ANA's Response to the AHCPR's Proposed Nursing Research Agenda

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The American Nurses Association's
Response to the
Agency for Health Care Policy and Research's
Proposed Nursing Research Agenda

Submitted on December 20, 1996

* The following comments were submitted to the Agency for Health Care Policy and Research (AHCPR) in the form of a letter in response to the proposed nursing agenda found in the Federal Register (November 13, 1996, Vol. 61, No. 220:58194-58195).

The American Nurses Association (ANA) appreciates the opportunity to comment and provide additional input into the development of a nursing research agenda which examines the impact of nurse staffing on the quality of care in hospitals. Professional nursing has expressed concern about the health care industry moving ahead with restructuring, reorganization and downsizing without any reliable data on the effect of these changes on patient care and on health care providers. Your leadership is to be applauded in developing and moving forward this agenda to show the links between nursing interventions, staffing levels and patient outcomes.

We are pleased that AHCPR is working with both NINR and the Division of Nursing. Overall, the list of proposed priority research topics appears to be concise, yet comprehensive, well formulated and clearly linked to the Institute of Medicine's report, Nursing Staff in Hospitals and Nursing Homes -- Is it Adequate? We would strongly concur that each of these research topics is applicable to settings beyond the hospital. The diversity of settings where care is provided is continually expanding. Further, non-hospital, long-term care and community settings have staffing and quality of care issues that will increase as the "baby boom" generation continues to age.


We concur with the key points in this section: 1) the need for standardization of conceptual as well as operational definitions of variables; 2) identification of the characteristics of the nurses providing care; 3) what nurses actually do; and 4) workplace organizational characteristics. Since the late 1970's, ANA has devoted much effort to the standardization of nursing nomenclatures and the adoption of ANA-recognized nomenclatures into clinical documentation systems. We have more recently initiated efforts to provide collection of standardized data regarding staffing levels, mix and outcomes of care.


We also concur that an evaluation of organizational factors and delivery of care factors must be conducted as part of studies directed toward examining relationships between nurse staffing and quality of care. Elements of organizational factors and delivery of care factors are discussed below.


Research Question #1 - What is the relationship between the organization and delivery of nursing care and patient outcomes?

The importance of nurse-sensitive quality measures is essential to understanding the relationship between the delivery of nursing care and patient outcomes. ANA has worked through its Safety and Quality Initiative to identify links between nursing care and quality outcomes. Further research on these measures will potentially improve the quality of patient care by promoting both the science of outcomes and the field of nursing and by identifying indicators essential in determining the appropriate staffing and skill mix. Thus far, ANA has focused on and defined the following quality indicators for acute care settings:

  • Nosocomial Infection Rate
  • Patient Injury Rate
  • Patient Satisfaction with
    • Nursing Care
    • Pain Management
    • Education Information
    • Overall Care
  • Maintenance of Skin Integrity
  • Nurse Staff Satisfaction
  • Mix of RNs, LPNs, and Unlicensed Staff Caring for Patients in Acute Care Settings

ANA commissioned a pilot project which has demonstrated statistically significant inverse relationships between the percent of registered nurse staffing and selected adverse outcomes of patient care. (1)(2) ANA has implemented the Quest for Quality Health Care . This project will implement collection and analysis of the quality indicators identified in Nursing's Report Card for Acute Care (3) in acute care settings. Further, the Quest for Quality Health Care also has been instrumental in establishing conceptual and operational definitions for the set of nursing-sensitive patient outcomes listed above. Work is now underway to develop similar definitions for nursing workforce variables, including the intensity of nursing care. ANA is also moving immediately to the next phase of the Safety and Quality Initiative: developing indicators of quality care for non-hospital and community settings. These activities can serve as foundations for the necessary research that will follow.

As ANA continued its work on Nursing's Quality Indicators for Acute Care Settings, it became clear that while we recommend surveying patients and nurses for satisfaction, we are not able to identify with precision the instruments or the criteria which could be used. This, we believe, will be essential in order to standardize what is being evaluated and how the evaluation is done, and to facilitate comparison of findings. Therefore, ANA strongly recommends that research be funded that seeks to identify the essential elements which evaluate satisfaction levels of staff nurses and patients. In addition, research needs to be undertaken that identifies the essential elements in patient classification instruments used to determine staffing and skill mix.

Research Question #2 - What are the unique skills and the mix of registered nurses and other nursing and ancillary staff that impact on outcomes?

Nursing is a cognitive discipline first, and a practice discipline second. Practice is the application of a large reservoir of knowledge with well developed critical thinking abilities provided by registered nurses. The reservoir of nursing knowledge has indicators of educational levels, certification status, experience base of the nurse and record of seeking and obtaining continuing education, all of which must be examined to determine their relationship to the impact of registered nurse care on patient outcomes. In addition, ANA believes that the end result of analysis and comparison of the nurse sensitive structure and outcomes data will yield answers to the appropriate number and mix of nursing staff to maintain and improve the quality of patient care.

Research Question #3 - What specific organizational variables and delivery of care variables are related to specific patient outcomes?

We are assuming that the question related to organizational variables is directed to specific types of health care facilities (e.g., hospitals, nursing homes, home health care agencies, etc.), rather than the American healthcare system. Organizational variables other than the models used for direct patient care, might include: financial (e.g., capital expenditures, not-for-profit versus for-profit status), the administrative structure (centralized, decentralized, etc.), linkages to health care education, and a myriad of other factors. There are substantive sources in the health service research literature exploring these variables. These organizational variables critically affect nursing staffing and the ability of the registered nurse to provide quality patient care. For example, if capital expenditures are inadequate or inappropriately directed, there may be insufficient resources for the registered nurse to provide the required teaching, counseling and physical care for patients.

Of the various delivery of care models, critical components for nursing include nursing practice models, professional practice models and governance models. Allred provided a definition of a model of nursing practice as "a structure used to deliver patient care." (4) This is similar to the concept that a practice model is a "configuration of nursing practice or a pattern for the delivery of patient care." (5) Hoffart and Woods (in press) provide a clear distinction among the three structures when they define a professional practice model as "a system (structure, process and values) that supports registered nurse control over the delivery of nursing care and the environment in which care is delivered," and a governance or management model as "the structure and processes used to make decisions related to unit and organizational operations."

Each of these models, as well as others, influences the ability of registered nurses to provide quality patient care. Simultaneously, they affect all non-nurse practitioners as well. Thus, critical analysis of the models adopted by a healthcare organization is essential in research projects examining the impact of nurse staffing on patient care.

In addition, the American Academy of Nursing's Magnet Hospital program examined two questions: 1)What are the important variables in the hospital organization and its nursing service that create a magnetism that attracts and retains professional nurses on its staff? and 2) What particular combination of variables produces model(s) of hospital nursing practice in which nurses receive professional and personal satisfaction to the degree that recruitment and retention or qualified staff is achieved? As a result of this program, the following variables that facilitate professional nursing practice were identified.

  1. Nurse Autonomy
    • A supervisory staff that is supportive of the nurses
    • Nursing controls its own practice
    • Freedom to make important patient care and work decisions
    • Not being placed in a position of having to do things that are against my nursing judgement
    • A head nurses/supervisor who backs up the nursing staff in decision making, even if the conflict is with a physician
  2. Control over the practice setting
    • Adequate support services allow me to spend time with my patients
    • Enough time and opportunity to discuss patient care problems with other nurses
    • A head nurse who is a good manager and leader
    • Enough staff to get the work done
    • Opportunity to work on a highly specialized patient care unit
    • Patient care assignments that foster continuity of care, i.e., the same nurse cares for the patient from one day to the next
  3. Nurse Relations with Physicians
    • Physicians and nurses have good relationships
    • A lot of team work between nurses and doctors

Given the historical fluctuation of the nursing workforce, research which validates these variables as significant to the recruitment and retention of nurses -- altered to allow for adaption to other settings -- would be extremely valuable.

Research Question #4 - What is the impact of computer technology on patient outcomes?

This particular question needs to be broadened to information technologies as these technologies will be key factors in informing nurses' decision-making and in optimizing the acquisition, manipulation and dissemination of information. The impact of information technologies on nurse staffing, nurse skill mix, and the quality of care must be carefully evaluated before there is wholesale adoption of any particular technology or set of technologies. This issue needs to be a high priority in the research agenda as the health care industry already is incorporating a myriad of unevaluated information technologies as fast as the market produces them.

Research Question #5 - What is costworthy in an era when limited resources are available for hospital care?

ANA is concerned about the wording of this question because it assumes that we must restrict spending for direct care. There may be other more appropriate areas to reduce costs. In addition, it will be necessary to consider what kind of research and data can complement the ethical issues inherent in constructing and using a framework which ensures that quality is not compromised by efforts to cut or control costs.

Where research looks at limited resources, the focus must be on the patient outcome, especially across the continuum of healing. There is, for example, the effectiveness of nursing interventions on a specific nursing problem, during an episode of acute care. There may be a positive outcome during the acute care episode; but, since healing and recovery continues long past hospitalization (especially in these days of radically short stays), it is essential that the evaluation of outcomes of care not be limited to the initial setting. Patients must be followed for a sufficient period of time (e.g., 18 months) to evaluate accurately the cost impact (financial, societal and human) of initial interventions, ongoing care, and the patient's own healing responses on the patient's recovery, stabilization or death. It is only this long-term perspective on the evaluation of health care that will provide the answers to all of the above questions and to the more fundamental societal questions of the cost and quality of health care interventions.


Question #1 - What is "adequate" versus "inadequate" staffing and how can this be determined while accommodating the complex heterogeneity of patient populations and nursing staff?

Question #2 - What is the impact of staffing and skill mix on nursing staff health and productivity, both in the short-term and the long-term? What are the implications for safety and quality of care?

The IOM report notes that while the injury and illness rate in private industry has remained stable or declined since the 1980s, the rates for hospitals and nursing homes have increased by about 52 percent in hospitals and 62 percent in nursing homes. Health care workers are increasingly being exposed to dangerous hazards in the workplace. The IOM committee "was struck by the high rate of injuries to nursing personnel in both hospitals and nursing homes, but except for back injuries the committee is unable to substantiate conclusively any linkages among staffing numbers, skill mix, and work-related problems." ANA considers replication of the study completed by the Minnesota Nurses Association on the safety and health effects of staff reduction to be crucial. This study found a positive relationship between hospital downsizing in Minnesota and the incidence of workplace injury and illness among registered nurses. In the near future, ANA will provide additional information on the structure of this particularly research project.

In addition, the National Institute for Occupational Safety and Health (NIOSH) in its National Occupational Research Agenda has identified two areas which are particularly relevant to the work of AHCPR, NINR and the Division of Nursing. NIOSH's Agenda provides a framework to guide occupational safety and health research in the next decade.

First, NIOSH's health service research agenda reads as follows:

"Health services research includes assessment of the way in which health care is organized and paid for and the effectiveness of the treatment and prevention of diseases and injuries. This research, which provides much of the data necessary for the formulation of health policy, is largely undeveloped when it comes to occupational safety and health. Diverse approaches to care are urgently needed to address important concerns about access to care for work-related problems, quality of care (including clinical and preventive practice guidelines), health professional needs and availability, and cost and service utilization patterns."

The second significant agenda item relates to the organization of work.

"Organization of work refers to the way work processes are structured and managed. In addition, to the long recognized job stress associated with aspects of work organization, studies are now identifying its contributions to other diverse health problems, including musculoskeletal disorders and cardiovascular diseases. Research is needed to better understand how work organization is being influenced by the changing economy and workplace and what the potential effects are on worker safety and health. Research opportunities include surveillance, etiologic studies of risk factors and intervention strategies to mitigate adverse work organization factors and outcomes."

NIOSH recognizes that the workforce is aging rapidly and becoming increasingly diverse. With trends such as re-engineering and downsizing and as temporary or part-time jobs become more common, adverse effects are likely to occur. Resulting effects include increased work load demands, longer and more varied work shifts, and job insecurity. What is unclear is the overall impact of these changes in work on the health and well-being of the worker.

NIOSH has taken an enormous step forward in identifying these types of concerns from an occupational safety and health standpoint. ANA believes that much would be gained by full collaboration among NIOSH, AHCPR, NINR and the Division of Nursing to move this priority forward.

Question #3 - Where are the cost/benefit analyses of formalized health system accreditation processes and the accompanying myriad standards?

While in theory ANA supports such systems, we do know that the cost of responding to these is enormous and divert organizational resources from the direct delivery of patient care. It is time to research and develop empirical data to substantiate the inferred link between accreditation and positive patient outcomes.

In terms of the overall process, ANA strongly recommends that where oversight committees or expert panels are convened there be significant representation of frontline, hands-on health care providers. It is critical that the nurses whose practice is impacted most by changes in delivery systems, downsizing and changes in skill mix and who have the most direct experience with the impact of these changes on patient care have input into the direction and evaluation of this research.

* ANA is especially concerned about funding for this agenda. ANA does not believe that funding should be a barrier to initiating complimentary research projects and has offered to work with the AHCPR in the development and implementation of this agenda.

For more information on the NIOSH agenda, National Occupational Research Agenda, you may call (800)-35-NIOSH or visit


  1. American Nurses Association. (in press). Implementing Nursing's Report Card: A Study of RN Staffing, Length of Stay and Patient Outcomes. Washington, DC: Author.
  2. Percent of RNs = number of RNs divided by total nursing personnel on a given hospital patient care unit.
  3. American Nurses Association (1995). Nursing's report card for acute care. Washington, DC: Author.
  4. Allred, C.A., Michel, Y., Arford, P.A., Carter, V., Veitch, J.S., Dring, R., Beason, S., Hiott, A.J., & Finch, N.J. (1994). Environmental uncertainty: Implications for practice model redesign. Nursing Economic$, 12, 318-326.
  5. Poulin, M. (1985). Issues in professional nursing practice: 5. Configurations of nursing practice. Kansas City, MO: American Nurses Association.

For more information regarding the Policy Series, contact policy products specialist at (202) 651-7022. If you have specific questions about this document, please mention No. 96-GOV-10.