Focus on…Quality and Patient Safety


Nurse staffing and patient experience outcomes: A close connection

As healthcare providers set and refine their strategies for staying competitive in a value-based delivery and payment system, a sharper understanding of the interplay between inputs and outputs becomes a strategic imperative. Nurse staffing is a key input for acute-care hospitals—key both for its impact on care and its budget prominence. This puts it squarely at the center of hospitals’ efforts to deliver on their value promise.

The relationship between staff­ing and patient outcomes across quality, safety, and experience domains is appreciated intuitively, if not always precisely understood. The imperative to strike the perfect balance drives considerable interest and research in fine-tuning this understanding. Yet vast scholarship on the topic hasn’t produced a precise staffing formula that will lead predictably to desirable outcomes.

That’s because high-quality nursing care hinges on much more than the number of nurses on the job for a particular patient load. It also depends on multiple under­-lying structural and process factors, such as nurses’ skills and education, availability of sufficient supplies and equipment, staff training, facilities, and reliable use of demonstrated best nursing practices—as well as such factors as interprofessional relationships, nurse engagement, and job satisfaction.
To fully understand the impact of staffing levels on patients’ clinical and experience outcomes, we must consider the relationships within and among these variables—something we can do only through data integration and cross-domain analytics.

Value of NDNQI data

In 2014, Press Ganey acquired the National Database of Nursing Quality Indicators® (NDNQI®)—the industry gold standard for assessing nursing excellence—from the American Nurses Association. NDNQI national benchmarking data are invaluable for monitoring key nursing-sensitive structure, process, and outcome measures. Similarly, Press Ganey’s vast patient experience database offers critical insight into patients’ perceptions about the effectiveness of hospital operations, clarity of the care team’s communication, and caregivers’ ability to meet patients’ needs.

As with nurse staffing, a growing body of evidence shows associations between patient-experience outcomes and clinical outcomes. Combining NDNQI and patient-
experience data provides unprecedented access to the relationships among key pieces of information. Together, these measures can help nurse leaders identify how performance changes in certain structural and process indicators affect patient safety, experience, and clinical outcomes.

Given the enormous impact of nursing on the patient experience—and because nurse staffing often is a lightning rod in the debate on how to deliver high-value care—using the combined dataset to better understand how the two relate is a research priority. Our early analyses show that performance on both Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains correlates significantly with nursing hours per patient day and RN hours per patient day, with the latter showing stronger associations in every domain. (See Correlations between nurse staffing and HCAHPS scores.) The link between more bedside nurses and a better patient experience isn’t surprising. That the correlations stretch across all experience domains—not just those that examine quality and frequency of nurse-patient interactions—is eye-opening.

Correlations between nurse staffing and HCAHPS scores

Staffing that meets patient needs and reduces suffering

While domain-level correlations confirm long-held beliefs about the relationship between staffing and patient experience, we seek to understand which aspects of the patient experience are most sensitive to staffing. Where do staffing levels make a difference in caregivers’ success in meeting patient needs? Where can staffing serve as a lever to improve performance?
Item- and question-level analyses help answer these questions. In the two tables HCAHPS scores and nursing hours per patient day and Press Ganey mean score, we see that for HCAHPS top-box scores and Press Ganey mean scores, every item showed sensitivity to staffing levels. Where the difference in patient experience scores is greatest (meaning when hospitals in the top decile of staffing ratios dramatically out­-perform hospitals in the bottom decile), staffing can be viewed as a more powerful performance-improvement lever.

HCAHPS scores and nursing hours per patient day

Reducing patient suffering

Of particular interest are differences in performance on key patient-experience questions related to patient suffering, which may indicate how effectively an organization provides patient-centered, personalized care. Press Ganey staff believe that relieving suffering should be central to efforts aimed at providing patient-centered care.

Patient suffering falls into two categories:

  • Inherent suffering results from the patient’s diagnosis, treatment, or both. It can’t be avoided entirely, but it can be mitigated. Some types of inherent suffering are well understood and addressed with some consistency—for instance, using pain control and explaining and managing symptoms. Inherent suffering includes psychosocial suffering, which caregivers are less comfortable with and therefore less practiced at addressing. Such suffering includes fear, anxiety, confusion, loss of dignity and autonomy, and uncertainty about self-care after discharge.
  • Avoidable suffering arises from systemic defects, which may include long waits to receive treatment, poor communication, poor coordination among providers, errors, and failure to follow best practices. An important first step in determining how to avoid that kind of suffering is to understand that dysfunction creates additional suffering for people already burdened by inherent suffering.

Inherent suffering can be reduced by understanding and meeting inherent patient needs. Performance on certain patient-experience survey questions can tell caregivers much about how well they’re meeting patients’ needs. Examining the relationship between staffing ratios and performance on these questions is illuminating. The table Reducing suffering: Top-decile vs. bottom-decile hospitals illustrates the dramatic differences in performance between top-decile and bottom-decile hospitals on questions relating to patient anxiety, autonomy, and the need to be informed about and involved in their care. These differences speak volumes about the importance of adequately resourced nursing units to give caregivers sufficient time to meet these patient needs.

Reducing suffering Top-decile hospitals

It’s never just one thing

These findings don’t suggest that increasing nurse-patient ratios will automatically lead to performance improvements. Certainly, adequate nurse staffing is key to a range of outcomes, but changing staffing volume alone won’t produce optimal outcomes. Multiple aspects of structure and process also shape outcomes, and these findings must be leveraged with that in mind.

Such factors as demographics of the nursing force, education and certification, engagement, and organizational staffing models are associated with patient-experience outcomes, as are cultural and structural practices and processes. In this regard, answers to the questions below also factor into outcomes:

  • Is the nursing staff following best practices associated with better patient experiences?
  • Are they executing on those best practices consistently and in the prescribed manner every single time?
  • Do nurses have the right resources and training to promote consistency?

For example, a best practice such as purposeful hourly rounding on patient experience can have a dramatic impact. A 2013 Press Ganey study shows that patients who report they were visited by staff hourly during their hospital stay were much more likely to give top box scores on all HCAHPS questions—a clear sign their needs were being met more consistently. See the table Effect of hourly rounding on HCAHPS scores for details.

Effect of hourly rounding on HCAHPS scores

The concept of value over volume extends beyond changes to delivery and payment models. For hospitals, “getting it right” with their nursing organizations is particularly important because nursing care provides much of the value hospitals create. Adequate human resources are critical, but they’re not enough on their own. Nurse leaders must consider the full range of inputs—in addition to adequate human resources—that drive outcomes, including staff quality or caliber, the environment in which they operate, and shared commitment to providing a high-value experience for patients.

Nell Buhlman is senior vice president of Clinical and Quality Solutions at Press Ganey Associates in South Bend, Indiana. Note: Charts are copyrighted by Press Ganey and used with permission.

Selected references

Armstrong K, Laschinger H, Wong C. Workplace empowerment and Magnet hospital characteristics as predictors of patient safety climate. J Nurs Care Qual. 2009;24(1):55-62.

Dempsey C, Reilly B, Buhlman N. Improving the patient experience: real-world strategies for engaging nurses. J Nurs Adm. 2014; 44(3):142-51.

Halm MA. Hourly rounds: what does the evidence indicate? Am J Crit Care. 2009;18(6): 581-84.

On the road to zero CAUTIs: Reducing urinary catheter device days

Catheter-associated urinary tract infections (CAUTIs) are common healthcare-associated infections that can prolong lengths of stay and increase morbidity and mortality. Despite their best efforts, many hospitals continue to struggle with climbing CAUTI rates. Recognizing inappropriate or prolonged urinary catheterization as a primary risk factor, our team decided to target urinary-catheter device days as a way to reduce CAUTIs.

The specific aim of this quality-improvement initiative was to decrease the number of urinary catheters inserted and reduce the time they stayed in place. Each additional day of indwelling catheterization further increases the risk of developing a CAUTI. We anticipated that by inserting fewer catheters and removing them earlier, we would decrease CAUTI incidence.

Targeted areas for improvement included all five of the noncritical care units at our 140-bed community medical center. At the start of this initiative, our critical care unit was exceeding at preventing device-associated infections, but our medical-surgical units were seeing a higher-than-expected CAUTI incidence. As we approached 2013, a system-wide task force was poised to introduce several evidence-based initiatives aimed at reducing CAUTIs.

In addition to the task-force solutions intended to standardize the evidence-based processes used with urinary catheters, our team added several other strategies to enhance our culture of safety and accountability around urinary catheters. To monitor our progress, we identified the urinary catheter device-utilization ratio (DUR) and actual number of CAUTIs as performance measures. Reported monthly, the DUR reflects the proportion of total patients with indwelling urinary catheters. Before our project began, validation studies were done to ensure the accuracy of DUR reporting. CAUTIs were identified and reported by the infection preventionist.

Electronic solutions

In January 2013, we implemented several electronic solutions to support our goal of reducing urinary catheter device days. We also implemented evidence-based indications for urinary catheter insertion and maintenance, based on guidelines from the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Association for Professionals in Infection Control and Epidemiology (APIC), recommended by the system-wide task force for CAUTI prevention. (See Evidence-based indications for indwelling urinary catheters).

Time-limited catheterization orders and a nurse-driven protocol for catheter removal were the primary electronic solutions supporting this initiative. We also implemented:

  • an algorithm for bladder scanning and intermittent catheterization for failure to void
  • electronic alerts to remind physicians and nurses when a temporary catheter had been in place more than 48 hours
  • revised nursing flowsheets to align our documentation with intervention-bundle recommendations from HICPAC and APIC.

These interventions reinforced our commitment to keeping each catheter in place only as long as medically indicated.

Clinician education and training

Recognizing the importance of clinician education and training to
im­prove outcomes and prevent complications related to urinary catheters, we partnered with the manufacturer of our urinary cathe­ters to develop and implement a training program aimed at expanding knowledge and improving catheter insertion and maintenance competencies. Each unit identified a nurse champion to attend this special training event. In addition to acquiring knowledge and skills, champions learned strategies for sharing the information at the unit level.

As part of the training program, skill stations were set up to review competencies and update techniques. Training emphasized the maintenance bundle and daily reevaluation of the continued need for a catheter.

Nurses aren’t the only clinicians who interact with catheterized patients, so a special session was held for non-nursing staff, such as physical therapists and transport personnel. This contributed to an overall increase in bundle compliance.

Improving our culture of safety

The final and most challenging aspect of this initiative was implementing interventions aimed at improving our culture of safety and accountability around urinary catheters. We recognized this as the most crucial step to sustaining the change. Our goal was to transform our culture from one where the urinary catheter is considered the norm for certain types of patients to one where it’s seen as an exception.

Daily review of all catheters

The team implemented a daily review of all catheters, including the indication for the catheter and patient’s length of stay, at unit-based shift huddles and the daily hospital-wide safety huddle. Sharing this information in as many forums as possible provides an opportunity for peer coaching and peer checking. It encourages nurses to challenge each other about the patient’s ongoing need for a catheter and offers a forum to suggest alternatives.

Partnering with physicians also was crucial to the success of our project. To gain physicians’ participation and input, we incorporated a review of urinary catheters at daily interdisciplinary rounds. This promoted further collaboration and teamwork around this initiative.

Finally, we engaged patients and family members, explaining the risks associated with catheterization and setting the stage for early removal at the time of catheter insertion. One of our best strategies has been to educate patients so they request early catheter removal.

Redundant auditing processes

To monitor the effectiveness of our interventions, we established redundant auditing processes to determine compliance with evidence-based recommendations for in- sertion and care maintenance bundles. (See Maintenance bundle audit elements.) Clinical nurses on each unit, nurse leaders across the organization, and third-party auditors from the clinical effectiveness department participate in the audit process. Results are shared at the unit level and with relevant committees and workgroups. Trends are identified and analyzed to help determine solutions.

Compliance with each bundle element as well as overall compliance has risen steadily since implementation. For October 2014, the overall urinary catheter bundle compliance rate was 94.7%. A true measure of success for this project has been the steady decline in urinary catheter device days and the actual number of CAUTIs. (See Statistics tell the story.)

Nurses at all levels can influence patient outcomes in a positive way. By focusing on evidence-based prevention strategies and promoting a culture of safety and accountability, we were able to exceed our goal for reducing urinary-catheter device days. We saw a shift in culture when our nurses began leading the way by advocating for fewer catheter insertions and promoting earlier removal. As a result, we are well on our way to zero CAUTIs—and your organization can be, too. 9

Editor’s note: For more information about CAUTI, see “ANA CAUTI Reduction Tool” at

Selected references

Association for Professionals in Infection Control and Epidemiology. Guide to Preventing Catheter-Associated Urinary Tract Infections. April 2014.
Accessed November 3, 2014.

Centers for Medicare & Medicaid Services. Catheter-Associated Urinary Tract Infections (CAUTIs). Accessed November 14, 2014.

Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-26. Accessed November 3, 2014.

Institute for Healthcare Improvement. How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Updated December 2011. Accessed November 14, 2014.

Catherine V. Smith is a clinical nurse specialist at Sentara Williamsburg Regional Medical Center in Williamsburg, Virginia.

Developing a quality framework for annual nursing competencies

Patients expect safe, high-quality care when they enter a healthcare facility, and healthcare facilities pride themselves on the care they provide. With so much emphasis on quality, many people were shocked in 1999 when the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System. This report estimated that 44,000 to 98,000 preventable medical errors occur each year and called for a greater focus on safe, high-quality care in the U.S. healthcare delivery system.

With the problem clearly identified, healthcare facilities have since been brainstorming ways to improve the quality of care they provide. In 2005, the Robert Wood Johnson Foundation funded “Quality and Safety Education for Nurses” (QSEN), an initiative that identified six key areas of focus building on the IOM’s recommendations—patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

QSEN sought to infuse these six key areas into nursing education programs throughout the country. The original pilot programs saw great success. The academic side has been developing a clear, consistent framework of high-quality, safe nursing care. But in the clinical environment, segregated changes have occurred with no consistency among organizations.

This perception intensified when the 2010 IOM report The Future of Nursing: Leading Change, Advancing Health found that quality and safety issues are still prevalent. The report called on healthcare organizations to strengthen continuing-education programs. With this call, an opportunity to integrate QSEN competencies into clinical education has emerged. The framework and standardization of QSEN, based partly on the IOM reports, may be the answer to the need for a structured response to healthcare quality and safety.

QSEN as a model

Seeing an opportunity for quality improvement (QI), I began a QI project focusing on a large teaching hospital in central Pennsylvania. Although the nursing education department and 25 clinical educators form the backbone of annual competency development, they lacked a standard format to guide them from year to year. Nursing leaders at this hospital, which has more than 1,500 nurses in dozens of care areas, were challenged to find a way to hold competencies to a standardized plan while allowing for the unique needs of each unit.

Realizing the QSEN initiative could serve as a model for solving this dilemma, I approached the director of education about a QI project through which to imbed key quality and safety focus areas in a standardized framework for annual competencies. The project was quickly approved, and I posed the following question to guide it: Regarding acute-care clinical nurse educators, what are the effects of a QSEN-based workshop on educator knowledge and ability to develop evidence-based, safe, quality care competencies compared to pre-education knowledge and ability?

Project description

After receiving approval from the institutional review boards of my educational institution and the hospital serving as the project site, I developed an educational plan, which the hospital’s director of nursing education approved. At a staff meeting scheduled before the design of competencies for 2013, I described the project to all educators present; all of them gave their consent to participate.

After the educators completed a pre-knowledge and confidence survey, they viewed a presentation covering the current state of competency design, the gap related to quality and safety, and the ability of the QSEN project to serve as a foundation for a framework. The presentation covered each individual competency area in detail. After the educational session, attendees completed a post-knowledge and confidence survey.

After the live educational session, biweekly emails were sent to all consenting participants over the next 26 weeks. The emails were designed to support educators as they began to design competencies for the 2013 competency year. Topics included a focus on the six key competency areas as well as competency design and overall support for the nurse educator role. Once the 13 biweekly emails were sent and the 2013 competency year was underway in the nursing education department, a summative follow-up computerized survey was sent to solicit final thoughts on the project and the ability to improve the quality and safety aspect of annual nursing competencies. I met with the nurse-educator group for a final summary and wrap-up meeting.

Results of knowledge and confidence surveys

Twelve participants completed the pre- and post-surveys around the live educational session. Quantitative data analysis using statistical computerized software showed significant differences in educators’ knowledge of the QSEN competency project, confidence in designing and implementing annual competencies, and potential for competency development in such key areas as informatics and collaboration. The analysis found marked improvements in educator confidence in designing competencies within the various quality and safety areas after the educational intervention.

Qualitative data analysis of the pre-education surveys showed many focus areas where educators couldn’t identify examples of competencies. But in the post-education survey, educators gave examples for all categories. For patient-centered care, they submitted such competencies as early mobilization and pain control. For informatics, they submitted medication documentation and exit care (patient-education material). Other categories yielded similar responses. Compared to pre-education qualitative data, post-education data showed an overall increase in educator confidence and knowledge in designing competencies in most of the quality and safety areas.

Final survey results

After the biweekly emails and launch of the 2013 competency year, the summative computerized survey was sent; the response rate was 7/12 (58%). The eight survey questions explored how the framework of quality and safety focus areas affects nursing competencies and educators’ ability to design them. All respondents said the framework helped them to better focus and measure competency, specifically in the areas of quality and safety; 88% believed adding the framework strengthened the overall process of competency measurement. A request to identify specific competencies used for each of the six focus areas yielded many responses—except in the informatics area, which got no specific responses. (See Major themes of qualitative survey results below.)

Major themes of qualitative survey results

Qualitative results were analyzed for themes. Three major themes came through:

• Keeping quality and safety at the forefront of the competency program required the framework presented.
• Respondents appreciated the evidence base for the process of competency development.
• Respondents wished to continue the processes that had been started.


This QI project sought to determine the effects of a QSEN-based workshop on the knowledge and ability of acute-care clinical nurse educators to develop evidence-based, safe, quality-care competencies, compared to pre-education knowledge and ability. The project found that providing a workshop focused on nurse educators’ knowledge and ability to design safe, quality-care competencies made a statistically significant difference in annual competency planning. Everyone involved at the project hospital, from administrators to nurse educators, enthusiastically accepted the overall idea of presenting such a focused framework for acute-care nursing competencies. At the initial education session, it was clear that the nursing education department already was focusing on specific areas to achieve quality care but hadn’t broken the work down into a framework.

The framework provided was consistent to hold all areas of acute care accountable, but flexible enough so each diverse unit could create specific competencies related to its patient population. For example, while all units designed a competency around teamwork and collaboration, the step-down unit’s specific competency differed from that of the surgical intensive care unit.

Not all participants preferred email communication, but they agreed it was helpful to have constant reinforcement of key topics to motivate and empower them when designing competencies. The director of nursing education was especially excited about the project because it provided a specific way to document the work being done toward improving the quality and safety of patient care.

Quality and safety are necessities in health care. The nursing profession must respond in specific ways to calls for a higher quality of care. Starting with annual nursing competencies, a great opportunity exists to make a difference by standardizing a framework of competency design that keeps nursing departments accountable to evidence-based focus areas while sustaining the drive toward quality outcomes. This project is a first step in bridging the gap and improving care in clinical areas.

Selected references

Armstrong G, Headrick L, Madigosky W, Ogrinc G. Designing education to improve care. Jt Comm J Qual Patient Saf. 2012; 38(1):5-14.

Conway ME. Competency control. HomeCare. 2009; March.

Disch J. QSEN? What’s QSEN? Nurs Outlook. 2012;60(2):58-9.

Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.

Joint Commission, The. Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. February 23, 2010.
Accessed November 10, 2014.

Quality and Safety Education for Nurses. Competencies. Accessed November 11, 2014.

Aislynn Moyer is the director of professional development for the Pennsylvania State Nurses Association in Harrisburg.