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What are clinical/patient outcomes and why is important to link them to the care provided? Why is it so difficult to attribute clinical outcomes to nursing performance? What are clinical practice guidelines and what factors affecting their adoption? What strategies can be used to support their implementation?use attached chapter
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Translation of Evidence to Improve
Clinical Outcomes
Julie Stanik-Hutt
PATIENT OUTCOMES MANAGEMENT AND THE APPLICATION OF evidence to practice are
powerful tools that can improve quality of care (The Joint Commission, 2008). The application of these symbiotic processes is the responsibility of all nurses (Foster, 2001).
Since Florence Nightingale, the assessment of patient outcomes has been inextricably
intertwined with nursing care. In fact, Nightingale’s collection and analysis of data regarding morbidity and mortality rates of soldiers under her care in the Crimea contributed to
changes in care and, ultimately, to improved patient outcomes. Its later publication led to
public and political support for the profession of nursing.
The application of the nursing process involves the identification of desired patient
outcomes. Desired patient outcomes are established to direct the application of selected
care interventions. Nursing interventions, based on the biopsychosocial sciences, are developed and implemented with the intention of attaining the established desired outcome.
Finally, results of nursing interventions are assessed and evaluated by comparing the patient’s actual outcomes to the desired outcomes. By doing so, quality and effectiveness of
the delivered care are assessed, and the need for continued or altered care is determined.
The application of evidence-based care is one tool nurses use to improve patient outcomes. Evidence-based practice (EBP) processes can be used to improve care outcomes
one patient at a time or can be used to create clinical practice guidelines (CPGs), which,
when applied in practice, can improve outcomes for groups or populations of patients.
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CLINICAL OUTCOMES
In health care, quality is defined as the “degree to which health services for individuals
and populations increase the likelihood of attaining desired health outcomes and are
consistent with current professional knowledge” (Institute of Medicine [IOM], 1990,
p. 21). Safety is also a component of quality. Safe care is unlikely to injure or harm
the patient (IOM, 2001; Newhouse & Poe, 2005). In addition, the IOM asserts that, in
order for care to be considered high quality, it should also be patient centered, timely,
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efficient, and equitable (IOM, 2001). These characteristics clearly link patient preferences
and care processes with quality (IOM, 1990). Donabedian, the “father” of health care
quality, suggested that care quality could be improved by establishing standards for care
structures and processes. Patient outcomes are the ultimate measures of quality as they
incorporate the influence of both structures and processes of care (Donabedian, 2005;
Van Driel, De Sutter, Christiaens, & De Maeseneer, 2005).
Clinical or patient outcomes are defined as the end results of care that can be attributed to services provided (treatments, interventions, and care). Donabedian (1985)
referred to outcomes as “changes in the actual or potential health status of individual
patients, groups, or communities” (p. 256). Clinical outcomes demonstrate the value and
effectiveness of care and can be assessed for individuals, populations, and organizations
(Hughes, 2008). Outcomes can be either desirable or undesirable (adverse). Outcomes
are quantified or measured through the use of indicators, sometimes also called “metrics.”
Outcome indicators or metrics gauge how patients are affected by their care. Indicators
must be valid and reliable measures that are related to the outcome.
For example, to measure the adequacy of blood glucose control in a patient with
diabetes, you might measure the patient’s finger-stick blood glucose or glycosylated hemoglobin levels. In this case, the finger-stick blood glucose or glycosylated hemoglobin
is the indicator or metric used to measure the outcome of blood glucose control. Indicators or metrics that are reported are referred to as “performance measures” (Dennison &
Hughes, 2009).
Structures that support care and processes that are used to provide care are also
important to care quality and are additional sources of relevant health care outcomes
(Donabedian, 2005; Hammermeister, Shroyer, Sethi, & Grover, 1995). Structure indicators assess the organization and delivery of nursing care. For example, the nurse-to-patient
ratio and skill mix of staff providing care are structure indicators. Process indicators evaluate the nature and amount of care that nurses provide. For example, documentation of
patient teaching or timely reassessment of a patient’s pain after the administration of an
analgesic is an indicator of care processes.
Some ask, “What is the difference between goals, objectives, indicators, and outcomes?” Should they all be called “outcomes?” Outcomes are used to characterize the
result (effect) of an intervention, treatment, or practitioner/provider (cause). This is essentially a cause-and-effect relationship (Parse, 2006). “Goals and objectives are something
to strive for; indicators are signs of progress toward achievement of something, whereas
outcomes are predictors of end-performance” (Parse, 2006, p. 189).
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LINKING OUTCOMES TO CARE
Assessing care outcomes is not the goal in and of itself. Instead, it is important to assess outcomes in relation to the care provided (Minnick, 2009). When outcomes data
are linked to interventions, they provide patients, payers, and practitioners (individuals,
e.g., nurses, nurse practitioners [NPs], physicians, physical therapists)/providers (organizations or agencies, e.g., hospitals, home care agencies) with information regarding the
potential effect that a health care intervention or practitioner/provider can have on their
lives. It can help patients to make decisions regarding their health care (Brooks & Barrett,
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4: TRANSLATION OF EVIDENCE TO IMPROVE CLINICAL OUTCOMES
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1998). The data can also influence a payer’s decision making regarding which services
to cover or which practitioners and providers to include in the network. For example,
outcomes data can be used to compare one treatment for a condition with an alternative
treatment or to compare care provided by different health care practitioners and agencies
(Dennison & Hughes, 2009). Outcomes data are useful to practitioners and providers
because they help them to better understand the effects of the services they provide to
their patients. Outcomes can also be compared with standard levels of performance, the
so-called “benchmarks” or “norms,” to determine whether a service, practitioner, or provider is performing at a level that meets the established norms.
Outcomes can be used by practitioners and providers to evaluate and improve the
care they deliver. The best care comes from practitioners who routinely evaluate care
outcomes and use that data to make adjustments to the care they provide as part of a
continuous quality improvement cycle (Mullins, Baldwin, & Perfetto, 1996). This is often called “outcomes management.” Outcomes management refers to the collection and
analysis, in relation to the processes of care, of information that indicates effectiveness of
care. It provides a “checks and balances” process in the provision of health care. It usually
focuses on aggregated outcomes data on groups of patients with common characteristics—for example, patients with diabetes or asthma or some other health problem. By
measuring and evaluating care outcomes of groups of patients, practitioners can identify
areas of their practice that need improvement. Once problems are identified, practitioners
can seek out evidence-based solutions to implement and evaluate. The effectiveness of
the solution is judged by the new outcomes attained. In this way, outcomes measurement
can be linked to EBP, and both can become “complementary, iterative processes which
contribute to quality improvement” (Deaton, 2001, p. 83).
Minnick (2009) discusses challenges encountered in the design and implementation of evidence-based outcome improvement projects. She emphasizes that the first step
is the identification of the overall outcome that a project is intended to address. A population, intervention, comparison, outcome (PICO) question or other formal purpose statement can be used to start the search for evidence, benchmarks, and other data related to
the desired outcome. A PICO question allows one to explore and link knowledge related
to the topic with the patient population and setting involved and the outcome of interest.
This information, as well as the necessary and available resources to carry out the outcome improvement project, should be verified and reviewed with project stakeholders.
Subsequently, a design for implementing and assessing the effects of the project, specifically the outcomes to be measured, should be identified.
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NURSING OUTCOMES
In the past, the “5 Ds”—death, disease, disability, discomfort, and dissatisfaction—were
the most commonly monitored outcomes of health care quality (Lohr, 1988). They are
outcomes that are easily measured and understood by the public and policy makers.
Donabedian (2005) described the use of patient outcomes of “recovery, restoration of
function and of survival” (p. 692) as indicators of care quality. However, these outcomes
do not adequately represent quality and are not specific to nursing. The first challenge is
to “describe what nurses do (nursing interventions) in response to what sort of patient
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conditions (nursing diagnoses) with what effect (nursing outcomes)” (Marek, 1997, p. 8).
Researchers at the University of Iowa have provided leadership in this area by creating the
Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC)
that link nursing interventions to diagnoses and outcomes. These systems allow the evaluation of care provided by nurses and facilitate communication regarding the same.
In 2003, 15 nursing care outcomes were selected for national reporting on nursing
care performance. They included measures of patient-centered outcomes (death among
surgical inpatients with treatable serious complications, pressure ulcer prevalence, falls
prevalence, falls with injury, restraint prevalence, catheter-related urinary tract infections,
central line catheter–associated blood stream infection, and ventilator-associated pneumonia), nursing-centered intervention processes (smoking cessation counseling for acute
myocardial infarction [AMI], heart failure [HF], and pneumonia), and system-centered
structures and processes (skill mix, nursing care hours per patient day, Practice Environment Scale-Nursing Work Index, and voluntary turnover; Kurtzman & Corrigan, 2007).
Since then, several other patient-centered outcomes (patient satisfaction with pain management, patient education, overall care and nursing care, pediatric peripheral intravenous infiltrations, and psychiatric physical/sexual assault) and system-centered structures
and processes (nursing education and certification, nurse job satisfaction) have been added to the list. In addition to their use in performance reporting, these measures can be
used in research, quality improvement, and health care policy activities. For example,
several of the measures are included in the Robert Wood Johnson Foundation’s Transforming Care at the Bedside initiative.
There are various other outcomes that are of interest to and demonstrate the broader effects of nursing care (Mitchell, 2008). These broader categories of outcomes relevant
to nursing would include physiologic, psychosocial, functional, behavioral, symptoms,
quality of life, knowledge, and satisfaction. Physiologic outcomes would include pulse,
blood pressure, blood sugar and lipid levels, peak expiratory flow rates, weight, skin condition, and many other parameters. Psychosocial outcomes could include the individual’s
mood, attitudes, and abilities to interact with others. An individual’s mobility, physical
independence, and ability to participate in desired activities of daily living are functional
outcomes. For example, the ability of a patient with asthma to engage in physical activities such as walking, exercising, or doing housework is a functional outcome. Behavioral
outcomes could include adequacy of coping with health care needs or a patient’s ability
to follow (adhere to) recommended care. Symptoms, such as pain, dyspnea, fatigue, and
others command attention, independent of the diseases that cause them. Because symptoms interfere with a patient’s physiologic, psychosocial, and functional status and quality of life, nurses are especially interested in their control. Quality of life, another natural
outcome of interest for nurses, is a patient’s general perception of the physical and mental
well-being that can be affected by many factors including disease and injury, stress and
emotions, symptom control and functional status, as well as others. Knowledge level, the
individual’s understanding of health-related information, is another outcome of interest.
For example, a patient’s understanding of the causes of asthma and factors that can trigger
and prevent exacerbations would be important to nurses because teaching patients and
supporting their self-care management is a role of nursing. Although patient satisfaction is
a quality indicator for all health care and health care providers, patients’ satisfaction with
their nursing care would be relevant to nurses.
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Outcomes of interest to nurses in advanced practice roles include these broad areas as well and would also include outcomes specific to their advanced practice roles.
Oermann and Floyd (2002) categorize outcomes of advanced practice registered nurses
(APRNs) into clinical, functional, cost, and satisfaction outcomes. For example, certified registered nurse anesthetists (CRNAs) might be interested in complications of oral
intubation or extubation failures, epidural catheter insertion site infections, or patient
satisfaction with postoperative pain relief. Certified nurse-midwives (CNMs) might monitor perineal laceration rates or newborn Apgar scores, and certified nurse practitioners
(CNPs) would be interested in missed diagnoses or prescribing patterns. Data regarding
outcomes and impact derived from APRN practice support policy initiatives related to
APRN education, workforce planning, recognition, regulation, and reimbursement.
Identifying the outcomes that can be clearly attributed only to nursing is a challenge. Attribution requires a high level of confidence that the outcome is a direct result
of the care provided (Dennison & Hughes, 2009). When many care practitioners interact with patients and contribute to the care, it is sometimes difficult to attribute the
outcome in the patient to only one practitioner or treatment. For example, a diabetic
patient is consistently having high fasting blood glucose levels. The NP discusses the
problem and alternative medication adjustments with the patient and then orders a new
daily and sliding scale insulin dose. The RN teaches the patient the correct technique
for finger-stick glucose monitoring. The registered dietitian (RD) reviews the recommended diet and helps the patient practice making better food selections. When the
patient’s mean fasting blood glucose levels fall to within the desired parameters, who
will get the credit? To whom are these results attributed? Is it the NP, the RN, the RD,
or the team?
Nurses affect patient safety outcomes by identifying and mitigating risks, monitoring patient status and communicating with others regarding changes in the patient’s
condition, and surveillance activities that lead to systems improvement to enhance safety.
On the micro level, nurses’ effect on safety variables such as medication errors or patient
falls might be possible. However, it is again difficult to quantify nursing’s effect on safety
outcomes because of the multidisciplinary nature and complexity of our current health
care systems.
Finally, patients’ utilization of health care services, both increased and decreased,
can reflect the influence of nursing care. An increased utilization might derive from nurses
teaching and coaching patients regarding when, where, and how to seek care. Conversely,
if nursing care increases an individual’s ability for self-care management, the need for
unintended office and emergency department visits—decreased utilization—could be the
outcome. Examples of utilization of service outcomes would be intended and unintended
office visits, use of the emergency room, hospital admissions, and length of stay.
Theoretical frameworks can be used to identify and explore the factors that influence nursing’s effect on patient outcomes. Joseph (2007) proposed a theoretical
approach to the examination of the effect of nursing on patient and organizational
outcomes. She proposed that six constructs influence outcomes, including the environment of the health facility, qualities of the nursing unit, the individual nurse, and the
patient, as well as nursing care. She suggested that nursing care is affected by qualities
of the nursing unit where care is given, by the nurse providing the care, and by patient
qualities associated with their needs. Joseph also proposed that the larger environment
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of the health facility also affects care by providing the context of care through its mission, organizational structure, and characteristics, as well as its leadership milieu. This
framework is useful in identifying variables that may influence patient as well as organizational outcomes.
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TRANSLATION OF EVIDENCE TO IMPROVE OUTCOMES
Research findings support the effect of research-based nursing on patient outcomes
(Heater, Becker, & Olson, 1988). A meta-analysis was used to determine the contribution that research-based nursing practice makes to patient outcomes compared with
routine, procedural nursing care. Eighty-four studies (63 published, 21 unpublished) of
independent nursing interventions from 1977 to 1984 were evaluated, and effect sizes
were calculated. Outcomes were grouped into four content areas: behavioral, knowledge, physiological, and psychosocial. Results indicated that individuals who received
research-based nursing care had better outcomes than 72% of subjects who received
routine, procedural nursing care.
Unfortunately, health care practitioners frequently fail to integrate available evidence
into day-to-day patient care (McGlynn et al., 2003). It is reported that the average time
gap from discovery of knowledge to its application in practice is 17 years (IOM, 2001).
Historically, care processes have been based on ritual, personal, and local institutional
preferences (Ackerman, 1999; Kingston, Krumberger, & Peruzzi, 2000). For more than
25 years, attempts have been made to increase the linkage of empiric research results to
practice and to narrow the “bench-to-bedside” gap to improve patient care. But very little
progress has been made in synthesizing and applying the results of research to improve
patient care. To bridge the bench-to-bedside gap, evidence needs to be incorporated into
care protocols that are easily implemented in practice.
Probably one of the earliest examples of the creation of an evidence-based approach
to care was the development in the 1970s of consistent expectations for the performance
of cardiopulmonary resuscitation (CPR). These standards were used to train and test the
competency of health care providers to perform external cardiac massage and rescue
breathing for patients suffering from cardiopulmonary arrest. These standards were based
on limited research data regarding CPR as well as expert opinion, but it standardized the
process of CPR across the country and across disciplines.
Soon thereafter, many institutions developed standing orders (or order sets) to provide consistent care to specific patient populations. These documents were developed for
use in one or perhaps two nursing units within an individual hospital. They simplified
care by establishing one set of orders for the care of a highly selected group of patients—
for example, only those admitted with specific diagnoses, usually surgical procedures.
They were based on preferences and personal expertise of a single physician or small
group of physicians. They sometimes underwent institutional vetting processes.
Critical pathways began to emerge in the 1980s and 1990s as payers and institutions responded to the demands for managed care. Managed care initiatives set expectations for the provision of timely, streamlined, evidence-based care to optimize patient
outcomes (Rotter et al., 2009). Care pathways were usually created by a multidisciplinary
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team to establish a unified but detailed care plan for a set of specific patients, with clearly
described patient outcomes and timelines that could be used to implement patient care
and monitor progress. Variance from the path triggered analysis and intervention. Over
time, these care pathways were more likely to reflect input from all care practitioners
involved with the patient population and were approved through consensus processes.
These multidisciplinary teams included physicians in private practice. The pathways were
used locally for all or most of the patients fitting the population and described the care
they would receive and when they would receive care. They were also used in contracting
with payers to provide specific services for their insured.
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CLINICAL PRACTICE GUIDELINES
In 1994, the federal government became involved in the movement to translate research
to practice. At that time, the Agency for Health Care Policy and Research (AHCPR), now
the Agency for Healthcare Research and Quality (AHRQ), began to develop care recommendations for common problems (acute pain, cancer pain, pressure ulcers, etc.) and
published them as CPGs. These documents were developed by teams comprising experts
from multiple health care professions who completed exhaustive searches of the research
literature related to the identified problem. The resulting body of research literature was
subsequently reviewed, rated for quality, and synthesized into recommendations related
to risk identification, problem assessment, prevention, and treatment. Larger groups of
experts were asked to review and provide comments on the CPGs before revision and dissemination of the final versions. The Centers for Disease Control and Prevention (CDC)
also got involved in establishing CPGs. For example, in 2003, they established guidelines
for the prevention of health care–associated pneumonia (Tablan et al., 2004).
Today, demands from patients and families, insurers, business leaders, consumer
groups (AARP, American Lung Association, American Cancer Society, etc.), and professional organizations (American Association of Critical-Care Nurses, American College
of Chest Physicians, etc.) are promoting the increased integration of available research
knowledge, practitioner expertise, and patient preferences to improve patient health care.
This is called evidence-based practice. By using EBP to create CPGs, the best available research evidence is translated into a clinically useful form that can be employed by practitioners in day-to-day practice to improve patient outcomes.
CPGs are official recommendations made by recognized authorities regarding the
screening, diagnosis, treatment, and management of specific conditions. They are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (Lohr & Field, 1992, p. 27).
Evidence-based CPGs may help bridge the gap between research and practice. In these
CPGs, research provides the evidence that an intervention is efficacious (produces better
outcomes). The CPG facilitates transfer of this intervention to everyday practice, and
subsequently allows the evaluation of its effect on outcomes in broader patient populations (effectiveness). In this way, EBP leads to the development of practice-based
evidence (Green, 2006). It allows the accumulation of evaluation data on both efficacy
and effectiveness of the intervention.
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FACTORS THAT AFFECT ADOPTION OF CPG S
Various factors affect the adoption of CPGs. Qualities of CPGs, including ease of use,
complexity, clear scientific basis, strong link between evidence and recommendations,
and other factors influence their use (Davis & Taylor-Vaisey, 1997; Sox, 1994).
The existence of conflicting CPGs with differing recommendations regarding the
same intervention or population, such as have recently been reported for several types of
cancer screening, probably undermine their use. Characteristics of the health care professional also influence the use of CPGs. For example, personal involvement in CPG
development, awareness of as well as agreement and familiarity with CPGs may influence
their use (Cabana et al., 1999; Davis & Taylor-Vaisey, 1997; Haynes, 1993). Vetting by
and support from professional nursing organizations is important to the successful implementation of nursing care guidelines (Davies, Edwards, Ploeg, & Virani, 2008; Ploeg,
Davies, Edwards, Gifford, & Miller, 2007). Health care providers who perceive CPGs
as “cookbook medicine or as a threat to practitioner autonomy are not likely to follow a
CPG” (Sox, 1994). Patient-related factors, such as the ability to predict effect on the patient or the presence of multiple comorbid conditions and even patient satisfaction with
the CPG, have been reported to influence the practitioner’s use of CPGs (Francke, Smit,
de Veer, & Mistiaen, 2008; Sox, 1994). Characteristics of the practice setting, such as
availability of time and personnel, work pressures, and even costs to the practice related
to the implementation of a CPG influence its use (Francke et al., 2008).
An emerging issue that will affect provider use of CPGs, or at least the explanations
of their application with patients, is consumers’ understanding of and attitudes toward
CPGs (Carman et al., 2010; Francke et al., 2008). Recent evidence reveals that patients
do not understand that EBP and CPGs are meant to improve their health and the quality
of health care delivered without increasing patient costs (Carman et al., 2010). Instead,
they believe that care, at least provided by their own physician, is optimal and that use of
a CPG will restrict their access to desired care. Some also believe CPGs are used only to
protect physicians from malpractice claims. These patient attitudes and beliefs could have
a significant effect on their acceptance of CPG recommendations.
Qualitative and quantitative methods and one meta-review have examined the perceptions of administrators, nurses, and a variety of other health care providers regarding
the factors that support and hinder guideline implementation in practice. (Davies et al.,
2008; Dogherty, Harrison, Graham, Vandyk, & Keeping-Burke, 2013; Francke et al.,
2008; Ploeg et al., 2007). One new model specifically focuses on successful implementation of guidelines in nursing (Matther-Maich, Ploeg, Dobbins, & Jack, 2013).
Two recent publications sum up current knowledge regarding the impact of major factors on CPG implementation. Francke et al. (2008) completed a systematic metareview of evidence regarding factors that impact guideline implementation and strategies used to support implementation. They summarized their findings by characterizing
evidence that impacts the implementation of guidelines into one of four categories: the
guideline itself, the professionals involved, the patients involved, and the practice environment. They found that guidelines that were “easy to understand” and grounded in
evidence are more likely to be successfully implemented. There was inadequate data to
determine the relative impact of individual implementation strategies, though most projects used two or more strategies, and those that were integrated into care processes by the
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individual health care provider were the most successful. Lack of knowledge about and
agreement with the guideline among health care providers were identified as major impediments to implementation. Patients who did not understand the value in following a
guideline or provider concerns regarding the presence of multiple comorbid conditions in
a patient hindered guideline implementation. Finally, negative staff or leadership attitudes
and lack of time and resources were environmental factors impeding the implementation
of guidelines.
Dogherty et al. (2013) completed a recent thematic analysis of critical incident
technique data from nurse leaders involved in guideline implementation. Their analysis
emphasized factors to support successful implementation. They found that focus on a
high-priority problem and use of evidence that is not only relevant to the practice but
easy to access and apply is critical. They also cited the importance of a strong cohesive
team (multidisciplinary engagement of stakeholders who share responsibility), “strategic
choreography” (planning, providing resources, anticipating and navigating through challenges, etc.), and enlisting a skilled leader to facilitate the implementation (p. 133).
The federal government and some private payers are devising payment initiatives
related to the use of CPGs. Although the evidence to support these plans is at best controversial, Medicare has implemented incentive programs to reward providers, hospitals,
nursing homes, and home health agencies that demonstrate application of EBP as well as
patient outcomes monitoring (Tanenbaum, 2009). These programs reflect their desire to
improve patient care and control costs through the use of patient outcomes monitoring
combined with the application of research to practice. The Medicare Physician Quality
Reporting Initiative (PQRI), also known as “pay for performance” (P4P), began in 2007. It
allows providers (including NPs), who report satisfactory patient outcomes data related to
covered professional services, to qualify to earn additional payments. Concerns have been
expressed regarding the potential unexpected consequence of P4P, in that the need to
meet patient outcomes’ benchmarks could cause provider avoidance of patients with comorbid or difficult-to-treat problems (“cherry picking”), which might dilute the providers’ ability to show improved patient outcomes (Dennison & Hughes, 2009). Penalties for
poor patient outcomes have also been adopted by Medicare. Since 2009, hospitals have
not been reimbursed for services provided to treat nosocomial infections and other preventable conditions (e.g., catheter-related urinary tract infections, catheter-related blood
stream infections, decubitus ulcers, air emboli). Although this may have reduced hospital
reimbursement rates, it has also driven agencies to examine their patient outcomes and
to search out and apply evidence-based solutions, often in the form of CPGs, to prevent
these adverse patient outcomes.
CPG use has migrated into the h
