Quality clinical in NursingQuality:Quality in a product or service is not what the provider puts in. It is what the customer gets out.Quality clinical nursing :Applying Theory to Clinical Practice, Education, and Leadership.QUALITY AND PROFESSIONAL NURSING PRACTICE :As the largest group of health care professionals, nurses contribute in positive and negative ways to the health care quality problem. Nurses have intimate knowledge of patient needs, and the continuous interactions nurses maintain with patients and families uniquely position them to positively influence their hospital experiences and resultant outcomes.In fact, the Transforming Care at the Bedside initiative supports that “RNs play a central role in ensuring the quality of hospital care”. While few reports were found in the professional literature regarding poor nurse quality, perceptions of a decline in quality among hospital nurses an patients have risen in recent years.]In 2001, the Milbank Memorial Fund published a report by Dr. Claire Fagin of the University of Pennsylvania to document these perceptions. The report synthesized research studies, newspaper and magazine articles, and personal experience to conclude that “there is considerable evidence that nurses and families are very concerned about the erosion of care and fearful about hospital safety”.One aspect of the report suggested that the reduction in the amount of time professional nurses spend in direct patient care was a cause. The growinguse of unlicensed assistive personnel (UAP) since the mid-90s has contributed to this perception. Coupled with the nursing shortage, the perception persists thatprofessional nurses are less involved with direct care and more often observed administering medications or supervising others direct care Personal experienceby this author and others substantiates that hospital professional nurses have little time to spend listening to patients’ concerns, coming to know them as unique human beings, educating them about their illnesses, and attending to their needs for comfort, support, and security. In fact, some health care providers advise taking another health professional or reliable family member to the hospital during admissions to ensure high quality care .An important U.S. study of the quality of nursing care found significant variations in nursing care quality. Using a retrospective medical records peer review process, heart failure (HF) and 283 stroke patients’ records were randomly selected from 5 states. Trained nurse peer-reviewers used a quality rating scale based on the nursing process to evaluate the overall quality of nursing care.THE CRISIS OF QUALITY IN HEALTH CARE:In the now famous Institute of Medicine (IOM) reports, health care quality and safety threats were widely acknowledged .In fact, it was estimated that almost 100,000 Americans die annually in hospitals due to errors. In another report, it was recognized that 18% of hospitalized patients experience a serious medication error .Furthermore, using the Centers for Disease Control (CDC).reported health care–associated infections, an estimated 1.7 million infections and 99,000 associated deaths occur each year 2007). A landmark RAND corporation study completed in reported that Americans only receive half of recommended medical care and that having health insurance was not a ticket to quality care. Reports of Americans choosing hospitals in other countries are rising ,and in one northeastern state, a teaching hospital was fined for operating on the wrong side of patients’ heads for the third time . And, in long-term care, “serious problems concerning quality of nursing care . continue to affect residents of this country’s nursing homes”.publicly listed 54 nursing homes as the worst in their states in order to stimulate improvement in their clinical services . What is even worse is that several years after these reports highlighted the rising health care quality crisis, many Americans say they do not believe the nation’s health care has improved; in fact, 40% believe it has gotten worse .Since 2001, quality improvement initiatives and research have documented that while many indicators of quality are improving, many more remain problematic. For example, in a recent supplement to the Joint Commission Journal of Quality and Patient Safety authors cited fatigue, inadequate nurse stiffening levels, and emergency department crowding as persistent threats to patient safety, reported that “significant variation in the quality of care provided by the nation’s hospitals has persisted over the last eight years despite numerous quality initiatives at the hospital, local, state and federal levels "The reality is that American health care professionals remain in denial about the quality of care they provide and the somewhat overt problems that plague the system. The education of physicians and nurses, while slowly changing, remains fact-based and rule-dominated; providers themselves are overworked and do not regularly practice their own self-caring; hospitals and long-term care facilities are slow to change; and reimbursement pressures plague the system.INDICATORS OF NURSING QUALITY :Indicators, or measures, that specifically reflect nursing care are considerednursing-sensitive and are used to evaluate and demonstrate to the public how nursing contributes to the quality and safety of health care recipients, particularly those who are hospitalized. the quality assurance effort in nursing beginning in the early 1970s, developing a model of nursing quality assessment, publishing inpeer-reviewed journals, and conducting numerous workshops advocating10 Quality Caring in Nursing for a standardized nursing language and consulting in both nursing education and nursing service .She helped enhance the knowledge of evidence-based nursing and provided a lens from which to viewand improve nursing quality.In 1995, the American Nurses Association (ANA) embarked on a study of nursing-sensitive indicators from which they could track data linked to nursing care. Using a series of focus groups and a Delphi approach, the ANA identified 10 indicators for acute care while an additional 10 indicators for community-based nursing were added in 2000 (See Tables 1.1 and 1.2 foa list of the ANA indicators.)The ANA’s investment in the program Patient Safety Nurse Quality,a national comparative database of nursing-sensitive quality indicatorsintended to measure the impact of professional nurses on health care outcomes, is used by hospitals to improve the quality of their nursing services. The database, known as the National Database of Nursing Quality Indicators (NDNQI), uses the structure, process, and outcomes indicators that reflect nursing’s contribution to patient care .Figure 1.1 Nursing’s fractured foundationfor a standardized nursing language and consulting in both nursing education and nursing service .She helped enhance the knowledge of evidence-based nursing and provided a lens from which to view and improve nursing quality.OPPORTUNITIES FOR ENHANCING THE QUALITY OF NURSING PRACTICE:The increasing evidence that nursing is a worthy contributor to safe and quality health care is long overdue. While nurses have always known that they are the frontline advocates for high quality and safe care, evidence supporting this link was weak. Continued, methodologically strong research is crucial for enhancing the quality of nursing practice. For example, testing theory-based professional practice models and nursing interventions focused on patient safety and quality in various patient populations is urgently needed to showcase the efforts of professional nursing. Dedicated nursing research teams with expertise in differing populations who are committed to safety and quality questions workingefficiently could expedite such studies. Participatory action research and demonstration projects involving practicing staff nurses using academic/ service partnerships may facilitate more creative solutions that can be implemented and evaluated sooner. Strengthening the nursing workforce through education by providing meaningful experiential opportunities that enable practicing staff nurses to complete baccalaureate degrees efficiently will add to the proportion of more educated nurses. Certification credentials and continuing education in information technology and research skills will enable RNs to capitalize on existing evidence. Although presently underfunded, more nursing educational research will be needed to build a portfolio demonstrating how nurses learn best and what personal characteristics of nurses most impact safe and quality health care .