A significant number of patients are harmed or die every year because of unsafe, inappropriate or inadequate healthcare delivery. The Agency for HealthCare Research and Quality has identified Registered Nurses (RNs) as a patient safety strategy for reducing patient mortality and morbidity. However, variability in research findings indicate the relationship is not as simple as `more nurses = better outcomes'. Despite the fact that RNs are the largest health workforce component, with identified potential to improve patient safety, currently no evidence-based frontline RN care model exists. The long-term goal of this research is to generate critical knowledge that enables wide-spread implementation and sustained utilization of evidence-based frontline RN care models that maximize the quality and safety of care received. One emerging model highlighted by policy makers and increasingly taken up by health systems across the nation is the Clinical Nurse Leader (CNL) care model. The purpose of this study is to estimate the CNL care model's effectiveness in impacting better care and better health. It leverages a natural experiment in 66 clinical care units in 9 hospitals across 5 states (GA, TX, MI, NC, IL) that are integrating CNLs into their frontline nursing care delivery model. A hybrid type II implementation-effectiveness study will be used to accomplish the following aims.
Aim 1. Evaluate the effect of CNL-integrated care delivery on changes in nationally endorsed and standardized quality and safety outcomes including patient satisfaction, infection rates, falls, LOS, and readmissions. Quasi-experimental interrupted time series (ITS) design using regression methods to evaluate outcome change for individual units. A meta-analysis implementing multilevel random effects models will provide combined unit-specific and overall estimates of effect size for each outcome. All analysis will control for pre-intervention trends, seasonality, temporal dependence, and unit-level demographics.
Aim 2. Identify characteristics of CNL implementation that are sufficient and necessary to achieve outcomes. Already collected data (surveys, interviews) will be used to identify, characterize, and measure CNL implementation in each clinical unit. Qualitative Comparative Analysis will be used to identify CNL implementation and practice characteristics that are consistently present in units with improved outcomes (sufficient conditions) and thresholds that must be in place for outcomes to occur (necessary conditions). By leveraging sophisticated analytic methods that capture the dynamic interdependency of contextual factors in nursing practice, this study will be the first to examine nursing as an organizational strategy to increase care quality and safety, to measure its effectiveness, and provide specific `recipes' of successful CNL care model configurations that health systems can match to their needs to achieve intended quality and safety outcomes.
A significant number of patients are harmed or die every year because of unsafe, inappropriate or inadequate healthcare delivery. This study focuses on how registered nurses, the largest health workforce component, with identified potential to improve patient safety, can be effectively organized into specific care models to significantly improve the quality and safety of care delivery. By leveraging sophisticated analytic methods that capture the dynamic interdependency of contextual factors in nursing practice, this study will be the first to examine nursing as a care delivery model to increase care quality and safety, to measure its effectiveness, and provide specific `recipes' of successful care model configurations that health systems can match to their needs to achieve intended quality and safety outcomes.
