler

Manon Lemonde

Ellen Rukholm

Debra Bennett

Nancy Jacko

Andrea McLellan

Tiziana Silveri

Marilyn Travglini

Janice Hardy

Lucille Perreault

Margaret Catt

Dot Allen

Lynda Dukacz

Carol Halt

Michelle Remillard

Patient Services Leader

Director, Patient CareServices

Director of Nursing andDiagnostics


Assistant Professor

Director of Nursing

Director, Patient CareServices

Program Director

Coordinator, QualityImprovement Education

Program Director, Surgery,Maternal Child Care Centre

Program Director


Vice President & ChiefNursing Officer


Manager, Surgical Services

Director, Emergency, CriticalCare & Mental HealthPrograms

Director, Surgical &Obstetrical Programs

Assistant Executive Director,Patient Care Services

Englehart & District Hospital

Espanola General Hospital

Huntsville District MemorialHospital

Kirkland & District Hospital

Laurentian University

Laurentian University

Manitoulin Health Centre

North Bay General Hospital



Sault Ste. Marie GeneralHospital

South Muskoka MemorialHospital

Sudbury Regional Hospital

Temiskaming Hospital

Thunder Bay RegionalHospital

Timmins & District Hospital

Timmins & District Hospital

West Nipissing GeneralHospital

SUDBURY CONSULTATION SESSION

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Nursing

Renee Kenny

Anne Coghlan

Betty Steinhofer

Denise Hardenne

Nabila Lowe

Marg Czaus

Marlene Jackson

Margaret Blastorah

Janet E. Roberts

Lianne Jeffs

Peggy White

Leslie Vincent

Joan Wallace

Jacqueline Choiniere

Kim Jarvi

Kirsten Krull-Naraj

Barb Mildon

Marg Black

Janice Allen

Jane Mosley

Dawn Sidenberg

Ella Ferris

Chair of Nursing

Executive Director

Director, Patient Services

Vice President, ProfessionalPractice

Program Leader, Medicine

Operations Director, MedicalPrograms

Director, Patient Services

Practice Leader, Nursing

Vice President

Senior Policy Analyst

Leader, Nursing & HealthOutcomes Project

Vice President, Nursing

Educator, Obstetrics &Gynecology

Director, Policy & Research

Senior Economist

Vice President, Patient CareServices & Chief NursingOfficer

Vice President, NursingLeadership

School of Health Sciences

Manager, Cardiology & CCU

Director, ProfessionalPractice & Chief NursingOfficer

Director, QualityManagement

Program Director, Heart/ICU

Centennial College

College of Nurses ofOntario

Dufferin-Caledon HealthcareCorporation

Halton Healthcare ServicesCorporation

Halton Healthcare ServicesCorporation

Humber River RegionalHospital

Huronia District Hospital

Markham Stouffville HealthCentre

Markham Stouffville HealthCentre

Ministry of Health andLong-Term Care

Ministry of Health andLong-Term Care

Mount Sinai Hospital

North York General Hospital

Registered NursesAssociation of Ontario

Registered NursesAssociation of Ontario

Royal Victoria Hospital

Saint Elizabeth Healthcare

Seneca College

Southlake Regional HealthCentre

St. Joseph’s Health Centre

St. Joseph’s Health Centre

St. Michael’s Hospital

TORONTO CONSULTATION SESSION

80


Shalimar Santos-Comia

Janet Rush

Marla Fryers

Heather Blachford

Jane Moser

Amy McCutcheon

Nancy Purdy

Ainsley Lee

Coordinator, NursingEducation & CommunityPartnerships

Chief of Nursing

Chief Nursing Officer &Lead, Professional Practice


Acting Chief Nursing Officer

Vice President, Patient CareServices



Sunnybrook & Women’sCollege Health SciencesCentre

The Hospital for SickChildren

Toronto East General &Orthopaedic Hospital

Trillium Health Centre

University Health Network

Stevenson MemorialHospital

William Osler Health Centre

York Central Hospital

Appendix B: Key Informants andRelated Initiative ParticipantsNursing Best Practices ProjectTazim Virani Project Director Registered Nurses

Association of Ontario

Institute for Work & Health – St. Michael’s HospitalLynda Robson Research Associate Institute for Work and

Health

Personal Consult for Patient Satisfaction QuadrantGeorgi Beal Chief, Nursing Practice Centre for Addiction

and Professional Services and Mental Health

Margrét Comack Vice President and Huron-Perth HospitalsChief Nursing Officer Partnership

Eric Doucette Manager, Practice Setting, College of Nurses ofConsultation Program and OntarioEmployer Support

Mary Ferguson-Paré Vice President, Baycrest Centre forNursing Services Geriatric Care

Karen Perkin Professional Practice Leader St. Joseph’s HealthCare London

Patricia Petryshen Vice President and St. Michael’s HospitalChief Nursing Officer

Janet Rush Chief of Nursing The Hospital for SickChildren

Carol Wong Professional Practice Leader London Health SciencesCentre

Personal Consult for Financial Performance and Condition QuadrantDonna Thomson Doctoral Fellow Faculty of Nursing,

University of Toronto

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Appendix C: Summary ofRecommended Modifications to theSystem Integration and ChangeSurvey

This appendix summarizes proposed changes to the system integration and change survey to integrate a nursing care perspective into the HospitalReport Series. Based on the literature review and the Consultation Sessions, itis recommended that items be included in the sections on clinical informationtechnology, clinical pathways, continuity of care and alternate level of care(ALC) patients.

In the clinical information technology indicator, items are recommended toincrease the visibility of nursing in clinical and administrative databases, aswell as assess the nurses’ ability to access information within the organization.Items have been recommended examining the amount and type of nursinginformation accessed from patient records and included in databases. Nurses’ability to access information electronically is also suggested. The HospitalReport Series explores the development and implementation of clinicalpathways. Within this section of the survey, it is suggested that items beincluded that examine the nurse’s role in the clinical pathway process. Itemshave also been recommended to be included that assess the nurse’s role inmanaging patients designated as “ALC”.

To assess coordination of care, items were identified to be included in thePatient Satisfaction survey examining the type of communication transferredand the support patients and their families receive prior to and followingdischarge from the hospital.

One new indicator was recommended to be introduced within the existinghealth human resource indicator to reflect the challenges of maintainingquality patient care while meeting the evolving demands of the changinghealthcare system, and specifically nursing shortages. The nurse integrationand management indicator is based on the work of Shortell and colleagues58

and integration delivery system theory. This indicator examines nurses’identification with the organization and how they actively participate in theplanning, management and governance. The specific items recommendedexamine the areas of:

• Retention;• Work Intensity and Environment;• Leadership and Support;• Professional Autonomy;• Communication;• Nursing Knowledge;• Recruitment Strategies;• Orientation;• Nurse Satisfaction; and• Nurse Integration within the Organization.

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Appendix D: Feasibility of DataCollection Indicator Feasibility for Data Data Source

Collection in 2002

System Integration and Change Indicators

Clinical Information Technology Yes System Integration and Change Survey

Collection of Clinical Data Yes System Integration and Change Survey

Benchmarking of Outcomes Yes System Integration and Change Survey

Intensity of Information Use Yes System Integration and Change Survey

Nursing Databases Yes System Integration and Change Survey

Development and Use of Clinical Pathways Yes System Integration and Change Survey

Coordination of Care Yes Patient Satisfaction Survey

Continuity of Care Yes Patient Satisfaction Survey

Inter-Organizational Relationships Yes System Integration and Change Survey

Strategies for Managing Alternate Levels of Care (ALC) Patients Yes System Integration and Change Survey

Nurse Integration and Management Yes System Integration and Change Survey

Clinical Utilization and Outcomes Indicators

Functional Status No Not available

Self-Care Status No Not available

Symptom Control No Not available

Patient Falls Yes Hospital Records/CIHI DAD

Urinary Tract Infections Yes Hospital Records/CIHI DAD

Pneumonia Yes Hospital Records/CIHI DAD

Pressure Ulcers Yes Hospital Records/CIHI DAD

Upper Gastrointestinal Bleeding No Not available

Failure to Rescue No Not available

Patient Satisfaction Indicators

Information You Were Given Yes PJHQ Survey

Instructions Yes PJHQ Survey

Ease of Getting Information Yes PJHQ Survey

Information Given by Nurses Yes PJHQ Survey

Informing Family or Friends Yes PJHQ Survey

Involving Family or Friends in Your Care Yes PJHQ Survey

Concern and Caring by Nurses Yes PJHQ Survey

Attention of Nurses to Your Condition Yes PJHQ Survey

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Recognition of Your Opinions Yes PJHQ Survey

Consideration of Your Needs Yes PJHQ Survey

The Daily Routine of Nurses Yes PJHQ Survey

Helpfulness Yes PJHQ Survey

Nursing Staff Response to Your Calls Yes PJHQ Survey

Skill and Competence of Nurses Yes PJHQ Survey

Coordination of Care Yes PJHQ Survey

Restful Atmosphere Provided by Nurses Yes PJHQ Survey

Privacy Yes PJHQ Survey

Discharge Instructions Yes PJHQ Survey

Coordination of Care After Discharge Yes PJHQ Survey

Overall Quality of Care and Services You Received Yes PJHQ Survey

Overall Quality of Nursing Care Yes PJHQ Survey

Financial Performance and Condition Indicators

Inpatient Nursing Earned Hours per Inpatient Weighted Case Yes OHRS/Nursing MIS Database

UPP (RN, RPN, and Non-professional Staff) Earned Hours per Inpatient Weighted Case Yes OHRS/Nursing MIS Database

RN Staff Earned Hours per Inpatient Weighted Case Yes OHRS/Nursing MIS Database

Percent of total inpatient nursing earned hours utilized for direct nursing care Yes OHRS/Nursing MIS Database

Percent professional nursing staff hours utilized for RNs Yes OHRS/Nursing MIS Database

Percent of direct nursing care earned hours utilized for non-professional staff Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for full time RNs Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for full time RPNs Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for full time non-professional staff Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for part time RNs Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for part time RPNs Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for part time non-professional staff Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for casual RNs Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for casual time RPNs Yes OHRS/Nursing MIS Database

Percent of nursing care earned hours utilized for casual non-professional staff Yes OHRS/Nursing MIS Database

Percent nursing staff hours utilized for orientation No Not available

Percent nursing staff hours utilized for absenteeism No Not available

Percent nursing staff hours utilized for ongoing education No Not available

Percent nursing staff hours utilized for overtime No Not available

Percent nursing staff hours utilized for agency staff Yes OHRS/Nursing MIS Database

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Appendix E: Authors – NursingReport, Hospital Report ResearchCollaborativeLinda McGillis Hall

Linda McGillis Hall, RN, MSc, PhD, is an Assistant Professor with the Facultyof Nursing, University of Toronto and is a co-investigator with the NursingEffectiveness, Utilization, and Outcomes Research Unit operating out of theUniversity of Toronto and McMaster University. Her research interests relate todetermining the effectiveness of nursing practices within the healthcaresystem. She has developed a research program aimed at studyingmechanisms for examining different staffing mixes in the nursing workforce inCanada and the skills and knowledge needed for nurses to work effectively ina productive and cost-efficient manner within the healthcare system.

Joan AlmostJoan Almost, RN, ACNP, MScN, is a Lecturer and 4th Year Coordinator in the

University of Western Ontario, School of Nursing, Faculty of Health Sciences inLondon, Ontario. She teaches courses in the undergraduate program relatedto medical/surgical nursing. During the past three years, she has worked as aResearch Assistant with Dr. Laschinger at The University of Western Ontario.

Diane DoranDiane Doran, PhD, RN, is an Associate Professor in the Faculty of Nursing

and Director of the Combined MN/MBA Program. She is a co-investigator withthe Nursing Effectiveness, Utilization, and Outcomes Research Unit, Faculty ofNursing, University of Toronto. Diane is also a recipient of the PremiersResearch Excellence Award. She is a co-theme leader (human resources) withthe Home Care Evaluation Research Centre, University of Toronto. The foci ofher research are healthcare teams; the evaluation of methods for improvingquality in nursing practice; and the design and measurement of nursingsensitive patient outcomes. One group of studies has focused on theevaluation of an intervention designed to teach members of multidisciplinaryteams methods for making improvements in clinical practice. A second groupof studies is focusing on evaluating alternative healthcare provider roles.Within this group, current studies focus on evaluating the acute care nursepractitioner role and the primary care nurse practitioner role. A third group ofstudies is focusing on an evaluation of outcome indicators for assessing thequality of nursing care.

Claire MalletteClaire Mallette, RN, MSc, PhD Candidate, has expertise in health human

resources, quality of nursing worklife and environmental complexity. She ispresently starting her third year of doctoral studies at the Faculty of Nursing,

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University of Toronto and is a Canadian Health Services ResearchFoundation/Social Science and Humanities Research Council Doctoral Fellow.She was also awarded a National Health and Research Development ProgramDoctoral fellowship. Her Master’s thesis examined work conditions in arestructured environment, workload measurement instruments and the impactof change on nurses. Her PhD examines changing employment patterns andthe psychological contract and the impact of the two on the individual,organization and the profession. As Senior Research Associate for the NursingEffectiveness, Utilization and Outcomes Research Unit (McMaster Site), shedeveloped extensive literature reviews and participated in large researchprojects. She is an invited speaker on change management and employmentrelationships and has done project work for the College of Nurses of Ontarioand the Registered Nurses Association of Ontario. She also has a diverseclinical background and has taught nursing at the university and college level.

Linda-Lee O’Brien-PallasLinda-Lee O’Brien-Pallas, RN, PhD is a Professor at the Faculty of Nursing,

University of Toronto. She is cross-appointed to the Department of HealthPolicy, Management and Evaluation, Faculty of Medicine and is a member ofthe Hospital Management Research Unit. She is the Canadian Health ServicesResearch Foundation/Canadian Institutes of Health Research National Chair inNursing Human Resources. She is the Co-Principal Investigator (University ofToronto site) of the Nursing Effectiveness, Utilization and Outcomes ResearchUnit that is funded by the Ontario Ministry of Health and Long-Term Care. Herresearch interests include nursing health human resources, workloadmeasurement and patient classification systems, factors influencing variabilityin nursing resource use and patient outcomes, and the quality of nursingworklife. Her research has crossed all sectors of the healthcare system and shehas published widely in her areas of research. She has served on local,provincial, national, and international committees to examine approaches tohealth human resources prediction and modeling, to develop standards forpractice, next generation workload measurement approaches, and thedevelopment of clinical and educational databases for planning and evaluatingnursing resources. She is a member of the Boards of Directors of theRegistered Nurses Association of Ontario and the Canadian NursesAssociation. She recently served on Ontario’s Expert Panel on PhysicianHuman Resource Planning Committee, co-chaired its modeling sub-committee,and completed a ten year career scientist award through the Ontario Ministryof Health.

Cheryl PedersenCheryl Pedersen, MSc, is presently employed as a Research Officer in the

Faculty of Nursing, University of Toronto. She entered the field of healthsciences at the University of Western Ontario in London, Ontario where sheearned an undergraduate degree from the School of Kinesiology, Faculty ofHealth Sciences with an area of concentration in Psychology. From there shewent on to earn her Masters degree in the field of Sports Medicine at theUniversity of Western Ontario where she developed an interest in research. Asa Masters student she developed a survey tool that has been implemented inseveral study protocols. Cheryl has been a tutorial assistant and guest lecturerin undergraduate health sciences courses. She is also a recipient of theHonours Award for Teaching Excellence from the University of WesternOntario.

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Heather K. Spence LaschingerHeather K. Spence Laschinger, RN, PhD, is Professor and Associate Director

Nursing Research in the University of Western Ontario, School of Nursing,Faculty of Health Sciences in London, Ontario. She teaches courses in thegraduate program related to research methodology and organizational theory.Heather has published and presented papers in the areas of workplaceempowerment, nursing and medical education, and health education theory.Her research interests include workplace empowerment in nursing worksettings and the impact of work conditions on nurses’ work behaviours,attitudes, and mental and physical health. Since 1992, she has been PrincipalInvestigator of a program of research designed to investigate nursing workenvironments using Kanter’s organizational empowerment theory. Heather hasbeen involved in the International Study of Hospital Outcomes led by Dr. Judith Shamian and Dr. Linda Aiken, a 4-country study designed to linknursing work conditions to patient and nursing outcomes. She is Co-principalInvestigator with Dr. Michael Kerr of the Institute of Work and Health on aCHSRF study to investigate the feasibility of establishing an ongoing system tomonitor the health of nurses. For the past two years, she has served on theMinistry of Health Expert Panel on Nursing and Hospital Outcomes. Her workon patient satisfaction as a nurse sensitive outcome led to her involvementwith the Ontario Nursing Report Project led by Dr. Linda McGillis Hall. She isalso a member of the Advisory Group for the Ontario Hospital AssociationNursing Strategy Project.

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