Patient safety and quality

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When General Ghebreyesus of the World Health Organization suggested making 2020 the Year of the Nurse and the Midwife, he described nurses as the “bridge to healthcare,” linking families, communities, and complex healthcare systems. In the mid-1800s, Florence Nightingale constructed such a bridge as she cared for British soldiers during the Crimean War. She inquired about environments that contributed to patient betterment, collected data to encourage innovation, spurred education, and kept the patient in the center all that nurses do for patients. Today, the role of nurses in improving patient quality and safety is ongoing.

For this Assignment, find a current article published within the last five years on 
how a nurse-led improvement or research project has enhanced patient safety and quality in a health care setting.

Nurse-led projects may be related to infections and complications; patient-centered care and engagement; teamwork, communication, and care transitions; health information technology; health care value; safety and quality measures; systems engineering; and healthcare worker performance; and etcetera. Health care setting examples include acute care hospitals; rehabilitation centers; schools; correctional institutions; nursing homes; specialized outpatient services.

Assignment: 2–3-page paper

· Begin by describing the nurse-led improvement or research project found in the article. Include a short description of the purpose, method, and outcomes.

· Evaluate how this project has the potential to improve quality and safety for patients.

· What are at least two insights you gained from this project that enhance your personal professional goals?

· Reference your selected articles in APA format.






This criterion is linked to a Learning OutcomeRequired Content Begin by describing the nurse-led improvement or research project found in the article. Include a short description of the purpose, method, and outcomes.

39 to >34.0 pts


Student provided a fully developed description of the nurse-led improvement or research project found in the article including the purpose, method, and outcomes.

34 to >30.0 pts


Student provided a developed description of the nurse-led improvement or research project found in the article including the purpose, method, and outcomes.

30 to >26.0 pts


Student provided a minimally developed description of the nurse-led improvement or research project found in the article including the purpose, method, and outcomes.

26 to >0 pts

Needs Improvement

Student provided an under-developed description of the nurse-led improvement or research project found in the article including the purpose, method, and outcomes.

39 pts

This criterion is linked to a Learning OutcomeEvaluate how this project has the potential to improve quality and safety for patients.

40 to >35.0 pts


Student provided a fully developed evaluation of how this project has the potential to improve quality and safety for patients.

35 to >31.0 pts


Student provided a developed evaluation of how this project has the potential to improve quality and safety for patients.

31 to >27.0 pts


Student provided a minimally developed evaluation of how this project has the potential to improve quality and safety for patients.

27 to >0 pts

Needs Improvement

Student provided an under-developed evaluation of how this project has the potential to improve quality and safety for patients.

40 pts

This criterion is linked to a Learning OutcomeWhat are at least two insights you gained from this project that enhance your personal professional goals?

40 to >35.0 pts


Student provided a fully developed description of at least two insights you gained from this project that enhanced your personal professional goals.

35 to >31.0 pts


Student provided a developed description of at least two insights you gained from this project that enhanced your personal professional goals.

31 to >27.0 pts


Student provided a minimally developed description of at least two insights you gained from this project that enhanced your personal professional goals.

27 to >0 pts

Needs Improvement

Student provided an under-developed description of at least two insights you gained from this project that enhanced your personal professional goals.

40 pts

This criterion is linked to a Learning OutcomeProfessional Writing: Clarity, Flow, and Organization

17 to >15.0 pts


Content is free from spelling, punctuation, and grammar/syntax errors. Writing demonstrates very well-formed sentence and paragraph structure. Content presented is completely clear, logical, and well-organized.

15 to >13.0 pts


Content contains minor spelling, punctuation, and/or grammar/syntax errors. Writing demonstrates appropriate sentence and paragraph structure. Content presented is mostly clear, logical, and well-organized.

13 to >11.0 pts


Content contains moderate spelling, punctuation, and/or grammar/syntax errors. Writing demonstrates adequate sentence and paragraph structure and may require some editing. Content presented is adequately clear, logical, and/or organized, but could benefit from additional editing/revision.

11 to >0 pts

Needs Improvement

Content contains significant spelling, punctuation, and/or grammar/syntax errors. Writing does not demonstrate adequate sentence and paragraph structure and requires additional editing/proofreading. Key sections of presented content lack clarity, logical flow, and/or organization.

17 pts

This criterion is linked to a Learning OutcomeProfessional Writing: Context, Audience, Purpose, and Tone

17 to >15.0 pts


Content clearly demonstrates awareness of context, audience, and purpose. Tone is highly professional, scholarly, and free from bias, and style is appropriate for the professional setting/workplace context.

15 to >13.0 pts


Content demonstrates satisfactory awareness of context, audience, and purpose. Tone is adequately professional, scholarly, and/or free from bias, and style is consistent with the professional setting/workplace context.

13 to >11.0 pts


Content demonstrates basic awareness of context, audience, and purpose. Tone is somewhat professional, scholarly, and/or free from bias, and style is mostly consistent with the professional setting/workplace context.

11 to >0 pts

Needs Improvement

Content minimally or does not demonstrate awareness of context, audience, and/or purpose. Writing is not reflective of professional/scholarly tone and/or is not free of bias. Style is inconsistent with the professional setting/workplace context and reflects the need for additional editing.

17 pts

This criterion is linked to a Learning OutcomeProfessional Writing: Originality, Source Credibility, and Attribution of Ideas

17 to >15.0 pts


Content reflects original thought and writing and proper paraphrasing. Writing demonstrates full adherence to reference requirements, including the use of credible evidence to support a claim, with appropriate source attribution (when applicable) and references.

15 to >13.0 pts


Content adequately reflects original writing and paraphrasing. Writing demonstrates adequate adherence to reference requirements, including the use of credible evidence to support a claim, with appropriate source attribution (when applicable) and references. There are one or two minor errors.

13 to >11.0 pts


Content somewhat reflects original writing and paraphrasing. Writing somewhat demonstrates adherence to reference requirements, including the use of credible evidence to support a claim, with appropriate source attribution (when applicable) and references. There are two or three minor errors.

11 to >0 pts

Needs Improvement

Content does not adequately reflect original writing and/or paraphrasing. Writing demonstrates inconsistent adherence to reference requirements, including the use of credible evidence to support a claim, with appropriate source attribution (when applicable) and reference. There are numerous and/or significant errors.

17 pts

Total Points: 170



Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022152

Original Article

were significantly lower in the experimental
group than the control group with P = 0.001.

Conclusion: The current study concluded
that adjuvant to routine treatment FFNI will
improve the functional ability of the client
along with routine psychiatric treatment for
Key Message: Nurses play a vital role
in connecting patients families and
therapeutic team in planning treatment.
Indian setting nursing led clinics and
intervention are novel one. FFNI is one of its
kind of intervention for the improvement of
functional level of bipolar clients.

Keywords: Bipolar, Functional improvement,
Family-focused, BPAD, Family-focused
nursing intervention

Bipolar affective disorder (BPAD) is
a common serious mental disor-
der affecting approximately 1% to

2% of the total adult population in the
world.1 It begins in early adulthood in
all societies at about the same rate,

HOW TO CITe THIS aRTICle: Kavitha RR, Kamalam S and Rajkumar RP. Effectiveness of Family-Focused Nurse-led Intervention on
Functional Improvement of Patients with Bipolar Disorder at a Tertiary Hospital in South India: A Randomized Controlled Trial.
Indian J Psychol Med. 2022;44(2):152–159.


DOI: 10.1177/02537176211060557

Submitted: 5 Jan. 2020
Accepted: 28 Oct. 2021
Published Online: 3 Feb. 2022

Address for correspondence: Rajendran Rangasamy Kavitha, Dept. of Psychiatric
Nursing, College of Nursing, Jawaharlal Institute of Post Graduate Medical Education
and Research (JIPMER) , Puducherry 605006, India. E-mail: [email protected]

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative
Commons Attribution- NonCommercial 4.0 License (
which permits non-Commercial use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the SAGE and Open Access pages (https://

Copyright © The Author(s) 2022

1Dept. of Psychiatric Nursing, College of Nursing, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Puducherry, India.2Dept.
of Community Health Nursing, A G Padmavathi College of Nursing, Puducherry, India.3Dept. of Psychiatry, Jawaharlal Institute of Post Graduate Medical
Education and Research (JIPMER), Puducherry, India.

levels, were assessed using Longitudinal
Interval Follow-up Evaluation-Range of
Impaired Functioning Tool and Functional
Assessment Short Test. The control group
(74) received routine treatment; the
experimental group (75) received routine
treatment along with FFNI in seven
sessions, and posttest was conducted at
discharge, one-month, and at two-month
follow-up at OPD. The collected data were
analyzed using SPSS 20 (IBM Corp. Released
2011. IBM SPSS Statistics for Windows
Version 20.0, Armonk, NY: IBM Corp.),
independent sample t-test, analysis of
variance, and Pearson correlation used. A
P-value of less than 0.05 was considered as
a statistically significant result.

Results: At the end of the study, 149 clients
completed the treatment and follow-
up. Both the groups were comparable
at baseline in demography as well as
clinical variables. There was significant
improvement in the functional level after
FFNI. The total score of LIFE-RIFT and the
Functional Assessment Short Test score

effectiveness of Family-Focused Nurse-led
Intervention on Functional Improvement of
Patients with bipolar Disorder at a Tertiary
Hospital in South India: a Randomized
Controlled Trial

Background: Bipolar affective disorder
(BPAD) is a chronic, episodic illness that
can create problems and disruptions in the
social, occupational, and family functioning
of a client. Families are frequently most
affected by their bipolar member and
have a sense of helplessness to fix bipolar
symptoms. The current study aimed to
assess the effectiveness of Family-focused
Nursing Interventions (FFNI) on functional
improvement in the sample of symptomatic
bipolar affective disorder clients.

Method: In this experimental study, 149
patients with BPAD were interviewed
along with family members through the
consecutive sampling technique from the
inpatient ward. Varying block randomization
was used to allocate the patients to the
control and experimental groups. After
obtaining ethical clearance, the study was
registered under the Clinical trail registry
India (CTRI). Baseline sociodemographic
and clinical variables, and the functional

Rajendran Rangasamy Kavitha1 , Sethuramachandran Kamalam2 and Ravi Philip Rajkumar3

Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022 153

Original Article

ing psychosocial interventions for BPAD
patients’ functional improvement is very
scanty in India. Keeping the vital role
of the nurse in the inpatient care, the
importance of the family in the long-term
follow-up, and the dearth of studies on
nurse-led psychosocial intervention at
tertiary care hospitals, we felt the need for
researching this area.

Objectives and Hypothesis
This study aimed to assess the effec-
tiveness of FFNI on the functional
improvement of bipolar clients at a
tertiary care hospital. Research hypoth-
esis was that there will be a significant
difference in the improvement of the
functional level of patients with BPAD
between the experimental group and the
control group.

Material and Method
This randomized controlled trial (RCT)
study was conducted in psychiatric wards
at a tertiary care center in South India.
Data collection was done from Novem-
ber 2015 to July 2018. The research study
proposal was approved by the Institute
Scientific Advisory Committee. Ethical
clearance was accorded by the Institute
Ethics Committee (JIP/IEC/2015/19/699).
The study was registered under CTRI-
(CTRI/2017/09/009860 retrospectively).

Patients admitted to the adult psychi-
atric wards were assessed for eligibility
on their first day of admission and then
enrolled for the study. Adequate infor-
mation about the study was provided
in oral and written format in a vernacu-
lar language. Participants signed (after
acute phase management) the written
informed consent. One of the family
members also signed the legally autho-
rized representative (LAR) consent, since
the study involved vulnerable psychiatric
clients, after being explained about the
risk and benefits of the study. Confiden-
tiality and anonymity were maintained
during and after the study

Sample Size
The sample size was estimated using
the statistical formula for comparing
two means with equal standard devi-
ations at a 5% level of significance and
80% power (N = 2 × (1.96 + 0.845)/1.6)2 ×
3.22 = 63). A previous RCT 10 reported the
mean difference Longitudinal Interval

Follow-up Evaluation-Range of Impaired
Functioning Tool (LIFE-RIFT) as 1.6
between the groups after the inten-
sive psychosocial intervention. We
considered this difference as the
minimum expected difference for esti-
mating the sample size for the present
study. The expected difference in the
mean level of functioning LIFE-RIFT
between the groups was 1.6, with an stan-
dard deviation (SD) of 3.2. The estimated
sample size was 63. The sample size was
further modified, expecting a dropout
of 20% during follow-up. Thus, the final
sample size chosen was 75 in each group.

Inclusion Criteria
1. The patient has at least one primary

caregiver (a blood relative or a person
whom the patient stays with for more
than a year) who is willing to partici-
pate and is interested in taking care of
the patient.

2. The patient was diagnosed with BPAD
as per International Classification of
Diseases (ICD) 10 criteria and admit-
ted to the adult psychiatric ward for

Patients enrolled for any other psycho-
logical therapy, such as family therapy
and supportive therapy, were excluded.
Primary caregivers with mental illness or
cognitive impairment were excluded too.

Randomization Details
The patients were randomly assigned to
the control group and experimental group
using varying block randomization tech-
niques. Using randomization software, 25
blocks were prepared. The randomization
scheme consisted of a sequence of blocks
such that each block contained a prespec-
ified number of treatment assignments in
random order (block consisted of 4, 6, and
8). Computer-prepared sequences were
made by a statistician, and they were sealed
in an opaque envelope. When the research-
ers received any patient in the ward, the
covers were opened and the patient was
allotted to each arm according to the group
written on the cover. Eighty-one patients
were randomized to the experimental
group, and 80 to the control group.

Data Collection Tools and
Patients and primary caregivers
were interviewed to collect various

regardless of color, class, religion, or cul-

BPAD causes substantial psychosocial
morbidity that frequently affects the
patient’s marriage, children, occupa-
tion, and other aspects of life.3 It exacts a
heavy toll on the economy and time, and
the quality of life as well as functioning,
and it increases morbidity, comorbid-
ity, and mortality.2,4 Unlike the earlier
studies, recent studies point out a signifi-
cant degree of psychosocial dysfunction
even when the patients are euthymic.5,6

The treatment success rate with mood
stabilizers, antipsychotic medications,
and psychosocial therapy can be as high
as 60%1 with appropriate drug treat-
ment. Forty percent of the patients who
recover will suffer relapses.7 Psychosocial
interventions such as cognitive behavior
therapy, family focused therapy (FFT),
and interpersonal and social rhythm
therapy and group psychoeducation, in
conjunction with medication, have been
shown to improve outcomes in BPAD.7

FFT is an individualized intervention
that is developed to facilitate patient and
family coping through planed personal
visits, improving communication, and
involving patients and family for patient
care activities, support, and counseling.7

Nurses play a unique role in inpatient
care and patients’ family support by advo-
cating between the health team and the
patient’s family. Long-term episodic ill-
nesses like BPAD need home monitoring
and care by family members. Miklowitz
et al.8–10 have pioneered family-focused
psychoeducational treatments for BPAD.

Family-focused nursing intervention
(FFNI) is a method that respects the
pivotal role of the family.11,12 In FFNI,
nurses’ foremost duty is to address family
emotions and prepare them for FFT,
which is a powerful tool for fostering
stability within the family unit by involv-
ing them in inpatient care and educating
them about the role of life events in the
patient’s illness and how communication
can improve the patient’s condition.13

An international study conducted in
patients with BPAD across different mood
states highlighted the importance and
need to develop psychosocial interven-
tions targeting functional improvement.14
Furthermore, a study conducted in
Germany, Austria, and Switzerland found
that only less than 2% of family members
received psychoeducation.15 Data regard-

Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022154

Kavitha et al.

demographic profiles. After collect-
ing the demographic profile, a pretest
assessment was done for patients using
LIFE-RIFT16 and Functional Assessment
Short Test (FAST).17

LIFE-RIFT had been validated pre-
viously on Indian samples14,18,19 of
individuals with unipolar and bipolar
disorder, with adequate internal con-
sistency and interrater agreement. The
internal consistency reliability of the
scale was supported with alpha coeffi-
cients ranging from 0.81 to 0.83. The
inter-rater reliability intraclass cor-
relation coefficient (ICC) was 0.94. The
predictive validity of the tool showed
that impairment was positively associ-
ated with subsequent recurrence and
negatively associated with subsequent
recovery. A lower score indicates a better
functional level. The cut-off for func-
tional impairment is eight.

The validity and reliability of FAST
were tested by the researchers using a
pilot study. The pilot study was con-
ducted among 45 BPAD patients. ICC
was performed to assess test-retest reli-
ability, and internal validity Cronbach’s
alpha of FAST was 0.909. The test-
retest reliability analysis showed a strong
correlation between the two measures
carried out one week apart (ICC = 0.98;
P = 0.001). The higher the score, the more
functional impairment the client has.
The impairment cut-off for FAST was 12.

The control group received routine
psychiatric treatment such as medicine
and standard ward routines. The exper-
imental group received FFNI in seven
sessions, along with routine psychiatric
treatment. FFNI was given to the patient
and one of the family members who was
the primary caregiver.

In initial sessions, only the family
members participated. Patients were
included after the acute phase manage-
ment and when they were able to sit
for the sessions, keeping in mind that
psychoeducation should be delivered
as soon as possible in the illness course,
supporting the idea of early interven-
tion. The researchers ensured that all
FFNI sessions were attended by patients
and family members in an individual
session or a family session (Table 1).
Separate session attendance was
maintained to avoid overlapping of
information and contamination of infor-
mation. Strict instruction was given

Table 1.

FFNI Sessions Prepared and administered by Researchers
S. no. Session Content Time Participants

1 Introduction to BPAD, its risk factors, and
causes, epidemiology

45 min Initially, family member;
once client stabilized,

client included2 Identification of signs and symptoms,
and course of BPAD

30 min

3 Treatment and management: Myths and
facts about BPAD and the treatment


30 min

4 Identification and management of
early warning symptoms and episodes.

Importance of regular follow-ups.
Information on prognosis.

Importance of sleep.

45 min Client and family

5 Assertive communication and techniques 45 min Client and family

6 Positive communication 45 min Client and family

7 Problem-solving 45 min Client and family

FFNI – Family-focused nursing intervention.

to patients and family members not
to discuss the treatment with other
patients, to avoid contamination.

Posttest was done at three intervals
for both the groups, using LIFE-RIFT
and FAST. The first posttest was done
at discharge from the inpatient ward,
the second was done at a one-month
follow-up at psychiatric Out Patient
Department (OPD), and the third was
done on the second-month follow-up at
psychiatric OPD. During follow-up, from
the experimental group, one left because
of relocation, while in the control group,
three were lost because of relocation.

Development of
FFNI was prepared by the researchers
based on their review of the previous
literature, the client’s needs, family con-
cerns, and standardized therapies for
BPAD. FFT, Fallon model of family
group education, Barcelona group psy-
choeducation program for BPAD by
Colom and Vieta, and Rea et al.’s family-
focused education are the standardized
interventions for BPAD. After reviewing
the aforementioned interventions, the
researchers prepared a culture-specific
FFNI for BPAD, based on the guidance,
suggestions, and opinions of mental
health experts. FFNI has been validated
by the experts and by pilot testing. The

final version had 100% consensuses
between the experts. Experts were from
the fields of nursing, psychology, social
work, and psychiatry.

The tool and intervention package
were translated into the local language
Tamil and then translated back to
English. Tamil validation was taken from
Tamil literature teachers as well as from
experts to ensure the standardization of
the Tamil content before the ethical clear-
ance. After the pilot testing, the protocol
didn’t need any modification.

At the end of the study, group educa-
tional sessions were organized for the
control group participants, and a booklet
regarding BPAD was distributed as a
part of study. Once the desired sample
size was achieved, the trial was stopped
for analysis.

Method of Data Analysis
and Presentation
The distribution of categorical vari-
ables such as sex, clinical characteristics,
treatment factors, etc. is expressed as
frequency and percentage. The distribu-
tion of data on responses in the different
items in the LIFE-RIFT scale and FAST
scale are expressed as frequency and per-
centage. The Shapiro–Wilk test was used
to check the normality. The changes in
LIFE-RIFT score and FAST score in each
group over time were carried out using

Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022 155

Original Article

FIguRe 1.

Consort Flowchart

one-way repeated measures of analysis
of variance (ANOVA), and the changes
over time between the groups were
carried out using two-way repeated-
measures ANOVA.

All statistical analyses were done using
IBM SPSS 21 and were carried out at a
5% level of significance, and the P-value
< 0.05 was considered significant.

Out of 161 randomized patients, 149
were included for analysis after exclud-
ing dropouts. In the experimental and
control groups, mean ages were 29.6 ±
8.4 and 31 ± 8.7, respectively, with the
range of 17 to 58 and 18 to 58.

The clients’ illness days in the past
year ranged from 0 to 90 in both groups.

In terms of the total number of manic
episodes in the past, the control group
had zero to six episodes, while the experi-
mental group had zero to eight episodes.
Experimental group caregivers’ mean age
in years was 47.5 ± 11, with a range of 18
to 69. The corresponding values for the
control group were 50 ± 12 and 16 to 75.

Clinical Characteristics
A chi-square test was used to compare
the baseline demographic details. Sixty
in the experimental group (80%) and
forty-five in the control group (60.8%)
were not having any history of alcohol
or smoking habits. This difference was
statistically significant (P = 0.021). Thus,
both the group participants’ habits were
not comparable.

The majority in the experimental and
control groups had 1 to 2 admissions:
26 (34.7%) and 28 (37.8%), respectively.
In the experimental group, 12 (16%) and
7 (9.5%) in the control group were never
admitted before to the hospital.

The total duration of illness in the
experimental and control groups was
2 years to 5 years. In the experimental
group, 14 (18.7%) had less than a year of
illness, and in the control group, 7 (9.5%)
had less than a year of illness.

In both groups, mania was the major
subtype. In the experimental group,
50 (66.7 %) had mania, while in the
control group, 52 (70.3%) had mania.

Except for the habit of drugs, none of
the other variables such as number of
previous admissions, current episode,
number of previous episodes, duration
of illness, or family history significantly
varied between the groups.

Demographic Details of
The majority of the caregivers were
married. Concerning the occupation
status, the majority in the experimental
and control groups were semi-skilled:
42 (56%) and 32 (43.2%), respectively. In
the experimental group, the majority
had primary (34 [45.3%]) or secondary
(21 [28%]) education. In the control group,
47 (63.5%) had primary education.

The majority in both groups had
parents as the primary caregiver.
Variables such as caregivers’ sex, educa-
tional status, occupation, and relationship
to the client were not statistically signifi-
cantly different between the groups.

Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022156

Kavitha et al.

Table 2.

group-wise Distribution of Demographic Profile of Patients
(N = 149)

Demographic Group Chi-square

Experimental (75) Control (74)

f (%) f (%) Value P-Value

Sex Male 33 (44) 44 (59.5) 3.57 0.06

Female 42 (56) 30 (40.5)

Marital status Single 35 (46.7) 40 (54.1) 1.68 0.64

Married 38 (50.7) 33 (44.6)


2 (2.6) 1 (1.4)

Religion Hindu 58 (77.3) 64 (86.5) 3.29 0.07

Muslim 10 (13.3) 8 (10.8)

Christian 6 (8) 2 (2.7)

Others 1 (1.3) 0

Education Primary 7 (9.3) 12 (16.2) 1.50 0.99

Secondary 24 (32) 21 (28.4)


26 (34.7) 17 (23.0)

UG 16 (21.3) 21 (28.4)

PG 2 (2.7) 3 (4.1)

Occupation Skilled 5 (6.7) 5 (6.8) 0.18 0.68

Semiskilled 24 (32) 17 (23)

Professional 8 (10.7) 11 (14.9)

Coolie 14 (18.7) 19 (25.70)

Unemployed 18 (24) 17 (23)

Student 6 (8) 5 (6.8)

Income < 5000 60 (80) 47 (63.5) 1.40 0.23

5001–10,000 10 (13.3) 24 (32.4)

10,001–15,000 3 (4) 2 (2.7)

> 15,000 2 (2.7) 1 (1.4)

Family type Nuclear 62 (82.7) 66 (89.2) 1.73 0.19

Joint family 12 (16) 8 (10.8)

Others 1 (1.3) 0 (0)

Siblings Nil 3 (4) 2 (2) 0.14 0.71

One 37 (49.3) 38 (51.4)

Two 25 (33.3) 28 (37.8)

Three 9 (12) 5 (6.8)

> three 1 (1.3) 1 (1.4)


Mania 50 (66.7) 52 (70.3) 0.002 0.96

Depression 11 (14.7) 6 (8.1)

Mixed 14 (18.7) 16 (21.6)

Note: *Significant, chi-square test.

LIFE-RIFT and FAST scales showed
that the baseline functional scores were
comparable for the groups with P = 0.32
and 0.08, respectively. Both the groups
had a noticeable functional deficit. This
shows that patients with BPAD had poor
overall functional levels and even poor
domain-wise functional levels.

Functional Level After
The significant effect of FFNI on the
functional improvement was seen as a
decrease in the mean score from admis-
sion to the end of the study period. In
the experimental group, employment

scores (9.2–4.3), interpersonal scores
(10.9–5.0), recreation scores (4.1–1.7), and
satisfaction scores (4.17–1.71) showed a
reduction. Employment score (9.2–5.2),
interpersonal score (11.3–6.0), recreation
score (4.2–2.2), and satisfaction score
(4.2–2.2) of the control group also fol-
lowed the same pattern, but the decrease
in the mean score in the experimental
group was much lower.

Repeated measures ANOVA was used to
assess the functional improvement at the
domain level between the control group
and experimental group, which was signif-
icant with P < 0.05 (F value: 240.3).

Based on the FAST scale, functional
level domain wise in the experimental
group mean score of autonomy (10.3–1.2),
occupation (13.3–5), cognitive (12.6–2.4),
finance (4.6–0.52), Interpersonal rela-
tionship (IPR) (14.5–2), and leisure
(4.6–0.99) was lower from pretest to end
of the study. In the control group also,
a similar pattern existed for autonomy
(10.4–2.3), occupation (13.5–6.3), cognitive
(12.6–4.0), finance (4.8–1.1), IPR (14.8–3.6),
and leisure (4.9–1.49). Repeated mea-
sures ANOVA was used for variation. It
showed that the decrease in mean score
was significantly lower in the experimen-
tal group than in the control group, with
P < 0.001 (F value: 282.7). The domain-
wise score was significantly lower in the
experimental group than in the control
group, with P < 0.001 in both scales.

The total score of LIFE-RIFT and the
FAST score was significantly lower in
the experimental group than the control
group, from pretest to posttest.

Interaction Effect
In terms of LIFE-RIFT functional assess-
ment (Figure 2), both groups had a
significant reduction in the functional
score, indicating significant improve-
ment in the functional level, with
P < 0.001.

Even in terms of FAST, in the control
group, the initial score was 61.43 ± 8.73,
and the score at the end of the third
month was 19.04 ± 11.42 (Figure 3),
which was also a statistically significant
reduction (P < 0.001). But, compared to
the experimental group, the mean score
of the control group was slightly high,
which indicates that the experimental
group had a better outcome.

Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022 157

Original Article

The mean global functional score based
on LIFE-RIFT was 28.56, 23.99, 18.24, and
12.77 at pretest, posttest one, posttest
two, and posttest three, respectively
(Figure 2). One-way ANOVA repeated
test has been applied to compare the
earlier given four mean values. Similarly,
the mean global functional score based on
LIFE-RIFT was 29.2, 25.8, 19.55, 19.55, and
15.77 at pretest, posttest one, posttest two,
and posttest three , respectively, for the
control group. There were changes over

time between the groups using two-way
repeated-measures ANOVA. The signif-
icant P-value indicates the mean global
functional scores have been different for
the four assessments. The significant
P-value indicates that the changes that
occur between pretest, posttest one,
posttest two, and posttest three are
statistically different for the two groups.
(F value 96.12 with P = 0.007).

Even with the FAST Scale assess-
ment, the changes over time between

FIguRe 2.

Comparison of Functional Improvement from Pretest to Posttest
Three, based on the Mean Score on lIFe-RIFT (N = 149)

LIFE-RIFT – Longitudinal Interval Followup Evaluation-Range of Impaired Functioning Tool.

FIguRe 3.

Comparison of Functional Improvement from Pretest to Posttest
Three, based on the Mean Score on FaST (N = 149)

FAST – Functional Assessment Short Test.

the groups using two-way repeated
measures ANOVA (Figure 3). The mean
global functional score was found to be
58.91, 44.17, 26.60, and 12.28 at pretest,
posttest one, posttest two, and posttest
three, respectively, in the experimental
group, and the mean score in control
group was 61.43, 49.4, 31.55, and 19.04 at
pretest, posttest one, posttest two, and
posttest three, respectively.

The significant P-value indicates that
the changes that occur between pretest,
posttest one, posttest two, and posttest
three are statistically different for the
two groups (F value: 2.66, with P = 0.045).

The significant P-value of the compar-
isons between the two groups indicates
that the increase in the mean score was
statistically higher in the experimental
group than in the control group.

In the current study, the LIFE-RIFT scale
and FAST brought out similar results
at baseline and were comparable. After
the FFNI, the patient’s functional level
significantly improved. At the pretest
level, the LIFE-RIFT score was high, indi-
cating more impairment. At the end of
the third month, the score was reduced.
The FAST score was high at the start of
the study, and at the end of the study, it
was reduced. The control group received
routine treatment. Even in the control
group, reductions in the functional
score were observed in both scales. The
significant P-value of the comparisons
between the two groups indicates that
the decrease in the mean score was statis-
tically higher in the experimental group
than in the control group. Similarly,
between-group, within-group changes
from pretest to posttest at three intervals
significantly varied each time between
the group with P < 0.001. Using skill-
based psychoeducation and involving
the family in therapeutic intervention
and medication improve the overall
function and BPAD symptoms.20

A large, randomized trial by Miklowitz
et al.21,22 indicated that FFT effectively
improved the course of BPAD in
multiple domains when used as an early

Even domain-wise score reduction
was seen in the current study in both
the groups significantly. Western
studies reported that after the inten-
sive intervention, interpersonal and life

Indian Journal of Psychological Medicine | Volume 44 | Issue 2 | March 2022158

Kavitha et al.

satisfaction functions had significant
improvement.23,24 But the US study23
contradicted the current study findings
that the intensive interventions had no
role in work and role functions. Simi-
larly, another study too brought out the
same results.25 Patients had better total
functioning, relationship functioning,
and life satisfaction scores over nine
months. A systematic review on psycho-
social outcomes on the functioning of
BPAD patients concluded that combined
therapies with psychoeducation improve
symptoms and social-occupational

The current study showed improve-
ment in global functioning as well as
domain-wise functioning. Similarly, a
nursing study conducted in Turkey that
assessed the effect of psychoeducation
on the functioning level of patients with
BPAD got the same result (P < 0.05).27

The experimental group had a
better functional improvement. Self-
management, communication, and
problem-solving strategies have
significantly improved after the family-
focused psychosocial intervention.
Hence the research hypothesis has been
accepted. Our study also emphasizes
that the family-focused intervention
(FFI), along with routine psychiatric
treatment, significantly improved the
functional level of patients with BPAD.

Overall, nurse-led FFI to improve the
functional level of patients with BPAD
is an accepted intervention. In India,
studies about psychosocial interventions
for functional improvement in BPAD are
scanty. Current study findings showed
that medication intervention combined
with psychoeducation, communication,
and problem-solving is better than
routine psychiatric treatment for BPAD
patients’ functional improvement. None
of the patients or families had any adverse/
advent events during the trial.

The study has some limitations. Since
the study was conducted in a single
center, contamination could not be
avoided. Only three months follow-was
done. Because of two follow-up assess-
ments on an outpatient basis, attrition
was unavoidable. FFNI was given in
seven sessions during the inpatient stay,
but, because of time factor, the patients
had only three posttest evaluations
in month interval for functional

Nurses can successfully implement FFI
to patients and their families to reduce
functional impairment. For the patient,
to achieve a better role in society, it is
important to have a fully functional
level. Functional impairment has been
noted not only in the acute period but
also during remission. So, this nurse-led
intervention can improve the functional
level during the hospital stay that can
continue even at home.

Declaration of Conflicting Interests
The authors declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.

The authors received no financial support for the
research, authorship, and/or publication of this

Rajendran Rangasamy Kavitha https://orcid.

1. Tasman A, Kay J, Lieberman JA,

et al. Psychiatry. 4th ed. London: Wiley
Blackwell; 2015.

2. Sadock BJ and Sadock VA. Synapsis of
Psychiatry. 11th ed. Philadelphia: Wolters
Kluwer; 2015.

3. Merikangas KR, Jin R, He JP, et al.
Prevalence and correlates of bipolar
spectrum disorder in the world mental
health survey initiative. Arch Gen
Psychiatry 2011; 68: 241–251.

4. American Psychiatric Association
(APA). Diagnostic and statistical
manual of mental disorders (text
revision). 4th ed. Washington, DC: APA;

5. Mayo Clinic. Bipolar disorder. Mayo
Clinic, 2021. https://www.mayoclinic.

6. Hamilton PM. Mood disorders:
Depression. Wild Iris Medical Education,
courses/346/index_nceu.html (accessed
January 2012)

7. National Institute of Mental Health.
Bipolar disorder. https://www.nimh.nih.
shtm (accessed July 2017).

8. Miklowitz DJ, Wisniewski SR, Miyahara
S, et al. Perceived criticism from family
members as a predictor of the 1-year
course of bipolar disorder. Psychiatry Res
2005 September; 136(2–3): 101–111.

9. Miklowitz DJ, Simoneau TL, George
EL, et al. Family-focused treatment
of bipolar disorder: 1-year effects
of a psychoeducational program in
conjunction with pharmacotherapy. Biol
Psychiatry 2000; 48(6): 582–592.

10. Miklowitz DJ, George EL, Richards JA,
et al. A randomized study of family-
focused psychoeducation and
pharmacotherapy in the outpatient
management of bipolar disorder. Arch
Gen Psychiatry 2003; 60(9): 904–912.

11. Morris CD, Miklowitz DJ, and
Waxmonsky JA. Family-focused
treatment for bipolar disorder in adults
and youth. J Clin Psychol 2007; 63(5):

12. Mitchell M, Chaboyer W, Burmeister
E, et al. Positive effects of a nursing
intervention on family-centered care in
adult critical care. Am J Crit Care 2009;
18(6): 543–552.

13. Goodwin G. Evidence-based guidelines
for treating bipolar disorder: Revised
second edition–recommendations
from the British Association for
Psychopharmacology. J Psychopharmacol
2009; 23: 4: 346–388.

14. Rosa AR, Reinares M, Michalak EE,
et al. Functional impairment and
disability across mood states in bipolar
disorder. Value Health 2010 December;
13(8): 984–988.

15. Rummel-Kluge C, Pitschel-Walz G, Bäuml
J, et al. Psychoeducation in schizophrenia–
results of a survey of all psychiatric
institutions in Germany, Austria, and
Switzerland. Schizophr Bull 2006
October; 32(4): 765–775.

16. Leon AC, Solomon DA, Mueller TI,
et al. The range of impaired functioning
tool (LIFE-RIFT): A brief measure of
functional impairment. Psychol Med
1999; 29: 869–878.

17. Rosa AR, Sánchez-Moreno J, Martínez-
Aran A, et al. Validity and reliability of
the Functioning Assessment Short Test
(FAST) in bipolar disorder. Clin Pract
Epidemiol Ment Health 2007; 3: 5.

18. Mehta S, Mittal PK, and Swami MK.
Psychosocial functioning in depressive
patients: A comparative study between
major depressive disorder and bipolar
affective disorder. Depress Res Treat ;
2014: 302741.

19. Chopra MP, Kumar KVK, Jain S, et al.
Psychosocial outcomes for persons
with bipolar-I disorder: Eight-year
follow-up of a rural cohort from
south India. Asian J Psychiatry 2010; 3:

20. Miklowitz DJ, Efthimiou O, Furukawa
TA, et al. Adjunctive psychotherapy for
bipolar disorder. A systematic review and
component network meta-analysis. JAMA
Psychiatry 2021 Feburary 1; 78(2): 141–150.

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21. Miklowitz DJ, OttoMW, Frank E, Reilly-

Harrington NA, Kogan JN, Sachs GS,
et al. Intensive Psychosocial Intervention
Enhances Functioning in Patients with
Bipolar Depression: Results from a
9-Month Randomized Controlled Trial.
Am J Psychiatry 2007 September; 164(9):

22. Miklowitz DJ, Otto MW, Frank E,
et al. Psychosocial treatments for
bipolar depression: A 1-year randomized
trial from the Systematic Treatment
Enhancement Program. Arch Gen
Psychiatry 2007 April; 64(4): 419–426.

youth at risk for bipolar disorder:
A 1-year treatment development
trial. Bipolar Disord 2011;
13(1): 67–75.

26. Miziou S, Tsitsipa E, Moysidou
S, et al. Psychosocial treatment and
interventions for bipolar disorder: A
systematic review. Ann Gen Psychiatry
2015; 14: 19.

27. Kurdal E, Tanriverdi D, and Savas HA.
The effect of psychoeducation on the
functioning level of patients with bipolar
disorder. West J Nurs Res 2014; 36(3):

23. Rea MM, Tompson M, Miklowitz DJ,
Goldstein MJ, et al. Family-focused
treatment vs. individual treatment for
bipolar disorder: Results of a randomized
clinical trial. J Consult Clin Psychol 2003;
71: 482–492.

24. Miklowitz DJ, Schneck CD, George EL,
et al. Pharmacotherapy and family-
focused treatment for adolescents with
bipolar I and II disorders: A 2-year
randomized trial. Am J Psychiatry 2014
June; 171(6): 658–667.

25. Miklowitz DJ, Chang KD, Taylor DO,
et al. Early psychosocial intervention for

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JONA: The Journal of Nursing Administration

Issue: Volume 45(9), September 2015, p 435-442
Copyright: Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights
Publication Type: [Articles]
DOI: 10.1097/NNA.0000000000000229
ISSN: 0002-0443
Accession: 00005110-201509000-00007


Linking Unit Collaboration and Nursing Leadership to Nurse Outcomes and
Quality of Care

Ma, Chenjuan PhD; Shang, Jingjing PhD, RN; Bott, Marjorie J. PhD, RN

Author Information

Author Affiliations: Assistant Professor (Dr Ma), College of Nursing, New York
University; Associate Professor (DrBott), School of Nursing, University of
Kansas, Kansas City; and Assistant Professor (Dr Shang), School of Nursing,
Columbia University, New York.

The authors declare no conflicts of interest.

Correspondence: Dr Ma, College of Nursing, New York University, 433 First Ave,
Office 506, New York, NY 10010 ([email protected]).




Review of the Literature


Data and Sample



Nursing Leadership

Nurse Outcomes

Nurse-Reported Quality of Care


Statistical Analysis





OBJECTIVE: The objective of this study is to identify the effects of unit
collaboration and nursing leadership on nurse outcomes and quality of care.

BACKGROUND: Along with the current healthcare reform, collaboration of care
providers and nursing leadership has been underscored; however, empirical
evidence of the impact on outcomes and quality of care has been limited.

METHODS: Data from 29742 nurses in 1228 units of 200 acute care hospitals in 41
states were analyzed using multilevel linear regressions. Collaboration
(nurse-nurse collaboration and nurse-physician collaboration) and nursing
leadership were measured at the unit level. Outcomes included nurse job
satisfaction, intent to leave, and nurse-reported quality of care.

RESULTS: Nurses reported lower intent to leave, higher job satisfaction, and
better quality of care in units with better collaboration and stronger nursing

CONCLUSION: Creating a care environment of strong collaboration among care
providers and nursing leadership can help hospitals maintain a competitive
nursing workforce supporting high quality of care.


Improving the nurse work environments has been recommended as a system-level
intervention to improve quality of care and patient safety.1-3 It also is a key
factor for retaining a competent nursing workforce.4 The nurse work environment
is multifaceted and consists of a set of organizational characteristics that can
facilitate or constrain professional nursing practice.5 Among these attributes,
collaboration among healthcare professionals and nursing leadership are 2
essential elements.6,7 In the Institute of Medicine’s report of The Future of
Nursing: Leading Change, Advancing Health,3 interdisciplinary partnership
between nurses and other healthcare professionals and nursing leadership were
underscored as challenges as well as opportunities to advance nursing and
improve quality of healthcare.

Review of the Literature

A literature review revealed that a body of research has described the status
quo of collaboration (mainly nurse-physician [NP] collaboration) and nursing
leadership and emphasized their importance in patient care.8-10 However, only a
few studies have empirically linked NP collaboration and nursing leadership to
nurse outcomes and quality of care.11,12 In 1 study, the researcher found that
NP communication, an approach to enhancing collaboration, had a direct effect on
nurses’ job satisfaction and mediated the relationship between structural
factors (eg, practice environment) and nurse outcomes (eg, nurse job satisfaction).13
In another study, Boyle and colleagues reported that unit managers’ leadership
style was significantly associated with critical care nurses’ intent to leave.14
While acknowledging the contributions of these studies, it should be noted that
the majority of them were limited by small samples, and they rarely operationalized
collaboration and leadership as an organizational factor (eg, unit- or
hospital-level factors) in analysis. In addition, teamwork among nurses-the
largest healthcare workforce-was rarely examined.

We had a unique opportunity to fill this knowledge gap by using nationwide
registered nurse (RN) survey data from the National Database of Nursing Quality
Indicators (NDNQI). NDNQI was founded in 1998 by the American Nursing Association
with the mission of aiding nurses in efforts of improving care quality and
patient safety.15 NDNQI is the only national nursing quality measurement data
repository in the United States that enables researchers to compare quality of
hospital nursing and nursing-sensitive patient outcomes at the unit level. The
hospital nursing unit is the micro-organization where interactions actually
happen between healthcare providers and patients and between healthcare
providers of different disciplines. Units of different types vary in social
milieu and team relations.16 In the NDNQI data, units from different hospitals
were consistently and systematically classified into a unit type based on the
patient population, type of care provided, and acuity level. This enables
comparative analysis of units across hospitals.

The purpose of this study was 2-fold: to examine the collaboration (both NP
collaboration and nurse-nurse [NN] collaboration) and nursing leadership at the
unit level in US acute care hospitals and to identify the extent to which
unit-level collaboration and nursing leadership were associated with nurse
outcomes and nurse-reported quality of care. We hypothesized that units with
better collaboration (NP collaboration and/or NN collaboration) and stronger
supportive nursing leadership would have superior nurse outcomes and quality of


This study is a secondary analysis of cross-sectional data from the 2012 NDNQI
RN survey, the most recent data available when we initiated the project. The
study protocol was approved by the institutional review board at a Midwestern
academic medical center.

Data and Sample

Aiming to better understand the characteristics of the nursing workforce, in
2004, NDNQI initiated an annual Web-based RN survey to collect data on nurse
work conditions, work attitudes, work content, and demographic information from
staff nurses in NDNQI member hospitals. In this study, we used data from
hospitals with nurses who completed the RN survey with the Job Satisfaction
Scale in the long form. In 2012, 73 808 RNs in 3,746 units from 237 hospitals
completed this survey form.

To be eligible for the survey, nurses had to meet the following criteria at the
time of survey: (1) spend at least 50% of their time providing direct patient
care, (2) have a minimum of 3-month employment in the current unit, and (3) not
agency or contract nurses. To ensure the reliability of the aggregated unit
measures from individual nurse reports, we excluded units that had less than 5
RN respondents and a response rate of less than 50%. A 50% response rate is a
generally accepted criterion for supporting the accuracy of inferences made from
aggregated data.17 We included 5 adult unit types: critical care, step-down,
medical, surgical, and medical-surgical combined units. Based on these inclusion
criteria, our analytic sample for this study included 29 742 RNs in 1 228 units
from 200 acute care hospitals in 41 states.



Collaboration was measured by two 6-item scales: NN interaction scale and NP
interaction scale. These 2 scales were adapted from the Index of Work Satisfaction,18
a widely used scale for measuring nurses’ attitudes toward specific aspects of
their job. The scales have been tested in pilot studies for feasibility and
reliability.19 The NN scale measures nurses’ experience of interactions among
nurses on their units. Sample items include the following: “Nursing staff pitch
in and help each other when things get in a rush” and “There is a good deal of
teamwork among nursing staff.” The NP scale measures nurses’ perception of
interactions between nurses and physicians. Sample items include the following:
“In general, physicians cooperate with nursing staff” and “There is a lot of
teamwork between nurses and doctors on our units.”

Nursing Leadership

Nursing leadership was measured by the supportive nursing management scale (5
items), a scale adapted from the Practice Environment Scales of Nursing Work
Index (PES-NWI).5 The PES-NWI is a nursing-sensitive instrument endorsed by the
National Quality Forum.20 This nursing management scale asks nurses about their
perception regarding nurse manager’s ability, skills, and styles, for example,
“Their nurse manager (NM) is supportive of nurses” and “Their NM consults with
staff on daily problems.”

We operationalized collaboration and nursing leadership as unit-level organizational
factors by aggregating individual nurse responses to unit level. For all the
items in the 3 scales (NN scale, NP scale, and NM scale), response options were
provided on a 6-point Likert-type scale from “strongly disagree” to “strongly
agree.” First, each scale score was calculated for each RN respondent as the
mean of the items comprising the respective scale; the unit-level scale scores
then were calculated as the mean of scale scores across all the RNs on a unit.
Higher scores represent better collaboration and/or more supportive nursing
leadership. In the regression models, we categorized scale scores into quartiles
for interpretive purpose. Our preliminary analysis suggested that the aggregated
unit measures were reliable. Each scale’s internal consistency reliability among
RN respondents was high (NN scale, [alpha] = .87; NP scale, [alpha] = .91; NM
scale, [alpha] = .92). The unit-level reliability, measured by the intraclass
correlation coefficient (ICC [1,2]) from 1-way analysis of variance (ANOVA),
ranged from 0.79 (NP scale) to 0.88 (NM scale). Researchers have suggested that
aggregated measures with an ICC of 0.6 or higher are considered sufficiently

Nurse Outcomes

Two nurse outcomes were measured: intent to leave and job satisfaction. In the
RN survey, nurses were asked to indicate their job plans for the next year. We
considered RNs who reported plans of leaving the current position in the next
year as having the intent to leave. Those RNs who planned to leave their current
position because of retirement were not considered having intent to leave.

RN’s job satisfaction was measured in an untraditional way. RNs were asked to
indicate the extent to which they would recommend their hospital to a friend as
a place for employment using a 6-point Likert-type scale from “strongly agree”
to “strongly disagree.” RNs who reported that they “strongly agreed” or “agreed”
were considered as being satisfied with their jobs. This method has been used in
measuring patient satisfaction with healthcare service from hospitals and has
been endorsed as a metric for public report on quality of care.22

Nurse-Reported Quality of Care

Nurse-reported quality of care was measured in 2 ways: overall quality of care
and improved quality of care. In the RN survey, nurses were asked to assess the
overall quality of care on their units using a 4-point scale ranging from “poor”
to “excellent”; this variable was denoted as nurse-reported overall quality of
care. Nurses also were asked to indicate whether they perceived that the quality
of care in their units had improved, remained the same, or deteriorated over the
past year; this variable represented nurse-reported improvement in quality of


Given that our data set had a 3-level structure, various variables at the
hospital, unit, and individual levels were included as covariates. Hospital-level
covariates included ownership, bed size, teaching status, Magnet(R) status, and
geographic location. Hospital ownership was categorized as not-profit, profit,
or government owned. Hospital size was measured by the number of staffed beds
and grouped into 2 categories (small, =300 beds). Teaching status was classified
as teaching or nonteaching. Hospitals also were identified whether it was a
Magnet-recognized hospital. Using the national standards, hospitals were grouped
into 4 census regions: Northeast, Midwest, South, and West.

Unit-level covariates included unit type and unit staffing levels. In the
survey, nurses were asked to report the number of patients assigned to them on
their last shift. Unit staffing levels were calculated as the mean number of
patients per nurse on a unit. This measure has shown to have greater predictive
validity than administratively reported nurse staffing, which often includes
nurses without direct inpatient care assignments.23,24

To adjust for differences in nurse mix across units and hospitals, nurse
demographics also were controlled in the regression models. These demographics
included age, gender, race/ethnicity, education (having BSN or higher degrees or
not), unit tenure (years on the current unit), specialty certification (having
specialty nursing certification awarded by a national nursing association or
not), and employment status (full time vs not full time).

Statistical Analysis

Descriptive statistics were used to characterize nurses, units, and hospitals in
our sample. Differences in unit collaboration (NN interaction and NP interaction)
and nursing leadership across unit types were tested using 1-way ANOVA with
Tukey-Kramer (TK) post hoc tests. Three-level hierarchical logistic regression
models were conducted to estimate the odds of nurses: (1) expressing intent to
leave, (2) being satisfied with their current job, (3) reporting excellent
overall quality of care on their units, and (4) perceiving improved quality of
care on their units over the past year, when working in units with a work
environment of different levels of NN collaboration, NP collaboration, or
nursing leadership. All the models controlled for nurse and hospital characteristics
and unit type and staffing levels. To account for the clustering of nurses
within a unit and units within a hospital, we included a unit-level random
intercept and a hospital-level random intercept in all regression models. All
analyses were conducted using Stata version 12.0 (StataCorp LP, College Station,
Texas) with statistical significance set at P


Table 1 summarizes the characteristics of nurse respondents and nurse-reported
outcomes. Nurses had a mean age of 38 (SD, 11) years. On average, nurses had
worked as an RN for 10 (SD, 9.8) years and been on the current unit for about 6
(SD, 6.4) years. The majority of nurses were female (90%), white (68%), and full
time (84%). Roughly 64% had a bachelor’s degree or higher, and 62% had specialty
nursing certification(s) awarded by a national association. About 1 in 4 nurses
was in critical care units, which had the lowest percentage of female nurses
(86%) and had the highest percentage of white (75%), BSN-prepared (72%) nurses
and nurses with specialty certification (96%), compared with units of other
types (not shown in Table 1). Nurses in critical care units also were most
experienced with an average RN tenure of 12 (SD, 10.1) years and unit tenure of
7 (SD, 7.3) years, not shown in Table 1).

Of the 29 742 nurses, 56% of nurses expressed satisfaction with their jobs,
approximately 43% of nurses reported excellent quality of care to patient, and
39% perceived improvement in quality of care over the past year. There were 28%
of nurses reporting intent to leave their current position in the next year.
Compared with nurses in other unit types, nurses in critical care units were
most likely to report excellent quality of care (50%), but least likely to
report intent to leave (25%), job satisfaction (55%), and improved quality of
(33%) (not presented in Table 1).

Table 2 describes the characteristics of hospitals and units. Of the 200
hospitals, the majority were nonprofit (80%) and non-Magnet hospitals (70%) and
had less than 300 beds (70%). Roughly half of the hospitals were teaching
hospitals (49%). About 34% of the hospitals were located in the Northeast, 32%
in the Midwest, 34% in the South, and 9% in the West. Of the 1228 units,
approximately 1 in 4 (24%) were medical-surgical combined units, followed by
medical units (23%), critical care units (21%), surgical units (17%), and
step-down units (15%). Units had an average nurse staffing level of 5 patients
per nurse, with the critical care units having the lowest patient-to-nurse ratio
(2.52) and the medical-surgical combined units having the highest (6.02)
patient-to-nurse ratio.

Table 3 depicts unit-level descriptive statistics for collaboration (NN and NP)
and nursing leadership. The overall mean scores on NN scale (measuring
collaboration among nurses), NP scale (measuring collaboration between nurses
and physicians), and NM scale (measuring nursing leadership) were 4.53 (SD,
0.37), 4.12 (SD, 0.38), and 4.28 (SD, 0.65), respectively. Although there were
slight unit-type differences in scores of each scale, ANOVAs with TK post hoc
tests indicated that none of these observed unit-type differences were
statistically significant.

Our estimates (Table 4) from multilevel regressions showed that unit-level
collaboration and nursing leadership were significantly associated with nurse
job satisfaction, intent to leave, and nurse-reported quality of care to
patients (overall quality and quality improvement), and these associations were
independent of nurse staffing. Compared with those in units with the worst
collaboration among nurses (1st quartile of the NN scale score), nurses in units
with the best NN collaboration (4th quartile of the NN scale score) were about 2
times more likely (odds ratio [OR], 3.06; 95% confidence interval [CI],
2.70-3.47) to recommend their hospitals for employment (denoted as job
satisfaction), 3 times more likely (OR, 4.07; 95% CI, 3.57-4.63) to report
excellent overall quality of care, 1 time more likely (OR, 2.42; 95% CI,
2.10-2.79) to report improved quality of care, and approximately 57% less likely
(OR, 0.43; 95% CI, 0.38-0.49) to express intent to leave. Compared with those in
units with the worst collaboration between nurses and physicians (1st quartile
of the NP scale score), nurses in units with the best NP collaboration (4th
quartile of the NP scale score) were approximately 2 times more likely to
recommend their hospitals (OR, 2.64, 95% CI, 2.31-3.01) or report excellent
quality of care (OR, 2.95; 95% CI, 2.56-3.40), 1 time more likely (OR, 1.88; 95%
CI, 1.62-2.18) to report improved quality of care, and 49% less likely (OR,
0.51; 95% CI, 0.45-0.58) to express intent to leave. Compared with those in
units with the worst nursing leadership (1st quartile of the NM scale score),
nurses in units with the best nursing leadership (4th quartile of the NM scale
score) were about 2 times more likely to recommend their hospitals (OR, 2.61;
95% CI, 2.32-2.93) or report improved quality of care (OR, 2.60; 95% CI,
2.29-2.96), 1 time more likely (OR, 2.47; 95% CI, 2.16-2.82) to report excellent
quality of care, and 57% less likely (OR, 0.43; 95% CI, 0.39-0.49) to express
intent to leave.


Our study provides empirical evidence that better collaboration (both NP
collaboration and NN collaboration) and nursing leadership as unit-level
organizational factors were associated with lower intent to leave, higher nurse
job satisfaction, and better quality of care as reported by nurses. These
findings suggest that hospital administrators can improve nurse outcomes and
quality of care with 2 approaches: (1) improving collaboration among nurses and
between nurses and other healthcare professionals and (2) strengthening nursing

Under the ongoing healthcare reform (eg, adopting a value-based purchase model
and enhancing integrated and coordinated care delivery across the care
continuum), interprofessional collaboration (particularly the collaboration
between nurses and physicians) is drawing growing attention from various
healthcare stakeholders as a potential strategy to achieve the goals of
healthcare reform.25 Findings from our study provided evidence that better NP
collaboration led to not only positive nurse outcomes but also superior quality
of patient care, which is consistent with previous studies.26 In addition to
interprofessional collaboration, our study suggests that NN collaboration also
deserves close attention because the quality of teamwork among nurses can
influence nurse outcomes and quality of care too, where empirical evidence has
been rare. Improving collegial relations among healthcare providers requires
strong commitment from the hospital administrators, but may be achieved at
little cost.27 Previous research has demonstrated that hospitals could improve
team collaborations via well-designed training programs that helped nurses and
physicians understand their respective practice and expertise, responsibilities,
and values.28,29 A valid source for improving teamwork is the TeamSTEPPS
program, which was developed by the Agency for Healthcare Research and Quality
and the Department of Defense to improve communication and teamwork among
healthcare providers.30 Another suggested approach of improving collaboration
across disciplines is providing interprofessional education to students of
different healthcare disciplines. Lack of formal training in collaborative
practice and team-based care has been considered a big barrier for effective
collaboration among healthcare providers. A recent report from Robert Wood
Johnson Foundation indicated that there is a trend of growth in the number of
schools requiring interprofessional education; however, the number of schools
that are able to provide interprofessional education is limited, and no
comprehensive data are available to quantify interprofessional activities and
courses offered nationwide.31 Academic institutions and hospitals need to invest
more in providing courses and training on interprofessional collaboration, and
policymakers can help promote interprofessional education by establishing
government funding.

Our study suggests that improving supportive nursing leadership is another
strategy to improve nurse outcomes and quality of care. Supportive leadership
can enhance nurses’ abilities to perform up to their competency in meeting
organizational goals.9 In a work environment with strong support from NMs and
other leaders, nurses feel safe to speak out issues regarding patient safety
such as medication errors.12 Magnet hospitals are the best exemplars of
favorable nursing leadership. Emerging research demonstrates that hospitals
implementing American Nurses Credentialing Center’s blueprint for Magnet
recognition achieved significant improvements in their practice environments
including nursing leadership.32,33 To build the skills and competency of nurse
leaders, it requires commitment of hospitals and nursing association to
investment in leadership development programs.34 For instance, in addition to
financial sources, hospitals should offer NMs protected time to participate in
leadership training. It has documented that 1 of the biggest barriers for nurse
leaders to enroll in leadership development programs is the lack of time away
from the clinical settings.35 Another approach of strengthening nursing
leadership is to create opportunities for nurses to take leadership positions at
all levels, for example, unit, hospital, state, or national level, so nurses can
have voices in health policy making and be a full partner with other healthcare

Our study is not without limitations. First, our findings are based on
cross-sectional data, and therefore, we cannot establish causality. Second, we
used unit-level data of a large and national sample of hospitals from the NDNQI
database, and it still should be cautious when generalizing the results from
this study to nonmember hospitals of NDNQI. Hospitals voluntarily chose to
participate in NDNQI; therefore, certain hospital characteristics (eg, larger
and Magnet hospitals) may be overpresented in the NDNQI data.36,37 Third, we
used nurse reports to measure quality of care instead of objective quality
indicators such as mortality, hospital readmission, and falls. It is desirable
to include objective outcomes measures; however, researchers have suggested
that, in addition to objective data, perceptions of nurses who provide direct
patient care at the bedside and round-the-clock are an importance source of
information when judging the quality of patient care.38 McHugh and Stimpfel 39
compared nurse-reported quality of care to objective indicators of quality,
including mortality and failure to rescue, and concluded that quality of care
reported by nurses is a valuable indicator of hospital quality.

In conclusion, this is the 1st study using unit level data from hospitals
nationwide to examine the role of collaboration (both between nurse and
physician and among nurses) and nursing leadership in nurse outcomes and quality
of care. Our findings of the significant influence of collaboration between
healthcare providers and administrative support on nurse job satisfaction,
intent to leave, and quality of care provide hospital executives and nurse
administrators empirical evidence and specific directions in creating a healthy
work environment for retaining a competent nursing workforce and obtaining
superior quality of care.


1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for
the 21st Century. Washington, DC: National Academies Press; 2001.

2. IOM. Keeping Patients Safe: Transforming the Work Environment of Nurses.
Washington, DC: National Academies Press; 2004.

3. IOM. The Future of Nursing: Leading Change, Advancing Health. Washington, DC:
National Academies Press; 2010.

4. Disch J. Creating healthy work environments for nursing practice. In: Chaska
N, ed. The Nursing Profession: Tomorrow and Beyond. Thousand Oaks, CA: Sage;

5. Lake ET. Development of the practice environment scale of the nursing work
index. Res Nurs Health. 2002; 25( 3): 176-188.

6. Schmalenberg C, Kramer M. Essentials of a productive nurse work environment.
Nurs Res. 2008; 57( 1): 2-13.

7. ANCC. Magnet Recognition Program overview.
Accessed August 3, 2014.

8. Tang CJ, Chan SW, Zhou WT, Liaw SY. Collaboration between hospital
physicians and nurses: an integrated literature review. Int Nurs Rev. 2013; 60(
3): 291-302.

9. Brady Germain P, Cummings GG. The influence of nursing leadership on nurse
performance: a systematic literature review. J Nurs Manag. 2010; 18( 4):

10. Hurley J, Hutchinson M. Setting a course: a critical review of the
literature on nurse leadership in Australia. Contemp Nurse. 2013; 43( 2):

11. Cypress BS. Exploring the concept of nurse-physician communication within
the context of health care outcomes using the evolutionary method of concept
analysis. Dimens Crit Care Nurs. 2011; 30( 1): 28-38.

12. Wong CA, Giallonardo LM. Authentic leadership and nurse-assessed adverse
patient outcomes. J Nurs Manag. 2013; 21( 5): 740-752.

13. Manojlovich M. Linking the practice environment to nurses’ job satisfaction
through nurse-physician communication. J Nurs Scholarsh. 2005; 37( 4): 367-373.

14. Boyle DK, Bott MJ, Hansen HE, Woods CQ, Taunton RL. Managers’ leadership
and critical care nurses’ intent to stay. Am J Crit Care. 1999; 8( 6): 361-371.

15. Montalvo I. The National Database of Nursing Quality Indicators (NDNQI).
OJIN. 2007; 12( 3), manuscript 2.

16. Choi J, Boyle DK. Differences in nursing practice environment among US
acute care unit types: a descriptive study. Int J Nurs Stud. 2014; 51( 11):

17. Verran JA, Gerber RM, Milton DA. Data aggregation: criteria for psychometric
evaluation. Res Nurs Health. 1995; 18( 1): 77-80.

18. Stamps P. Nurses and Work Satisfaction: An Index for Measurement. Chicago,
IL: Health Administration Press; 1997.

19. Taunton RL, Bott MJ, Koehn ML, et al. The NDNQI-Adapted Index of Work
Satisfaction. J Nurs Meas. 2004; 12( 2): 101-122.

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

21. Shrout P. Measurement reliability and agreement in psychiatry. Stat Methods
Med Res. 1998; 7( 3): 301-317.

22. CMS. The Hospital Consumer Assessment of Healthcare Providers and Systems
Accessed August 6, 2014.

23. McHugh MD, Ma C. Hospital nursing and 30-day readmissions among medicare
patients with heart failure, acute myocardial infarction, and pneumonia. Med
Care. 2013; 51( 1): 52-59.

24. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse
staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA.
2002; 288( 16): 1987-1993.

25. Jeffers BR, Astroth KS. The clinical nurse leader: prepared for an era of
healthcare reform. Nurs Forum. 2013; 48( 3): 223-229.

26. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care
environment on patient mortality and nurse outcomes. J Nurs Adm. 2008; 38( 5):

27. Mark BA, Lindley L, Jones CB. Nurse working conditions and nursing unit
costs. Policy Polit Nurs Pract. 2009; 10( 2): 120-128.

28. McCaffrey RG, Hayes R, Stuart W, et al. An educational program to promote
positive communication and collaboration between nurses and medical staff. J
Nurses Staff Dev. 2011; 27( 3): 121-127.

29. Boyle DK, Kochinda C. Enhancing collaborative communication of nurse and
physician leadership in two intensive care units. J Nurs Adm. 2004; 34( 2):

30. AHRQ. TeamSTEPPS national implementation project.
Accessed March 19, 2015.

31. RWJF. More nursing schools preparing students to provide team-based care.
Accessed August 14, 2014.

32. Bormann L, Abrahamson K. Do staff nurse perceptions of nurse leadership
behaviors influence staff nurse job satisfaction? The case of a hospital
applying for Magnet(R) designation. J Nurs Adm. 2014; 44( 4): 219-225.

33. Kramer M, Maguire P, Brewer BB. Clinical nurses in Magnet hospitals confirm
productive, healthy unit work environments. J Nurs Manag. 2011; 19( 1): 5-17.

34. Sherman R, Pross E. Growing future nurse leaders to build and sustain
healthy work environments at the unit level. Online J Issues Nurs. 2010; 15( 1),
manuscript 1.
Accessed March 18, 2015.

35. O’Neil E, Morjikian RL, Cherner D, Hirschkorn C, West T. Developing nursing
leaders: an overview of trends and programs. J Nurs Adm. 2008; 38( 4): 178-183.

36. Lake ET, Shang J, Klaus S, Dunton N. Patient falls: association with
hospital Magnet status and nursing unit staffing. Res Nurs Health. 2010; 33( 5):

37. Choi J, Boyle DK, Dunton N. A standardized measure: NDNQI nursing care
hours indicator. West J Nurs Res. 2014; 36( 1): 105-116.

38. Aiken LH, Sloane DM, Bruyneel L, van den Heede K, Sermeus W. Nurses’
reports of working conditions and hospital quality of care in 12 countries in
Europe. Int J Nurs Stud. 2013; 50( 2): 143-153.

39. McHugh MD, Stimpfel AW. Nurse reported quality of care: a measure of
hospital quality. Res Nurs Health. 2012; 35( 6): 566-575.


Discussion Post Writing Guide: Weeks 4-6

1. Read the discussion instructions carefully, highlighting the keywords.

• Purpose: What question or required reading are you being asked to respond to?

• Particulars: What is the word limit? When is the due date and time?

• Response type: Are you being asked to reflect on personal experience, determine a

solution to a problem, compare two ideas, or make an argument?

• Expectations: How will your discussion post be assessed? Consult the Discussion Rubric

and the Academic Writing Expectations Level 2000/3000 or Weeks 4-6.

2. Prepare.

• Access instructor feedback on your previous assignments. Don’t know how? See the

Check Grades Tutorial in the Walden eGuide. Based on that feedback, how do you want

to improve in this next post?

• Read the week’s learning resources with a critical eye.

• Jot down your initial reactions, ideas, and responses to the discussion question.

• From those notes, determine a couple strong ideas that show your unique perspective.

These ideas will focus your post.

• Sketch a rough outline to make your post logical and clear.

• When needed, research your topic in the Walden Library. See Week 3 for tips on


3. Construct a draft in Microsoft Word.

• Include a purpose / thesis statement at the start of your post to bring all ideas together and

convey your overall perspective.

o For instance: The three most important characteristics of an effective nurse leader

are compassion, nursing knowledge, and communication skills. From the thesis

statement, the reader knows that the post will be about these three characteristics

and why they are so important.

• Develop the points of your outline into paragraphs. Each paragraph should include a main

idea, evidence, analysis, and a lead-out. Altogether, these components are referred to as

the MEAL Plan.

• Integrate information from the learning resources or other library research you have done.

• Practice citing those sources in APA style.

• Type in sentence case and in a formal academic tone, avoiding slang or casual phrasing.

• Save the draft in Microsoft Word.

4. Review and revise. Ask yourself:

• Have I adequately addressed the discussion question and length requirements?

• Does my discussion post demonstrate that I have thought critically about the learning

resources and/or my experiences?

• Have I proposed a unique perspective that will lead to fruitful discussion?

• Have I met the Academic Writing Expectations?

 Clear sentences

 Fully developed paragraphs that follow the MEAL Plan

 A purpose / thesis statement that sets up a logical flow

 Evidence from the learning resources or library research

 Attempted citations for the sources used

5. Submit.

• Proofread for spelling and grammar. Tip: One of the best ways to catch mistakes is to

read your draft out loud!

• Copy and paste the final version of your Microsoft Word draft into the discussion forum.

• Submit. Yay! You’ve done it!

• Wait patiently for responses from your classmates.

6. Respond to others.

• Read postings by your classmates with an open mind; think critically about which posts

are the most interesting to you.

• When responding, use the student’s name and describe the point so that your whole class

can follow along. Example: Jessica, you make an interesting point about technology

increasing without adequate training.

• Whether you are asserting agreement or disagreement, provide reasoning for your views.

• Avoid using unsupported personal opinions, generalizations, or language that others

might find offensive.

• When in disagreement, keep responses respectful and academic in tone.

• Ask open-ended questions, rather than questions that can be answered with yes or no.

Those types of answers end the conversation, rather than leading to more discussion.

Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Orthopaedic Nurses.

12 Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 Copyright © 2017 The Author(s).

here are transformative changes occurring in
healthcare for which nurses, because of their
role, their education, and the respect they have
earned, are well positioned to contribute to and

lead. To be a major player in shaping these changes,
nurses must understand the factors driving the change,
the mandates for practice change, and the competencies
(knowledge, skills, and attitudes) that will be needed for
personal and systemwide success. This article discusses
the driving factors leading to healthcare transformation
and the role of the registered nurse (RN) in leading and
being a fully contributing member of the interprofes-
sional team as we shift from episodic, provider-based,
fee-for-service care to team-based, patient-centered care
across the continuum that provides seamless, affordable,

Factors driving healthcare transformation include fragmen-
tation, access problems, unsustainable costs, suboptimal
outcomes, and disparities. Cost and quality concerns along
with changing social and disease-type demographics cre-
ated the greatest urgency for the need for change. Caring
for and paying for medical treatments for patients suffering
from chronic health conditions are a signifi cant concern.
The Affordable Care Act includes programs now led by
the Centers for Medicare & Medicaid Services aiming to
improve quality and control cost. Greater coordination of
care—across providers and across settings—will improve
quality care, improve outcomes, and reduce spending, es-
pecially attributed to unnecessary hospitalization, unneces-
sary emergency department utilization, repeated diagnostic
testing, repeated medical histories, multiple prescriptions,
and adverse drug interactions. As a nation, we have taken
incremental steps toward achieving better quality and lower
costs for decades. Nurses are positioned to contribute to
and lead the transformative changes that are occurring
in healthcare by being a fully contributing member of the
interprofessional team as we shift from episodic, provider-
based, fee-for-service care to team-based, patient-centered
care across the continuum that provides seamless, afford-
able, and quality care. These shifts require a new or an
enhanced set of knowledge, skills, and attitudes around
wellness and population care with a renewed focus on
patient-centered care, care coordination, data analytics, and
quality improvement.

Healthcare Transformation and Changing
Roles for Nursing

Susan W. Salmond ▼ Mercedes Echevarria

Susan W. Salmond, EdD, RN, ANEF, FAAN, Professor & Executive Vice
Dean, Rutgers University School of Nursing, Westfi eld, NJ.

Mercedes Echevarria, DNP, RN, APN, Associate Dean of Advanced
Nursing Practice & Assistant Professor, Rutgers University School of
Nursing, Monroe Twonship, NJ.

This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the work
provided it is properly cited. The work cannot be changed in any way or
used commercially without permission from the journal.

The authors have no confl ict of interest to declare.

DOI: 10.1097/NOR.0000000000000308

and quality care. This new health paradigm requires the
nurse to be a full partner in relentless efforts to achieve
the triple aim of an improved patient experience of care
(including quality and satisfaction), improved outcomes
or health of populations, and a reduction in the per cap-
ita cost of healthcare.

Driving Forces for Change: Cost
and Quality Concerns
Table 1 provides an overview of key factors that have
been driving healthcare reform. Unsustainable growth
in healthcare costs without accompanying excellence in
quality and health outcomes for the U.S. population has
been escalating to the point at which federal and state
budgets, employers, and patients are unwilling or una-
ble to afford the bill ( Harris, 2014 ). The United States
spends more on healthcare than any other nation. In
fact, it spends approximately 2.5 times more than the
average of other high-income countries. Per capita
health spending in the United States was 42% higher
than Norway, the next highest per capita spender. In
2014, U.S. health care reached $3.0 trillion, or $9,523
per person ( Centers for Medicare & Medicaid Services
[CMS], 2014 ). This is almost 20% of the gross domestic
product (GDP), meaning that for every $5 spent in the
federal budget, about $1 will go to healthcare. The larg-
est expenditures are for hospital care (about 32%), phy-
sician and clinical services (26%), and prescription
drugs (10%) ( CMS, 2015 ). With the demographic shifts
in the aging population and those with chronic illness, it
is anticipated that in three short years, healthcare
spending will reach $4.3 trillion ( George & Shocksnider,
2014 , p. 79; Hudson, Comer, & Whichello, 2014 , p. 201).


Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Orthopaedic Nurses.

Copyright © 2017 The Author(s). Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 13

Cost • More resources are devoted to healthcare per capita in the United States than in any

other nation. Comparing with others, GDP spending for health is 16.2% in the United
States, followed by 10.9% in Switzerland, 10.7% in Germany, 9.7% in Canada, and
8.5% in the United Kingdom ( George & Shocksnider, 2014 ).

• Healthcare spending in the United States is 4.3 times greater than the amount spent
on the national defense.

• Healthcare spending is projected to reach $4.3 trillion by 2017 (19.5% of GDP) and
$4.6 trillion (19.8% of GDP) by 2020 ( George & Shocksnider, 2014 , p. 79; Hudson et al.,
2014 , p. 201).

• The rapid increase in healthcare spending in the United States over the past two dec-
ades and its anticipated growth in the coming years can be tied inextricably to the
increasing number of people with multiple chronic illnesses. It is estimated that 75%
of the more than $2.5 trillion we spend annually on healthcare are related to chronic
diseases ( CDC, n.d.-a ; Thomas, 2012).

Waste • 30 cents of every dollar spent on medical care in the United States is wasted, amount-
ing to $750 billion annually. Contributing to this is inefficient delivery of care, exces-
sive administrative costs, unnecessary services, inflated prices, prevention failures, and
fraud ( Berwick & HackBerth, 2012 ; Mercola, 2016 ).

Variability and
lack of

• The Dartmouth Atlas of Health Care report documents the variations in practice pat-
terns/care, healthcare costs, and patient outcomes by individual practitioners, geo-
graphical regions, type of insurance coverage, and type of condition ( http://www.dar- ) and reports significant variability in practice patterns/care and cost.

• The Blue Cross Blue Shield (2015) study of cost variations for knee and hip replace-
ment surgical procedures in the United States found similar cost variability—for exam-
ple, in the Dallas market, a knee replacement could cost between $16,772 and $61,585
(267% cost variation) depending on the hospital ( Blue Cross Blue Shield, 2015 ).

• Autonomy (the right, and obligation, to use your knowledge, skills, and judgment in
the manner you believe is best for your patient, within evidence-based accepted prac-
tice limits) is stressed over standardization. Yet, there are care protocols and other
types of evidence-based processes where greater efficiencies and safer outcomes result
from standardized work (central line protocols, wound care, perioperative use of pro-
phylactic antibiotics, deep vein thrombosis protocols; Leape, 2014 , p. 1571).

Quality • The U.S. health system ranks last or next to last compared with six other nations
(Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom)
on five dimensions of high-performance health system: quality, access, efficiency,
equity, and healthy lives ( Hudson et al., 2014 , p. 202).

• Fragmented system with recurring communication failures.
• Nonbeneficial or redundant healthcare tests and services.
• Unacceptable risk of error.
• Despite higher level of spending, the hospitals in the United States documented to

readmit an average of one fifth of Medicare patients within 30 days after discharge.
Reports indicate that 19.6% of the 11.8 million Medicare beneficiaries discharged from
a hospital in 2009 were rehospitalized within 30 days and 34% within 90 days, where-
as 25% of Medicare patients discharged to long-term care facilities were readmitted to
the hospital within 30 days ( Enderlin et al., 2013 , p. 48).

Healthcare system

• The system puts an emphasis on specialization and professionalism, while clearly
essential, tends to result in people working in ‘‘silos’’ where individuals often perform
at high levels of ability but sometimes interact little or ineffectively with those in other
disciplines ( Leape, 2014 , p. 1570).

• Most healthcare organizations have a hierarchical structure that inhibits communica-
tion, stifles full participation, and undermines teamwork ( Leape, 2014 ).

( continues )

Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Orthopaedic Nurses.

14 Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 Copyright © 2017 The Author(s).

The high cost of care is, in part, driven by the greater
use of sophisticated medical technology, greater con-
sumption of prescription drugs, and higher healthcare
prices charged for these procedures and medications
( The Commonwealth Fund, 2015 ). Also contributing to
high cost is waste. It is estimated that 30 cents of every
dollar spent on medical care in United States is wasted,
amounting to $750 billion annually. Components of
waste include ineffi cient delivery of care, excessive ad-
ministrative costs, unnecessary services, infl ated prices,
prevention failures, and fraud ( Berwick & HackBerth,
2012 ; Mercola, 2016 ).

Not only are the prices for procedures signifi cantly
higher in the United States but also the charges for
similar procedures vary dramatically, even within the
same geographic locale. Reporting on the variability

in healthcare charges for similar procedures, The
Washington Post ( Kliff & Keating, 2013 ) conveyed the
federal government’s release of the prices that hospi-
tals charge for the 100 most common inpatient proce-
dures ( CMS, 2013 ). The numbers revealed large,
seemingly random variation in the costs of services.
For joint replacements, the most common inpatient
surgery for Medicare patients, prices ranged from a
low of $5,304 in Ada, OK, to $223,373 in Monterey
Park, CA. The average charge across the 427,207
Medicare patients’ joint replacements was $52,063.
Looking at cost variation in a smaller geographic
area, the Blue Cross Blue Shield (2015) study of cost
variations for knee and hip replacement surgical pro-
cedures in the United States found similar cost vari-
ability. In the Dallas market, a knee replacement



• The financial incentives for both providers and patients in fee-for-service systems tend
to encourage the adoption of more expensive treatments and procedures, even if evi-
dence of their relative effectiveness is limited (Orszag & Ellis, 2007).

• The fee-for-service system provides “incentives for overuse and disincentives (i.e., little
or no compensation) for preventive, coordinated, and comprehensive care” ( Leape,
2014 , p. 1571).

• These financial and structural incentives restrict potential for better patient care out-
comes and effective resource allocation.

Aging demograph-
ics and increased

• The older population—persons 65 years or older—numbered 44.7 million in 2013 or
14.1% of U.S. population, one in every seven Americans ( Administration on Aging,
n.d. ).

• Those 65 years and older will grow to 21.7% of the population by 2040. By 2060, there
will be about 98 million older persons, more than twice their number in 2013. The
fastest growing group is those older than 85 years.

• Older adults transitioning between hospital units and settings often experience incon-
sistent nursing care and more adverse care incidents such as nosocomial infections,
delirium, falls, and medication errors ( Enderlin et. al, 2013 ).

• The frequent transition of older people between health services, social, and commu-
nity care providers upon discharge from inpatient care to home increases risk of
adverse incidents, poor health, and social outcomes (Allen, Ottmann, & Roberts, 2013,
p. 254).

Chronic illness • Noncommunicable diseases such as diabetes, heart disease, stroke, and cancer are
now the leading cause of death in the world (Lytton, 2013). It requires more than a
focus on acute illness but behavioral approaches to modify risk factors including poor
diet, obesity, and inactivity.

• 44% of the noninstitutionalized U.S. population (55 million people) is estimated to
have two or more chronic conditions, 85% of adults aged 65 years and older have at
least one chronic disease, and 62% have two or more chronic diseases (Wertenberger,
Yerardi, Drake, & Parlier, 2006).

• Two thirds of Medicare spending attributed to patients with five or more chronic illnesses.
• Medicare fee-for-service spending accounts for more than three fourths of the total

Medicare spending.
• Incidence of chronic illness projected to grow with aging demographics and rising

obesity epidemic.


• High rates of preventable diseases among racial and ethnic minorities.
• Among African Americans, the cost burden of three preventable diseases, high blood

pressure, diabetes, and stroke, was $23.9 billion in 2009. By 2050, this is expected to
increase to $50 billion a year (The Urban Institute, 2009).

• Latinos receive worse care than non-Latino Whites for about 60% of core measures
( AHRQ, 2011 )

Note . GDP = gross domestic product.

Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Orthopaedic Nurses.

Copyright © 2017 The Author(s). Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 15

could cost between $16,772 and $61,585 (267% cost
variation) depending on the hospital ( Blue Cross Blue
Shield, 2015 ).

Perhaps, if this outrageous price tag bought value, we
as a nation would accept the expense. After all, healthcare
is more vital than most other goods or services. However,
the stark reality is that despite outspending all other com-
parable high-income nations, our system ranks last or
near last on measures of health, quality, access, and cost.
The United States has higher infant mortality rates,
higher mortality rates for deaths amenable to healthcare
(mortality that results from medical conditions for which
there are recognized healthcare interventions that would
be expected to prevent death), higher lower extremity
amputations due to diabetes, higher rates of medical,
medication, and laboratory errors, and higher disease
burden, as measured by “disability-adjusted life-years,”
than comparable countries ( Peterson-Kaiser Health
Tracker System, 2015 ).

Examining quality within the system, we know that our
healthcare system is fragmented with recurring communi-
cation failure and unacceptable levels of error. The system
is diffi cult to navigate, especially when patients and car-
egivers are asked to seek care across multiple providers
and settings for which there is little to no coordination.
There are signifi cant barriers to accessing care, and this
problem is disproportionately true for racial and ethnic mi-
norities and those with low-socioeconomic status ( Agency
for Healthcare Research and Quality [AHRQ], 2011 ). With
a focus almost exclusively on acute care, the primary care
system in the United States is in disarray or, for some, non-
existent despite research data that associate access to pri-
mary care with lower mortality rates and lower overall
healthcare costs ( Bates, 2010 ). It is not surprising therefore
that when discharged from the hospital, an average of one
in fi ve Medicare patients (20%) was readmitted to the hos-
pital within 30 days after discharge in 2009 and 34% were
readmitted within 90 days. Moreover, 25% of Medicare pa-
tients discharged to long-term care facilities were readmit-
ted to the hospital within 30 days, clearly representing gaps
in care coordination ( Enderlin et al., 2013 , p. 48).

The absence or underuse of peer accountability, un-
derdeveloped quality improvement infrastructures,
lack of accountability for making quality happen, in-
consistent use of guidelines and provider decision-sup-
port tools, and lack of clinical information systems
that have the capacity to collect and use digital data to
improve care all contribute to quality care issues ( Shih
et al., 2008 ). Another impediment to quality is the hier-
archical structure of most healthcare organizations
that “inhibits communication, stifl es full participation,
and undermines teamwork” ( Leape, 2014, p. 1570 ).
Failure of these organizations to adopt and enforce “no
tolerance” policies for behaviors that are known to im-
pact quality (i.e., disrespectful, noncollaborative care
among team members that impedes safety to ask ques-
tions and express ideas; failure to comply with basic
care approaches such as hand washing hygiene and
time-out protocols that are known to decrease safety
risk) perpetuates the dysfunctional culture in health-
care where negative behaviors block progress toward
quality ( Leape, 2014 ).

Driving Factors for Change:
Changing Demographics
Changing social and disease-type demographics of our
citizens is also fueling the mandate for change. The de-
mographer James Johnson coined the phenomenon “the
browning of America” to illustrate that people of color
now account for most of the population growth in this
country. People of color face enduring and long-standing
disparities in health status including access to health
coverage that contributes to poorer health access and
outcomes and unnecessary cost. The AHRQ in its annual
National Healthcare Quality and Disparities Report has
provided evidence that racial and ethnic minorities and
poor people face more barriers to care and receive
poorer quality of care when accessed. These facts under-
score the imperative for change in our system.

The graying of America is another changing social
demographic, with signifi cant healthcare implications.
Beginning January 1, 2011, the oldest members of the
Baby Boom generation turned 65. In fact, each day
since that day, today, and for every day for the next 19
years, 10,000 Baby Boomers will reach the age of 65
years ( Pew Research Center, 2010 ). Currently, just 14.1%
of the U.S. population (44.7 million) is older than 65
years. By 2060, this fi gure will be 98 million or about
twice their current number ( Administration on Aging,
n.d. ). This shift will have signifi cant economic conse-
quences on Social Security and Medicare.

Overlapping with the changing social demographics
is the change in disease-type demographics due to the
fact that there is a rise in chronic disease among
Americans and signifi cantly so among older Americans.
Chronic disease (heart disease, stroke, cancer, Type 2
diabetes, obesity, and arthritis) is the leading cause of
death and disability for our citizens, affecting an esti-
mated 133 million people. Thought of by some as the
single biggest force threatening U.S. workforce produc-
tivity, as well as healthcare affordability and quality of
life, chronic diseases are among the most “common,
costly, and preventable of all health problems” ( Centers
for Disease Control and Prevention [CDC], n.d.-b ).
Those with chronic conditions utilize the greater num-
ber of healthcare resources, accounting for 81% of hos-
pital admissions, 91% of prescriptions fi lled, 76% of all
physician visits, and more than 75% of home visits
( Partnership to Fight Chronic Disease, n.d. ). Not sur-
prisingly, older people are more likely to have more co-
morbidities. Eighty-fi ve percent of adults aged 65 years
have at least one chronic disease, 62% have two or more
chronic diseases, and 23% have fi ve or more chronic
conditions, and these 23% account for two thirds of all
Medicare spending ( Volland, 2014 ).

The situation becomes even more serious when the
person also has a disability or activity limitation. Our
episodic healthcare model is not meeting the needs of
people with chronic conditions and often leads to poor
outcomes ( Anderson, 2010 ). More than a quarter of peo-
ple with chronic conditions have limitations when it
comes to activities of daily living such as dressing and
bathing or are restricted in their ability to work or attend
school. The number of people with arthritis is expected

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16 Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 Copyright © 2017 The Author(s).

to increase to 67 million by 2030 and of these 25 million
will have arthritis-attributable activity limitations ( CDC,
n.d.-a ). These numbers are conservative, as they do not
incorporate the current obesity trends that are likely to
add to future cases of osteoarthritis. A signifi cant chal-
lenge, both now and for the future, is how to care for and
pay for the care—medical treatment and other support-
ive services—that people with chronic conditions need.

Voluntary Change Is Not Enough
As a nation, we have taken incremental steps toward
achieving better quality and lower costs for decades.
With the turn of the century and the Institute of Medicine
(IOM) reports, To Err Is Human: Building a Safer Health
Care System and Crossing the Quality Chasm , we became
increasingly aware that the level of unintended harm in
medicine was too high and that there was a compelling
need to scrupulously examine and transform systems to
make healthcare safer and more reliable. The recom-
mendations in Crossing the Quality Chasm ( IOM, 2001 )
called for adopting a shared vision of six specifi c aims
for improvement that must be the core for healthcare
(see Table 2 ). Although, in principle, there was agree-
ment that these six aims were critical for an improved
and effective system and should be evident across all set-
tings, the reality is that widespread change did not occur.
As suggested in the report, there was an immense divide
between what we knew should be provided and what ac-
tually was provided. This divide was not a gap but a
chasm, and it was believed that the healthcare system as
it existed was fundamentally unable to achieve real im-
provement without a major system overhaul.

Enter Healthcare Reform
Continued skyrocketing of healthcare costs, less than
impressive heath status of the American people, safety
and quality issues within the healthcare system, grow-
ing concerns that cost and quality issues would inten-
sify with changing demographics, and the reality that
there were 50 million Americans uninsured and 40 mil-
lion underinsured in the United States ushered in the
Patient Protection and Affordable Care Act of 2010
( Salmond, 2015 ). The Affordable Care Act (ACA) is more
than insurance reform and greater access for the newly
insured but includes programs now led by the CMS
aiming to improve quality and control costs—what is
being termed value. Value is in essence a ratio, with

quality and outcomes in the numerator and cost in the
denominator ( Wehrwein, 2015 ).

Improving value means “avoiding costly mistakes and
readmissions, keeping patients healthy, rewarding qual-
ity instead of quantity, and creating the health informa-
tion technology infrastructure that enables new payment
and delivery models to work” (Burwell, 2015). Through
the ACA and the power vested in the CMS to implement
value, we are shifting to new principles underlying reim-
bursement and new models for care and payment
(see Table 3 ). For a while, healthcare, like a seesaw, will
balance in a precarious state of transition from the old to
the new ( Cipriano, 2014 ); however, no one is expecting a
return to the old approaches of payment and care. In
fact, it is expected by 2018 that 50 cents of every Medicare
dollar will be linked to an identifi ed quality outcome or
value (Burwell, 2015). And as the nation’s largest insurer,
Medicare leads the way in steering new programs and
setting the precedent for other private insurers.

As illustrated in Table 4 , these new models are shift-
ing the paradigm of care from a disease model of treat-
ing episodic illness, without attention to quality out-
comes, to a focus on health and systems that reward
providers for quality outcomes and intervening to pre-
vent illness and disease progression—in keeping popu-
lations well. Quality will be defi ned in terms of measur-
able outcomes and patient experience at the individual
and population levels, and payments (penalties and in-
centives) will be calculated on the basis of the outcomes.
Effi ciency will be maximized by reducing waste, avoid-
ing duplicative care, and appropriately using special-
ists. Outcomes will be tracked over longer periods of
time—making care integration and care across the con-
tinuum a mandate. Institutions and providers will be
incentivized for keeping people well so as not to need
acute hospital or emergency department (ED) service,
for meeting care and prevention criteria, and for ensur-
ing the perceived value of the healthcare experience or
patient satisfaction is high. This forces a shift from a
provider-centric healthcare system where the provider
knows best to a delivery system that is patient-centric
and respectfully engages the patient in developing self-
management and behavioral change capacity. Funds
have been made available through the ACA via the CMS
to help providers invest in electronic medical records
and other analytics needed to track outcomes and to
provide support in developing the skills and tools needed
to improve care delivery and transition to alternative
payment models ( McIntyre, 2013 ).

1. Safe . Safety must be a system property of healthcare where patients are protected from injury by the system of care that is intended to

help them. Reducing risk and ensuring safety require a systems focus to prevent and mitigate error.

2. Effective . Care and decision making must be evidence based with neither underuse nor overuse of the best available techniques.

3. Patient-centered . Care must be respectful and responsive of individual patient’s culture, social context, and specifi c needs, ensuring that
patients receive the necessary information and opportunity to participate in decisions and have their values guide all clinical decision mak-
ing about their own care.

4. Timely . The system must reduce waits and harmful delays.

5. Effi cient. The system must avoid waste, including waste of equipment, supplies, ideas, time, and energy.

6. Equitable. Care must be provided equitably without variation in quality because of personal characteristics such as race, gender, ethnicity,
geographic location, and socioeconomic status.

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Copyright © 2017 The Author(s). Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 17

The new principles for payment

Pay for Performance (P4P) P4P is the basic principle that undergirds new models of care being supported by the ACA. In these models,
providers are rewarded for achieving preestablished quality metrics. The quality metrics for acute care
organizations targets the experience of care (HCAHPS), processes of care (such as processes to reduce
healthcare-associated infections and improve surgical care), effi ciency, and outcomes (i.e., rates of mortal-
ity, surgical site infections). In the ambulatory care area, quality performance may be determined by any
of the HEDIS measures. The key point for practitioners is total familiarity with how quality is being defi ned
and measured. Knowing this allows for full participation in what must be done to achieve the quality.

Value-Based Purchasing

This approach switches the traditional model of healthcare fee structure from fee-for-service where reim-
bursement is for the number of visits, procedures, and tests to payment based on the value of care deliv-
ered—care that is safe, timely, effi cient, effective, equitable, and patient-centered. In VBP, insurers such as
Medicare set annual value expectations and accompanying incentive payment percentages for each
Medicare patient discharge. The purchasers of healthcare are able to make decisions that consider access,
price, quality, effi ciency, and alignment of incentives and can take their business to organizations/provid-
ers with established records for both cost and quality (Aroh, Colella, Douglas, & Eddings, 2015).

Shared Savings

Approaches to incentivize providers to offer quality services while reducing costs for a defi ned patient popu-
lation by reimbursing a percentage of any net savings realized. Medicare has established shared savings
programs in the PCMH and ACO models of care.

New programs and models of delivery and payment

Condition Reduction

Under the ACA, Medicare payments for hospitals that rank in the lowest performing quartile for conditions
that are hospital-acquired (i.e., infections [central line-associated bloodstream infections and catheter-as-
sociated urinary tract infections], postoperative hip fracture rate, postoperative sepsis rate, postoperative
pulmonary embolism, or deep vein thrombosis rate) will be reduced by 1%. Upcoming standards will be
expanded to include methicillin-resistant Staphylococcus aureus infections ( CMS, , n.d. ).

Hospital Readmissions
Reduction Program

Aimed at reducing readmissions within 30 days of discharge (readmission that currently cost Medicare
$26 billion per year). To reduce admissions, hospitals must have better coordination of care and support.
Hospitals with relatively high rates of readmissions will receive a reduction in Medicare payments. These
penalties were fi rst applied in 2013 to patients with congestive heart failure, pneumonia, and acute
myocardial infarction. The CMS added elective hip and knee replacements at the end of 2014 (Purvis,
Carter, & Morin, 2015).

In time, 60-, 90-, and 190-day readmissions will be examined.

Accountable Care
Organizations (ACOs)

The ACO is a network of health organizations and providers that take collective accountability for the cost
and quality of care for a specifi ed population of patients over time. Incentivized by shared savings ar-
rangements, there is a greater emphasis on care coordination and safety across the continuum, avoiding
duplication and waste, and promoting use of preventive services to maximize wellness.

Better coordinated, preventive care is anticipated to save Medicare dollars, and the savings will be shared with
the ACO. It is estimated that ACOs will save Medicare up to $940 million in the fi rst 4 years (Sebelius, 2013).

Patient-Centered Medical
Homes (PCMHs)

PCMHs is an approach to delivery of higher quality, cost-effective, primary care deemed critically important
for people living with chronic health conditions. Medical homes share common elements including com-
prehensive care addressing most of the physical and mental health needs of clients through a team-based
approach to care; patient-centered care providing holistic care that builds capacity for self-management
through patient and caregiver engagement that attends to the context of their culture, unique needs,
preferences, and values; coordinated care across the continuum of healthcare systems including specialty
care, hospitals, home healthcare, and community services and supports. Such coordination is particularly
critical during transitions between sites of care, such as when patients are being discharged from the hos-
pital; accessible care that minimizes wait times and includes expanded hours and after-hours access; and
care that emphasizes quality and safety through clinical decision-support tools, evidence-based care,
shared decision making, performance measurement, and population health management and incorpora-
tion of chronic care models for management of chronic disease (AHRQ, PCMH Resource Center). The
CMS has supported demonstration projects to shift its clinics to the medical home model.

Bundled Payment Models

Bundles are single payment models targeting discrete medical or surgical care episodes such as spine
surgery or joint replacement. Bundles provide lump sum to providers for a given service episode of care
inclusive of preservice time, the procedure itself, and a postservice global period, thereby crossing both
inpatient and outpatient services. Can be for a procedure or an episode of care … providers assume a
considerable portion of the economic risk of treatment ( McIntyre, 2013 ). The margin (positive or
negative) realized in this process depends on the ability of the different organizations and providers to
manage the costs and outcomes across the care continuum.

The Medicare Comprehensive Care for Joint Replacement model is a bundled care package aimed to
support better and more effi cient care for those seeking hip and knee replacement surgical procedures.
The bundle covers the episode from the time of the surgery through 90 days after hospital discharge.


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18 Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 Copyright © 2017 The Author(s).

We have been experiencing the fi rst wave of changes
toward value-based care for years. In 2002 (and updated
in 2006), the National Quality Forum (NQF) developed
a list of seriously reportable events in healthcare (such
as surgery on the wrong body part or a mismatched
blood transfusion) that became known as “never
events.” These never events were considered to be seri-
ous and costly healthcare errors that should never hap-
pen and are largely preventable through safety proce-
dures and/or the use of evidence-based guidelines.
Quality improvement measures were instituted to re-
duce “never events” to zero. It required establishing a
culture of safety such that incidents could be safely re-
ported and performing root–cause analyses when
“never” events occurred ( Lembitz & Clarke, 2009 ).

In October 2008, the CMS began denying payment for
hospitals’ extra costs to treat complications that resulted
from certain hospital-acquired conditions (HACs). Some
of the conditions from these two lists shared similarities
(surgery on the wrong patient or wrong body part, death/
disability from incompatible blood, Stage 3 or 4 pressure
ulcers after admission, and death/disability associated
with a fall within the facility). These events represent
rare, serious conditions that should not occur. However,
other conditions included on Medicare’s “no pay” list of
HACs were selected because they were high cost or high
volume (or both) and assumed preventable through use

of evidence-based guidelines. Some of these HACs occur
more commonly and have a comparatively greater im-
pact on cost. These “no pay” adverse events identifi ed by
the CMS but not by the NQF included deep vein throm-
bosis and pulmonary embolism in total knee and hip re-
placement and surgical site infection following ortho-
paedic surgery. This CMS policy was directed to
accelerate improvement of patient safety by implemen-
tation of standardized protocols to prevent the event.
These newly defi ned “never events” limit the ability of
the hospitals to bill Medicare for adverse events and
complications ( Lembitz & Clarke, 2009 ). Emerging from
quality improvement initiatives to prevent “never events”
was the concept of “always events” or behavior that
should be consistently implemented to maximize patient
safety and improve outcomes. Examples of “always
events” include “patient identifi cation by more than one
source, mandatory “read backs” of verbal orders for
high-alert medications, surgical time-out and making
critical information available at handoffs or transitions
in care” ( Lembitz & Clarke, 2009 , p. 31).

Today, we have the Hospital Acquired Condition
Reduction Program, implemented prior to the ACA but
formalized under this Act to broaden its defi nition of
unacceptable conditions. It uses fi nancial penalties for
high quartile scores in rates of adverse HACs. These
conditions, considered to be reasonably preventable


The Past The Future

Payment for illness or sick care that is triggered by visits to providers
and procedures done

Payment for prevention, care coordination, and care management
at the primary care level

Greatest fi nancial award for specialized services Payment for populations—shared risk for use of specialized services

Provider-centric, provider as expert Patient-centric, patient as partner

No accountability for inadequate quality. Quality and quality
improvement tasked to a department

Value-based payment asking “How well did patients do?” Quality
and quality improvement prime concerns of every practitioner

Quality measured at the individual level Quality measured at the individual and aggregate levels

Quality measured for a discrete time period Quality measured over longer periods

Inconsistent access to care Same-day appointments, timely access

Disrespect Respect

Top-down hierarchical command and control. Leadership focused
on siloed area of care

Team-based, collaborative care requiring integration of care across
the continuum

Nursing not leading or not recognized for their contribution to care Nursing fi nding their voice and take an active role in shaping the
future of healthcare. Nursing recognized for their value in care

Following orders Advocating for the patient and the family

Focus on task Focus on excellence and the patient experience


Private insurers and businesses are offering bundled payment packages for their participants to receive spe-
cialized joint or spine care at approved high-quality, cost-effective facilities. For example, Lowe’s and
Walmart arrange for no-cost knee and hip replacement surgical procedures for their 1.5 million employ-
ees and their dependents if they seek care at one of four approved sites in the United States. These com-
panies will cover the cost of consultations and treatment without deductibles along with travel, lodging,
and living expenses for the patient and the caregiver (The Advisory Company, 2013).

Note . ACA = Affordable Care Act; ACO = Accountable Care Organizations; CMS = Centers for Medicare & Medicaid Services;
PCMH = Patient-Centered Medical Home.

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Copyright © 2017 The Author(s). Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 19

conditions that were not present upon admission to the
hospital (see Table 3 ), must be monitored and reported.
Lowering these rates has occurred with careful moni-

toring and surveillance for events, implementation of
evidence-based best practices, creating checklists to en-
sure processes are followed, and transferring patients
out of EDs and critical care units as soon as possible.

Bundled payments, a model reimbursing two or more
providers for a discrete episode of care over a specifi c
period of time, are being used in orthopaedics for some
spine and total hip and knee arthroplasty surgical proce-
dures. A fully bundled payment system extends beyond
the institution, as it includes the surgeons and all other
providers involved in the care of the patient during and
after surgery. In this bundled model, lump sum pay-
ments are given to the institution to cover the episode of
care from the preservice or presurgery period, through
the procedure itself, and to a postservice period, gener-
ally anywhere from 30 to 90 days after surgery. This
eliminates fee-for-service where one payment is made to
the hospital, a second payment to the surgeon, and other
payments to the anesthetist, the physical therapist,
homecare, etc. The bundled payment is a prenegotiated
type of risk contract in which providers will not be com-
pensated for any costs that exceed the bundled payment.
In addition to breaking down the current payment silos,
bundles set quality standards to further the IOM aims of
healthcare that eliminates duplication and waste, in-
creases effi ciency, uses evidence-based protocols to max-
imize outcomes, and engages the patient in building ca-
pacity for self-care ( Enquist et al., 2011 ; McIntyre, 2013 ).

The Comprehensive Care for Joint Replacement model
is a bundled approach targeting higher quality and more
effi cient care for Medicare’s most common inpatient sur-
gical procedures—hip and knee replacements. Institutions
under this model have reengineered patient care pro-
cesses and standards developing standardized clinical
pathways to enhance reliability or consistency in care.
Processes identifi ed as important include comprehensive
patient teaching spanning from the preadmission phase
to the postdischarge recovery phase, standardized order
sets, early mobilization, redesign of services for coloca-
tion for patient rather than provider ease, use of nurse
practitioners to champion the pathway and ensure com-
pliance, and implementing efforts to move patients from
the hospital to home with home healthcare as opposed to
hospital to inpatient rehabilitation to home with home
healthcare ( Enquist et al., 2011 ; Marcus-Aiyeku, DeBari,
& Salmond, 2015 ). Practicing in a bundled model requires
that organizations examine the distribution of costs
across the service or episode, identify, understand, and
eliminate variation, map evidence-based pathways of
care, coordinate care with providers across the contin-
uum, and use ongoing evaluation and analytics to identify
where care can be managed more effi ciently and effec-
tively ( American Hospital Association, n.d. ).

Moving forward, we will see greater attention to ad-
dressing preventive and chronic care needs across an
entire population. The emphasis will be on interventions
that prevent acute illness and delay disease progression
and will require a true interprofessional team model to
accomplish. Accountable Care Organizations (ACOs)
and Patient-Centered Medical Homes are expected to

improve primary care and care across the continuum by
incentivizing providers to be accountable for improving
patient and population health outcomes through cost-
sharing approaches to reimbursement. It is more than
the traditional health visit and will require a focus on
both the individual and the population to advance
health. Primary healthcare under the ACA stresses pre-
vention, health promotion, continuous comprehensive
care, team approaches, collaboration, and community
participation ( Gottlieb, 2009 , p. 243).

If ACOs are to achieve their goals to improve the
health of populations and realize a positive profi t mar-
gin, they will need to adopt new ways of thinking about
health. There is growing awareness that overall health
outcomes are infl uenced by an array of factors beyond
clinical care. Figure 1 illustrates the County Health
Rankings model of population health. As can be seen,
health outcomes defi ned as length and quality of life are
determined by factors in the physical environment, so-
cial and economic factors, clinical care, and health be-
haviors. The model recognizes that “health is as much
the product of the social and physical environments
people occupy as it is of their biology and behavior”
( Kaplan, Spittel, & David, 2015 , p. iv). Using this frame-
work, it is easy to recognize the critical need to incorpo-
rate behavioral factors and social context when trying to
improve well-being and health outcomes. Individual
behavioral determinants include addressing issues re-
lated to diet, physical activity, alcohol, cigarette, and
other drug use, and sexual activity, all of which contrib-
ute to the rates of chronic disease. The social and physi-
cal contexts (together comprising what is called social
determinants of health) of where a person lives and
works infl uence half of the variability in overall health
outcomes, yet rarely are considered when one thinks of
healthcare. Table 5 presents social and physical deter-
minants as defi ned by Healthy People 2020. If we are to
achieve true population health, it will be essential to
have models in which clinical care is joined with a broad
array of services supporting behavioral change and is
integrated or coordinated with other community and
public health efforts to address the social context in
which people live and work. With these new reimburse-
ment models, healthcare organizations and providers
will be incentivized to identify the other 80% of factors
(health behaviors, social and economic factors, and
physical environment factors) and address them to im-
prove patient outcomes and generate savings.

Nursing’s Role in the New
Healthcare Arena
The Future of Nursing: Leading Change, Advancing
Health asserts that nursing has a critical contribution in
healthcare reform and the demands for a safe, quality,
patient-centered, accessible, and affordable healthcare
system ( IOM, 2010 ). To deliver these outcomes, nurses,
from the chief nursing offi cer to the staff nurse, must
understand how nursing practice must be dramatically
different to deliver the expected level of quality care and
proactively and passionately become involved in the
change. These changes will require a new or enhanced
skill set on wellness and population care, with a

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20 Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 Copyright © 2017 The Author(s).


Social Determinants Physical Determinants

Availability of resources to meet daily needs (e.g., safe housing and
local food markets)

Access to educational, economic, and job opportunities

Access to health care services

Quality of education and job training

Availability of community-based resources in support of community
living and opportunities for recreational and leisure-time activities

Transportation options

Public safety

Social support

Social norms and attitudes (e.g., discrimination, racism, and distrust
of government)

Exposure to crime, violence, and social disorder (e.g., presence of
trash and lack of cooperation in a community)

Socioeconomic conditions (e.g., concentrated poverty and the
stressful conditions that accompany it)

Residential segregation


Access to mass media and emerging technologies (e.g., cell phones,
the Internet, and social media)


Natural environment, such as green space (e.g., trees and grass)
or weather (e.g., climate change)

Built environment, such as buildings, sidewalks, bike lanes, and

Worksites, schools, and recreational settings

Housing and community design

Exposure to toxic substances and other physical hazards

Physical barriers, especially for people with disabilities

Aesthetic elements (e.g., good lighting, trees, and benches)

Note. Available at: .

FIGURE 1. County Health Rankings, Model of Population Health. From University of Wisconsin Population Health Institute. County
Health Rankings & Roadmaps 2016. Used with permission.

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Copyright © 2017 The Author(s). Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 21

renewed focus on patient-centered care, care coordina-
tion, data analytics, and quality improvement.

Transformation and the changes required will not be
easy—at the individual or systems level. Individually, it
requires an examination of one’s own knowledge, skills,
and attitudes and whether that places you as ready to
contribute or resist the coming change. At an organiza-
tional level, it requires an analysis of mission, goals,
partnerships, processes, leadership, and other essential
elements of the organization and then overhauling
them, thus disrupting things as we know it. The reality
is that everyone’s role is changing—the patients’, physi-
cians’, nurses’, and other healthcare professionals’—
across the entire continuum of care. Success will come
if all healthcare professionals work together to trans-
form and leverage the contribution of each provider
working at full scope of practice. Achieving patient-cen-
tered, coordinated care requires interprofessional col-
laboration, and it is an opportunity for nursing to shine.

We must shift from a care system that focuses on illness
to one that prioritizes wellness and prevention. This
means that wellness- and preventive-focused evaluations,
wellness and health education programs, and programs
to address environmental or social triggers of preventa-
ble disease conditions and care problems must take an
equal importance of focus as the disease-focused clinical
intervention that providers deliver ( Volland, 2014 ). What
does this look like in the real-world orthopaedic setting?
At a population health level, this means addressing “up-
stream” factors to prevent or minimize musculoskeletal
health problems. For example, workplace programs to
assess and prevent back and other musculoskeletal dis-
eases and disabilities or fall-reduction programs held in
the community to improve mobility for seniors both ad-
dress specifi c populations with an aim of keeping the
group well and preventing musculoskeletal injury.
Upstream of joint surgery could entail intervening prior
to surgery with programs around weight loss and exer-
cise that could prevent many chronic musculoskeletal
disorders and ultimately avoid or delay surgery and im-
prove outcomes in the case that surgery is needed.

At the organizational and individual practitioner lev-
els, wellness means thinking about the patient beyond the
current event (hospital or offi ce) and considering what
must be assessed or done to maximize the person’s well-
ness. For example, a 60-year-old woman presents to the
ED for a fall. She identifi ed that she had been having
some leg edema and could not wear her normal shoes so
was walking in a slipper-type shoe and slipped. The acute
episode is treated by obtaining an x-ray fi lm to rule out
fracture and a cardiac review to determine cause for
edema. A wellness perspective would go further and con-
sider what are the possible risks for future falls—a gait
analysis would be done, screening for osteoporosis would
be arranged for, and a plan to prevent or reduce risk to
prevent subsequent falls and potential fractures would be
implemented with possible referral to a Matter of Balance
program that could support the patient with strategies to
reduce falling and increase strength and balance.

The key is that instead of simply asking “What is
wrong here” or “What is wrong now” and focusing on the

immediate episode that brought the person to the clinic
or the hospital, the nurse also asks, “What happened that
the person needed this level of care?” “What could or
should have been done to better manage the person’s
health or prevent this episode? “What needs to be done to
prevent a recurrence or a worsening of presenting issue?”

Knowing the answer to these questions allows for the
development of a more individualized, holistic plan of
care that can begin at the moment and subsequently be
coordinated and managed across the continuum by RNs
and other providers no matter the care continuum setting.

Whether looking to stay well or recover from acute
illness or live well with chronic illness, there are few
community-based programs that meet one’s rehabilita-
tion and wellness needs. Nursing and other healthcare
professionals such as therapists and social workers are
well positioned to lead entrepreneurial ventures that
partner with community centers (YMCAs, adult day
care, housing, etc.) or participate in shared medical ap-
pointments to provide education, skills development,
and activities that maximize health and support con-
tinuing residence and care in the community.

Another necessary characteristic of the transformed
healthcare system must be an unwavering focus on the
patient. Patient- and family-centered care , rather than
provider-centric care, is essential if patients and fami-
lies are to assume responsibility for self-management.
The IOM (2001 ) defi nes patient-centered care as:

Health care that establishes a partnership among
practitioners, patients, and their families (when ap-
propriate) to ensure that decisions respect patients’
wants, needs, and preferences and that patients have
the education and support they need to make deci-
sions and participate in their own care. (p. 7)

Again, nurses are ideally positioned for this role, as
nursing has consistently embraced an approach to care
that is holistic, inclusive of patients, families, and commu-
nities and oriented toward empowering patients in their
care to assume responsibility for self- and disease manage-
ment ( American Nurses Association [ANA], 2012 ; George
& Shocksnider, 2014 ; Samuels & Woodward, 2015).

Practicing from a patient-centered approach means
acknowledging that patients, not providers, know them-
selves best and realizing that quality care can only be
achieved when we integrate patients and families into
decision making and care and focus on what is impor-
tant to patients. Without this, we will never deliver value.
Gone are the days of telling the patient what to do;
rather, asking “what matters to you” must begin the care
process. It helps defi ne patient-reported outcomes or
outcomes of medical care that are defi ned by the patient
directly. This shared understanding of what matters to
the patient provides the entrée for discussion of how to
effi ciently achieve these outcomes. Engaging the patient
in shared decision making and shared care planning
with patient-reported outcomes at the center of the plan
of care is essential for patient activation in self-manage-
ment. With patient-reported outcomes in mind, nurses
can partner with patients in providing client education

Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Orthopaedic Nurses.

22 Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 Copyright © 2017 The Author(s).

and coaching to strengthen the patient’s capacity toward
goal achievement. Use of motivational interviewing and
action planning as a strategy to assist patients with be-
havioral change is a needed skill. With action plans and
goals at the forefront, the nurse provides ongoing infor-
mation on treatment plans, provides coaching and
counseling to build self-confi dence in relation to new
behaviors, coordinates reminders for preventive and
follow-up care, and ensures that handoffs provide the
next set of providers with needed information to con-
tinue the plan of care and avoid duplicative ordering.

An integrated care continuum is posited to be a key
strategy for achieving the triple aim—better quality, bet-
ter service, and lower costs per unit of service. But what
is the continuum and what is the role of the nurse in
care coordination across the continuum? The contin-
uum of care concept was proposed in 1984 and was con-
ceptualized as a patient-centered system that guides
and follows individuals over time (potentially from
birth to end of life) through a comprehensive array of
seamless health, mental health, and social services
spanning all levels and intensity of care ( Evashwick,
1984 ). The World Health Organization (2008, p. 4) simi-
larly defi nes an integrated service delivery as “the man-
agement and delivery of health services so that clients
receive a continuum of preventive and curative services,
according to their needs over time and across different
levels of the health system.” Today, these defi nitions
hold, although there is a greater emphasis on the need
to expand the continuum to collaborate within the com-
munity to engage support of agencies and services pro-
vided by other nonprofi ts ( George & Shocksnider, 2014 ).
As the continuum consists of services from wellness to
illness, from birth to death, and from a variety of or-
ganizations, providers, and services, ongoing coordina-
tion to prevent or minimize fragmentation is critical.

Lamb (2014) emphasizes that the “work of care coor-
dination occurs at the intersection of patients, providers,
and healthcare settings and relies on integrative activi-
ties including communication and mobilization of ap-
propriate people and resources” (p. 3). All patients need
care coordination as it serves as a bridge—making the
fragmented health system become coherent and man-
ageable—an asset for both the patient and the provider.
For some patients, a more intensive form of care coordi-
nation is needed and may be assigned a care manager to
oversee their condition and changing care needs during
the different trajectories of their chronic illness. Others
may require a time-limited set of care and coordination
services to ensure care continuity across different sites or
levels of care. This care, referred to as transitional care,
has been a major focus, as it has been validated that tran-
sitions represent high-risk periods for safety issues and
negative outcomes because of lack of continuity of care
( Enderlin et al., 2013) . During this shifting in setting,
provider, or status, there have typically been problems
with handoffs such that the next provider/setting does
not have the information about what has been done for
the patient, the patient and family lack understanding
and ability to manage the care, medications have not

been reconciled, and patients have been challenged in
getting access to the care needed. To contend with these
issues, the ACA set goals to reduce fragmentation of care.
Numerous transitional care models such as Naylor’s
Transitional Care Model, Coleman’s Care Transitions
Program, and Project Re-engineered Discharge have
demonstrated effi cacy in reducing readmissions, reduc-
ing visits to the ED, improving safety, and improving pa-
tient satisfaction and outcomes ( ANA, 2012 ; Enderlin
et al., 2013 ).

Whatever the level of care coordination required, the
care coordinator uses skills of patient advocacy to pro-
mote self-management, navigate complex systems, and
ensure meaningful patient- and family-centered com-
munication and interprofessional communication to
facilitate a seamless, effi cient plan of care that spans the
boundaries within and between the patient/family and
formal organizational and community service providers
( Fraher, Spetz, & Nayor, 2015 ). Care coordination is not
something that is delegated to one individual or unique
to an individual who may hold the title of care coordina-
tor or navigator. All nurses, no matter what their role,
must prioritize care coordination. With this in mind, all
nurses should move away from the notion of discharg-
ing patients, which implies that their responsibilities for
care are fi nished. In contrast, nurses should provide
care with a mind to transitioning the patient to the next
level or stage. Transitioning implies a joint responsibil-
ity for care coordination over time. To know what tran-
sition needs are, the nurse must understand the patient’s
condition in respect to his or her own life continuum
and context and work to handoff to the next provider/
site of care. It is often the nurse at the point of care who
has formed a relationship with the patient and learned
important aspects of the patient’s social context, chal-
lenges in managing the patient’s health, and the patient’s
priorities of care. This information is invaluable and
must be integrated into the plan of care for the patient
across the continuum of care.

For those with more complex care needs, especially
those with multiple chronic illnesses, there is a need for
a specialized role to ensure that care is coordinated
across the continuum. Care coordinator roles grounded
in acute care or primary and ambulatory (case or care
managers, population health managers, patient naviga-
tors, healthcare coaches, transition coaches) may be
held by individuals with different professional and non-
professional roles. Nurses, with their unique skill set
and philosophy of care, are the provider of choice to
lead, manage, and participate in the care coordination
of groups of patients ( ANA, 2012 ; George & Shocksnider,
2014 ; Rodts, 2015 ). Nurses have both the clinical and
management knowledge and skill set needed to assume
key coordination roles. Strong clinical knowledge
grounded in the evidence is a priority characteristic for
the care coordinator as this individual must be able to
select and implement care processes and systems re-
fl ecting best practices, implement rapid-cycle improve-
ments in response to clinical data, and track and ana-
lyze trends. Lack of this requisite clinical knowledge
will impede implementation of best practices and po-
tentially impede strong interprofessional collaboration
and communication that must be exquisite within a

Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Orthopaedic Nurses.

Copyright © 2017 The Author(s). Orthopaedic Nursing • January/February 2017 • Volume 36 • Number 1 23

well-coordinated delivery system. Nurses have this
unique clinical knowledge, making them ideal for navi-
gating care across the continuum.

The American Academy of Ambulatory Care Nursing
has identifi ed nine key competencies for care coordina-
tion and transition management to include support for
self-management, education and engagement of pa-
tients and families, cross-setting communications and
care transitions, coaching and counseling of patients
and families, nursing process (a proxy for monitoring
and evaluation), teamwork and collaboration, patient-
centered care planning, population health manage-
ment, and advocacy ( Haas, Swan, & Haynes, 2013 ). The
Medical-Surgical Nursing Certifi cation Board and the
American Academy of Ambulatory Care Nursing have
collaborated to provide a certification in Care
Coordination and Transition Management. Information
is available at https:// .

We can only improve the care and health of populations
if we truly understand the care we deliver. Understanding
the care requires data. Nurses in the transformed
healthcare system will need to be able to gather data
and track clinical and fi nancial data over time and
across settings. Tracking of key metrics (treatments,
health status, functionality, quality of life) must occur at
the individual and population levels. This gives needed
information to understand the particular issues the in-
dividual patient is facing. However, “if you only look at
an individual’s health, you can miss important trends
across a group of patients within a population or com-
munity” ( Appold, 2016, p. 1 ). Improving care at the indi-
vidual level requires consideration of information on
the population from which the individual is drawn.

The fi rst step in understanding populations is to have
a much deeper understanding of the patient population
in order to drive better outcomes. Practice-based popu-
lation health is defi ned as an approach to care that uses
information on a group (“population”) of patients
within a care setting or across care settings (“practice-
based”) to improve the care and clinical outcomes of
patients ( Cusack, Knudson, Kronstadt, Singer, & Brown,
2010 ). To achieve the triple aim, it will be essential that
we track outcomes over time related to psychosocial
status, behavior change, clinical and health status, satis-
faction, quality of life, productivity, and cost. These data
are used in predictive modeling to stratify the popula-
tion according to disease state or risk profi le. This infor-
mation can then be used to engage patients in timely,
proactive, tailored manner based on their needs. Using
stratifi cation, those at no or low risk will be recipients of
health promotion and wellness and care. Those at mod-
erate risk will require more intensive interventions,
ranging from health risk management to care coordina-
tion and advocacy. Those who are at high risk and are
high utilizers require further disease or case manage-
ment services ( Care Continuum Alliance, 2012 ;
Verhaegh et al., 2014 ). These data are used at the indi-
vidual level to align the type of care with the patient
need and at the organizational level to focus resources
on segments of the population at greatest need.

Outcome data are one piece of the information needed
for improvement. With outcomes in mind, one needs to
examine what can be done to improve outcomes related
to the experience, effi ciency, or effectiveness of care. Use
of shadowing as a technique to examine the real-time
care experience provides valuable data on process fl ow,
patient experience, and team communication. Seeing
care through the eyes of the patient allows for an assess-
ment of the current state and development of improved
processes that are grounded in information provided by
patients and families ( DiGioia & Greenhouse, 2011 ;
Marcus-Aiyeku et al., 2015 ). Combining shadowing data
with Lean Six Sigma methodology or with rapid-cycle
improvement processes is an approach for ongoing qual-
ity improvement that must be integrated into role expec-
tations of the professional care team.

This is not an independent effort. In today’s practice
environment, interprofessional learning collaboratives
targeting specifi c populations (i.e., joint replacement,
elder hip fracture) are forming within and across or-
ganizations. These collaborative groups as organized
through quality departments, local hospital associa-
tions, the Institute of Health Innovation, and
professional medical and nursing associations use
benchmark data, shared either from their own facili-
ties or from registries (i.e., the American Joint
Replacement Registry) to examine variations in pa-
tient outcomes. This is complemented by discussions
and sharing around best practices and system ap-
proaches to improvement that can be implemented in
rapid improvement cycles at the point of care where
the interprofessional team collaborates on an identi-
fi ed problem, process issue, or care gap, looking to-
gether for what is best for the patient.

There is no doubt that nurses are poised to assume roles
to advance health, improve care, and increase value.
However, it will require new ways of thinking and prac-
ticing. Shifting your practice from a focus on the dis-
ease episode of care to promoting health and care across
the continuum is essential. Truly partnering with pa-
tients and their families to understand their social con-
text and engage them in care strategies to meet patient-
defi ned outcomes is essential. Gaining greater awareness
of resources across the continuum and within the com-
munity is needed so that patients can be connected with
the care and support needed for maximal wellness.
Tracking outcomes as a measure of effectiveness and
leading and participating in ongoing improvement to
ensure excellence will require exquisite teamwork as ex-
cellence crosses departments, roles, and responsibili-
ties. “Nurses can no longer take a back seat—the time
has come for nursing, at the heart of patient care, to
take the lead in the revolution to making healthcare
more patient-centered and quality-driven” ( Salmond,
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For 28 additional continuing nursing education activities on
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