Normalize ER Diagram and Improve Patient Engagement

· Normalize the following ER diagram.
TABLE TALK
The Growing Role of Patient
Engagement: Relationship-based
Care in a Changing Health Care
System
A
s health care providers, we rarely partici-
pate in discussions, watch interviews, or
read articles about our changing health
care system that do not concern patient engage-
ment. The Center for Advancing Health defines
patient engagement as
Actions individuals must take to obtain the
greatest benefit from the health care services
available to them. . . . Engagement is not syn-
onymous with compliance. . . . [Engagement]

signifies that a person is involved in a process in
which he [or she] harmonizes robust information
and professional advice with his [or her] own
needs, preferences, and abilities in order to
prevent, manage, and cure disease.
1
Patient engagement strategies have been shown
to improve care delivery and translate into better
outcomes related to patient satisfaction and re-
covery. One author captured the importance of
patient engagement with this statement: “If pa-
tient engagement were a [medication], it would
be the blockbuster [medication] of the century
Patient engagement begins with relationship-based care.
(Nurse’s warm-up jacket
and cap not shown.)
http://dx.doi.org/10.1016/j.aorn.2014.02.007
� AORN, Inc, 2014 April 2014 Vol 99 No 4 � AORN Journal j
517
http://dx.doi.org/10.1016/j.aorn.2014.02.007

and malpractice not to use it.”
2
Yet widespread
consensus among health care providers about how
to engage patients is still being determined.
The nursing profession’s role in patient engage-
ment and advocacy is key to the care that we de-
liver and continues to evolve to meet the needs of
patients. For example, before the 1970s, there was
not a high demand for patient’s rights.
3
In 2006,
AORN published a position statement on creating
an environment of safety, which set the ground-
work for patient-centered care as an important
element in defining the perioperative culture.
4
A
number of ethical, philosophical, and professional
considerations related to the rights of patients
have led to the nurse’s role as patient advocate.

According to one author, the three components of
this role are
1. informing patients of their rights,
2. providing patients with information necessary
to making informed decisions, and
3. supporting patients in their decisions.5
Regarding the patient’s role in engagement, one
author, who is also a perioperative RN, shared his
experiences as a surgical patient. In his article,
McGowan suggested that almost every patient en-
ters the surgical suite with anxiety and looks to
the perioperative team for reassurances. He be-
lieves that inaccurate portrayals of surgery in the
media “contribute to patients’ perceptions of sur-
gery and not always in a positive way.”
6(p493)
Critical to the health care provider’s ability to
establish trust is communicating in a manner that

informs and empowers the patient. For example,
he stated that, as a patient, he felt hurried in saying
goodbye to his partner before the procedure began,
which suggests that he perceived a lack of sup-
port from those providing his care. According to
McGowan, nurses must provide reassurances to
patients in their care and “remember the leap of
faith that [undergoing care] requires of patients
and never [to] take the trust that they place in
us lightly.”
6(p497)
By bringing together this panel of contributors,
my hope is that we come to a better understanding
of how we elicit our patients’ perspective and
involve them in improving satisfaction and health
outcomes. We would be remiss if this commentary
did not include the patient’s perspective. To that end,
a patient is one of the contributors. As you read these
commentaries, the clear themes among each disci-

pline and the engagement of key stakeholders can
be taken as a sign of the broader inclusion necessary
to achieving our desired outcomes. The panel of
contributors responded to the following statement:
Patient engagement and patient satisfaction
are playing critical roles in a changing health
care system and the emerging compensation
models. This directly impacts both the inpatient
environment and the ambulatory care setting.
From your perspective, please comment on what
you believe is the link between patient engage-
ment and improved outcomes for periopera-
tive patients.
CHARLOTTE L. GUGLIELMI
MA, BSN, RN, CNOR
PERIOPERATIVE NURSE SPECIALIST
BETH ISRAEL DEACONESS MEDICAL CENTER
BOSTON, MA
Nurse’s perspective

Our goal as health care providers is to meet the
physical, social, and emotional needs of patients
and their family members. This cannot be accom-
plished without fully engaging patients in their own
care or without fully engaging their families.
7
According to a white paper on patient and family
engagement from the Nursing Alliance for Quality
Care, “active engagement of patients, families,
and others is essential to improving quality and
reducing medical errors and harm to patients.”
8
As perioperative nurses, it is sometimes difficult
to see our role in this process because of the limited
518 j AORN Journal
April 2014 Vol 99 No 4 TABLE TALK
time for interaction and the drive for increasing
efficiencies. Perioperative leaders should promote

a culture that carefully balances efficiency, patient
safety, and patient participation by establishing
processes to support this philosophy. Strategies that
are developed to create this balance should estab-
lish a model for engaging patients and should en-
sure that perioperative nurses receive education on
communication techniques or methods that they
will use when interacting with those in their care.
At AnMed Health, Anderson, South Carolina,
perioperative leaders have adopted strategies that
offer a framework for successful engagement. Two
techniques that we use to guide personnel in their
interactions with patients and families are teach-
back (http://www.teachbacktraining.org) and Ask
Me 3
TM
(http://www.npsf.org/for-healthcare-profe
ssionals/programs/ask-me-3).

Teach-back is a research-based health literacy
intervention that improves patient-provider com-
munication and health outcomes.
9
By using inter-
active communication, the nurse prompts the
patient to explain, in his or her own words, the
information that the nurse has provided. This
method allows the patient to process health infor-
mation in a context that is meaningful to him or
her, and it demonstrates the patient’s understanding
to the health care provider. “Asking that patients
recall and restate what they have been told is one
of the 11 top patient safety practices based on the
strength of scientific evidence.”
10
Teach-back is a
particularly powerful tool to use when providing
postoperative discharge instructions. By using this
technique, nurses can be reasonably sure that the

patient and his or her family members understand
the postoperative care that will be needed at home.
This can help reduce the risk of complications re-
lated to miscommunication or misunderstanding
of instructions.
Ask Me 3 is a teaching methodology that is based
on health literacy principles and often is used in
combination with the teach-back approach. Part-
nership for Clear Health Communication developed
this technique with the intent of helping all patients
comprehend their particular health condition and
what they should do about it. There are three
questions
11
that patients are encouraged to ask
any health care provider:
n What is my main problem?
n What do I need to do?

n Why is it important for me to do this?
The use of these techniques adds structure to
patients’ interactions with their health care pro-
viders, thereby increasing patients’ engagement in
their own health. AnMed Health introduced these
methods in 2010, first in the surgical services and
pediatric departments, as part of an overall health
literacy and patient education initiative. Before
implementation, perioperative nurses received in-
depth training from the facility’s training and
organizational development department on both
techniques. Although these methods may seem
simplistic, both have proven effective in our facility
for allowing patients the opportunity to be part of
the conversation rather than passive receivers of
their medical information. The nurses in surgical
services directly teach patients to ask questions and
recall information. Nurses also use other commu-

nication methods, such as handouts and pamphlets,
to reinforce the delivery of information regarding
care. These methods of patient engagement start
when the patient arrives for surgical assessment
several days before surgery and continue through
postoperative discharge.
Although strategies provide a foundation for
patient engagement, it is nurses who establish re-
lationships with patients to make them partners in
their care. Nurses, in their role as committed patient
advocates, are uniquely positioned to embrace the
concept of active patient engagement. Therefore, it
is vitally important that perioperative leaders not
only provide the education and support necessary
for nurses to gain competency in patient engage-
ment practices but also actively participate in those
processes themselves. At AnMed Health, it is an
expectation that nurse managers and directors visit

with patients on a daily basis. Patient rounding by
AORN Journal j 519
TABLE TALK www.aornjournal.org
http://www.teachbacktraining.org
http://www.npsf.org/for-healthcare-professionals/programs/ask-
me-3
me-3
http://www.aornjournal.org
leaders sets an example for personnel but also
provides one more step in cementing the patient-
provider relationship that is so important to pa-
tient outcomes.
Helping personnel embrace “hardwire processes”
that are related to patient engagement is not sim-
ple, but perioperative leaders should be persistent
and supportive because these efforts are known
to be effective in improving postoperative patient
health.
12
Here are some key tips for nurses who are

getting started on this journey or who are renewing
their focus of patient engagement.
n Set aside a predetermined time each day to
round on patients. You can do this by putting
an appointment on your calendar. Allow enough
time to make the visits meaningful.
n Determine ahead of time the major points you
want to convey to the patient so that you can
work these into the conversation. Use teach-
back and Ask Me 3 whenever possible.
n Take a surgery schedule with you so that you
know the patient’s name, the scheduled surgical
procedure, and the name of the surgeon.
n If you are a director, ask a manager to ac-
company you for a few days. If you are a
manager, ask staff nurses to join you from
time to time.
n Manage up your team! Make sure you relay

to the patient what a wonderful team will be
providing his or her care.
MARTHA STRATTON
MSN, RN, MHSA, CNOR, NEA-BC
DIRECTOR OF NURSING, SURGICAL SERVICES
ANMED HEALTH
ANDERSON, SC
Surgeon’s perspective
The Institute of Medicine report To Err is Human:
Building a Safer Health System
13
documented sig-
nificant breaches in safe patient care. Many of the
breaches involved poor communication, a lack of
professionalism, and an inability to work as a team.
These deficiencies are major impediments to es-
tablishing good physician-patient relationships and
must be addressed by the profession. Doing so is
especially critical as the health care industry fo-
cuses on both increased patient engagement and

measured outcomes.
As surgeons, we have always been cognizant of
results (ie, outcomes). We have now been served
notice that we shall be rated and paid by the out-
comes we achieve. In many ways, however, we are
very reliant on others to achieve the best results
possible in any given patient encounter, perhaps
on none more so than the patient. Thus, educat-
ing and empowering the patient through effective
communication is now more important than ever.
By engaging with the patient in his or her own
care and providing education, health care providers
can show their dedication to safe patient care and
provide the patient with the feeling of not only
being cared for but cared about.
The surgeon must recognize his or her role as a
critical member of the preoperative, intraoperative,
and postoperative teams. A major component of

this role is serving as an educator to both the patient
and team members to explain the purpose, plan,
and expected outcome of the surgical procedure.
Each member of the team (eg, surgeon, anesthesia
professional, perioperative RN) must work together
to ready and empower the patient for the surgical
encounter. Silos are no longer effective or appro-
priate. As part of their engagement, patients and
their family members must be made aware that they
also have a responsibility to act as their own or as a
relative’s advocate and become part of the surgical
team. Thus, their goals and expectations must be
verbalized and understood by other members of the
team. I believe that having well-informed patients
and family members will lead to greater satisfac-
tion and will improve outcomes dramatically.
Yet, the world of health care becomes more
frenzied by the day, which has led to perioperative

520 j AORN Journal
personnel experiencing increased workloads and
greater stress. A sad fallout as a result of these
conditions is increased unprofessional behavior
on the part of members of the perioperative team.
When team members behave unprofessionally or
give the impression that they do not care about the
patient, it does not go unnoticed by patients and
serves only to sour their perception of the surgical
team, or at least some of its members. This weak-
ens their sense of engagement and increases the
possibility of a poor outcome.
14
Addressing the link
between stress levels and professional behaviors is
critical for physicians and nurses if we are to suc-
cessfully engage with our patients.

I believe that patients simply want to be part
of their own solution. A happy and relaxed patient
and surgical team are more successful than are an
unhappy and a stressed patient and surgical team in
achieving the desired positive outcome. Patients
want to understand what is happening to them and
to be informed about their care in a language that
they can understand. This means that they want to
be cared for in a safe environment by competent
professionals whose goal is a quality, cost-effective
outcome. In the end, we must not forget that pa-
tients do not care how much we know until they
know how much we care.
GERALD B. HEALY
MD, FACS
PAST PRESIDENT, AMERICAN COLLEGE OF
SURGEONS
PROFESSOR
HARVARD MEDICAL SCHOOL
BOSTON, MA

Anesthesiologist’s perspective
There can be very little argument that there is
indeed a link between patient engagement and
outcomes in the perioperative setting. This link
prevails across all settings of care, from hospitals
to ambulatory surgery centers to office surgery
suites. As a physician who has practiced almost
exclusively in the ambulatory surgery center set-
ting, I have no doubt that the patient plays a pivotal
role throughout the perioperative continuum in
the outpatient environment. Perhaps because of
the nature of the types of procedures we perform
(ie, those that are largely elective) and the relatively
short duration of the care provided (ie, usually less
than 24 hours), the extent to which personnel can
engage the patient and provide personalized, patient-
centered care is amplified in the ambulatory surgery
center setting.

Consequently, it is critical for the physician to
carefully assess the degree of patient, as well as
family member, engagement when considering the
most suitable location for the surgery to be per-
formed, regardless of the particular surgery and
anesthetic planned. A patient who is either unable
or unwilling to actively participate in his or her
own perioperative care, regardless of the reason,
is at an increased risk for poor outcomes. Further-
more, such a patient may be an unsuitable candi-
date for outpatient surgery.
As an example, a patient who is not motivated
to thoroughly administer his or her prescribed in-
testinal prep before a colonoscopy can adversely
affect the likelihood of an optimal procedure and is
at significant risk for cancellation entirely, there-
by defeating the opportunity for critical diagnosis
and treatment. Similarly, because patients are sent

home relatively quickly after outpatient procedures,
adherence to discharge instructions and attention to
possible signs and symptoms of surgical compli-
cations are crucial to a safe and timely recovery.
Although the relationship that perioperative
team members have with the patient is intuitive-
ly important, relationship-based care can place a
considerable burden both on the provider and on
the recipient of heath care in the outpatient setting.
For health care providers, it can be very difficult for
personnel to proactively ascertain the commitment
and ability of a patient to monitor and participate in
his or her own care, thereby making it difficult for
AORN Journal j 521
health care providers to help facilitate patient

compliance with the requisite postoperative self-
care regimens. For the recipient of health care (ie,
the patient), it can be very difficult to process and
attend to all the information communicated during
what is often a physically challenging and emo-
tionally charged time. Despite these difficulties, the
extent to which patient engagement can be lever-
aged during any given episode of care will almost
certainly enhance the outcome.
As definitive as I believe the relationship be-
tween patient engagement and outcomes is, the
relationship between patient engagement and pa-
tient satisfaction appears to be a bit less well es-
tablished or understood. The two are inexorably
intertwined, but the precise nature of the interaction
is considerably less clear. Are engagement and
satisfaction a cause or result of outcomes, or are
there other factors at play? I believe that, by clar-

ifying the factors that affect clinical outcomes, both
patient engagement and satisfaction will begin to
be better understood.
Although the very topical concept of patient
satisfaction recently has become the focus of an
inordinate amount of attention by the media and by
payers, I believe that much more research is needed
to determine the precise role that patient satisfac-
tion, or the patient experience, plays in health care
delivery and outcomes. At this time, however, the
precise nature of the patient-provider relationship
remains not only complicated but also largely un-
charted. Clearly, this is a fertile area of exploration
because patients, especially those undergoing sur-
gical or other invasive procedures, will most defi-
nitely play an increasingly important role in the
responsibility for their own perioperative care.
Only through further exploration and evidence-

based research will the precise nature of the link
between patient engagement and outcomes be
more clearly elucidated. As a result of this fo-
cus of endeavor, I anticipate that the concept of
relationship-based care will become more clearly
established as an important determinant of patient
satisfaction.
One important concept that surely will emerge
as an important area of continuing endeavor is to
arrive at clear, consistent, and universally accepted
definitions of terms such as engagement, satisfac-
tion, and outcome. Only after these definitions
have been refined and promulgated can we begin
the subsequent task of accurately quantifying, or
measuring, all the variables therein. Patient en-
gagement and patient satisfaction, therefore, are
an evolving and positive focus of health care, es-
pecially as we strive to improve the quality of

the perioperative services that we provide to our
patients. Surely, any efforts directed toward im-
provement on behalf of our patients are mission
critical for us as health care providers in the inpa-
tient and in the rapidly growing outpatient settings.
DAVID SHAPIRO
MD, CASC, CHCQM, CHC, CPHRM, LHRM
ANESTHESIOLOGIST
TALLAHASSEE, FL
Chief nursing officer’s perspective
I could not be happier with the growing focus on
patient satisfaction as a measure of quality. Mea-
suring patients’ perceptions of their care helps us,
their care providers, to understand their emotional
and spiritual health during all phases of periopera-
tive care. By referring to spiritual health in this
context, I am not discussing patients’ religious state
of mind but rather the health of the human spirit
that is inside all of us. Human beings are complex

creations who need to feel safe while also being
safe to thrive. Maslow’s hierarchy of needs de-
monstrated that, after an individual’s physical needs
are met, the individual ascends to more complex
needs to achieve self-actualization.
15
Understand-
ing the needs of our patients to thrive both physi-
cally and spiritually is critical to helping them
face whatever risks they encounter from disease
or injury.
522 j AORN Journal
As a nurse I have always viewed my practices as
providing a combination roles, that of scientist and
care provider. The scientist role allows me to focus
on assessing the physical needs, signs, and symp-
toms of those patients in my care so that I can

develop and implement suitable interventions. The
care provider role allows me to focus on enhancing
the spiritual health of my patients. I believe that we
are unable to be expert caregivers if we do not care
for all the needs of our patients, both physical and
spiritual.
16
Unfortunately, over the years, as the
cost of providing care has grown, our health care
systems have continually shifted the focus of care
delivery to developing processes and systems that
deliver physical care in as efficient a manner as
possible. In the surgical environment, we all have
experienced the ongoing push for efficiency and the
multiple meetings to discuss reducing turnover time
and cost per procedure. It was not until the Institute
of Medicine published its report, To Err is Human:
Building a Safer Health System,
13

which estimated
that 100,000 lives are lost each year because of
medical errors, that society demanded a response
to patient outcomes in the form of safer care de-
livery models that respect health care efficiency but
not at the expense of safety.
16
I believe the response to the Institute of Medicine
report aligns with Maslow’s theory. Nurses and
other members of the health care team have looked
to improve structures and processes to meet the
physical needs of the patient first. For example,
in the OR, perioperative personnel embrace safety
initiatives such as the time out and the Surgical Care
Improvement Project.
17
We have looked to reduce
variations to decrease human error from inexperi-
ence with a certain supply or piece of equipment.

Additionally, both the “captain of the ship” doctrine
and bullying behavior that were tolerated for so
many years have been replaced with huddles and
debriefings about the plan of care, so that all team
members can be equal partners in providing care.
Despite these efforts, we still face challenges
with outcomes. I believe that the realization must
be that problems related to mediocre outcomes
cannot be solved if we do not involve the patients in
their care. As McGowan stated in his article, a pa-
tient who is made to feel valued and part of the care
process is a patient who has a better chance to ex-
perience an optimal outcome.
6
Engaging patients
strengthens the health of their spirit. A healthy spirit
is critical to patients’ successdyet, up to this point,
everything the health care industry has been focused
on has been to address patients’ physical needs and

not their spiritual needs. It is only now that we are
responding to that oversight by enhancing physical
care with relationship-based care.
Let’s face it, receiving health care can be one
of the most dehumanizing experiences in a person’s
life. We strip patients of their clothes, their valu-
ables, and their family and friendsdand we may
even paralyze them with anesthesiadso that a
group of strangers whom they have never, or only
briefly, met can perform a surgical or other invasive
procedure on their body. I have had surgery only
as a child, but still I have wondered many times
as I put the safety strap on my patients about the
leap of faith that is required of those who undergo
surgery. The stress of a surgical procedure must
be enormous, and that stress can hinder a patient’s
ability to thrive throughout the perioperative course.
To me, this is why it is so important to engage our

patients and make them feel valued during the
perioperative process.
I believe that patients enter a hospital believing
that we know how to provide physical care, but
what they hope for, and are concerned about, is
whether we will value them as human beings.
When an individual feels valued, he or she feels
stronger; and the stronger the patient is, the better
the chances are for a great outcome. I frequently
see evidence of how important spiritual care is to
patients. In my 30 years as a nurse leader, almost
every letter I receive from patients discusses how
my nurse team members either did or did not make
them feel valued. Except for incidents of a clear-cut
error, patients rarely discuss the physical aspects of
care or their outcomes. It is clear to me that they
want to share their perception of the quality of the
AORN Journal j 523

spiritual care they received. For someone to stop
and take the time to write a message of thanks or
concern means that their spiritual care is something
they value very much; and, if this is important to
them, then it should be equally important to us as
their care providers.
WILLIAM J. DUFFY
RN, MJ, CNOR, FAAN
REGIONAL VICE PRESIDENT, CHIEF NURSE
OFFICER, PATIENT CARE SERVICES
LAKE SHORE REGION
PRESENCE HEALTH CARE
CHICAGO, IL
Patient’s perspective
My perspective as a surgical patient in an ambu-
latory setting is a bit unique because of my pro-
fessional background. For the past 42 years, I have

worked for a major surgical organization and have
witnessed the development of statements, guide-
lines, and protocols to meet the organization’s
mission to improve quality in surgery, trauma,
and cancer care and to have fewer complications,
better outcomes, and greater access for patientsd
all at lower costs. In my view, this laudable mis-
sion should include cooperative efforts from both
patients and perioperative team members. For
example, soon I will begin my term as the first
patient to serve on the Board of Directors of the
Council on Surgical and Perioperative Safety
(http://www.cspsteam.org), a coalition that previ-
ously comprised only representatives from profes-
sional societies.
I have been a surgical outpatient on three occa-
sions: for a torn meniscus repair, a cystoscopy, and
a colonoscopy. All three interventions had excellent

outcomes, and my recovery was within the normal,
prescribed time frames for each. Although I have
had additional surgical experiences as an inpatient
at a large Midwestern teaching hospital, all three
of the outpatient procedures were performed in
either a mid-size suburban hospital or in the sur-
geon’s office. In all three instances, I was impressed
with the level of preoperative and postoperative
care that personnel provided. During these experi-
ences, I was encouraged to ask questions about the
surgical procedure and was given written informa-
tion as well. I felt a part of the process and was
treated as a unique individual and not as an anon-
ymous patient or just another procedure.
I believe that patients must be their own advo-
cates or, if required, have someone with them to
serve in that role. No matter how routine a procedure
is for the perioperative team, it is perhaps the first

time for the patient. Not to be flippant, but I liken the
surgical experience to attending a Broadway play.
The cast and crew may have multiple performances
under their belts, but most members of the audience
are there for the first time and expect the best. Un-
like anticipating a delightful evening at the theater,
however, the patient may be fearful or anxious about
the procedure and outcome. These emotions usually
are linked to not knowing or understanding how the
perioperative phases of care will go. In my experi-
ence, patient education is instrumental to preoper-
ative planning and postoperative recovery. As stated
earlier, the written and verbal explanations were
very helpful and spoken in terms that were under-
standable to me as the patient. My questions were
encouraged and willingly answered, and I felt val-
ued as a human being.
In an outpatient setting, the nursing team does not

have much time with patients; therefore, effective
educational tools are far more focused and time
sensitive before and after the procedure compared
with the inpatient setting. In particular, I found the
postoperative follow-up telephone call after dis-
charge very helpful. The nursing team made sure
that I understood and was following the postoper-
ative instructions. At-home care regimens can in-
clude, but are not limited to, caring for the surgical
wound and pain management.
18
In addition, the
postdischarge call provides a great deal of comfort,
as it did for me. The subsequent follow-up visit with
the surgeon is critical to postoperative care. It is
524 j AORN Journal
http://www.cspsteam.org

during this visit that more extensive questions may
be addressed. Good follow-up leads to peace of
mind for the patient. For me, this appointment
provided great follow-up and peace of mind.
An engaged patient is usually a satisfied patient.
As the health care system in this country changes
and new compensation models are developed,
patients will probably have more concerns and
questions, and health care professionals, particu-
larly the perioperative team, should be prepared
and ready to guide and understand the patient’s
perspective. Health care providers also should be
aware that any of us may become a patient on any
given day; that alone should dictate a desire to
promote and provide optimal patient education.
BARBARA L. DEAN
FORMER DIRECTOR, EXECUTIVE SERVICES
AMERICAN COLLEGE OF SURGEONS
PATIENT MEMBER, BOARD OF DIRECTORS

COUNCIL ON SURGICAL AND PERIOPERATIVE
SAFETY
CHICAGO, IL
AORN perspective
The contributors to this “Table Talk” all have pro-
vided clear support of the link between patient and
family member engagement and clinical outcomes.
The growing importance of patient engagement to
the health care system role is recognized in section
3021
19
of the Affordable Care Act,
20,21
a statute the
Centers for Medicare & Medicaid Services Inno-
vation Center operationalized in 2011 through its
Partnership for Patients.
22
As a public-private
endeavor, the Partnership comprises a broad and

inclusive network of members (eg, physicians,
nurses, hospitals, associations, federal and state
governments, patients) who have joined together
to improve the quality, safety, and affordability of
health care for all Americans.
23
AORN was one of the first associations to
join the Partnership and pledge its support to
achieving outcomes that are consistent with the
mission and vision of AORN. Members of the
Partnership are committed to reaching two goals:
making care safer and improving care transitions.
The desired outcomes of these initiatives are a
40% reduction of preventable hospital-acquired
conditions and a 20% reduction of 30-day read-
missions, both by the end of 2013 as compared
with 2010 data.
23
As a major vehicle for improving patient care,

the Partnership leverages three key elements:
1. Hospital engagement networksdto identify
solutions for reducing hospital-acquired con-
ditions as well as share and spread successful
practices to other hospitals and health care
providers. (See “Resources: Partnership for
Patient Affinity Groups.”)
2. Community-based care transition programsd
to test models of improving care transitions
from the hospital to another setting, and to aid
in reducing the readmissions rate for high-risk
Medicare beneficiaries.
3. Patient and family engagementdto focus
on the importance of the relationship among
health care professionals and patients and their
family members in preventing health caree
associated illness as well as to help patients
heal without complications through improved

transitions across health care settings and re-
duced readmissions.
23
Regarding the Partnership’s third key element,
the importance of patient engagement is consistent
with AORN’s Perioperative Patient Focused Model
(Figure 1), which is a framework grounded around
the principle that the patient is the focus of all
nursing interventions to achieve optimal patient
outcomes. This model clearly illustrates the patient-
centered goal of perioperative nursing practice,
which is to assist patients and their family members
AORN Journal j 525
with achieving a level of wellness equal to or
greater than the level of wellness that the pa-
tients have before undergoing their operative

or other invasive procedure.
AORN provides resources for improving patient
and family engagement, such as Perioperative
Standards and Recommended Practices.
24
This
publication includes references to involving the
patient and family members during patient assess-
ment, developing expected outcomes of care, in-
cluding the patient in the implementation of the
care plan, verifying that interventions reflect the
rights and desires of the patient, and involving
the patient and family members in the postpro-
cedure evaluation process. The perioperative RN
coordinates patient care continually throughout
the patient’s perioperative experience and assists
the patient and family members with identifying
options for care. The Perioperative Standards
and Recommended Practices also indicates that

the perioperative RN uses ethical principles to
determine decisions and actions, such as by act-
ing as a patient advocate and encouraging patient
self-advocacy.
Additional AORN resources include AORN
position statements and tool kits. AORN position
statements serve to articulate the Association’s
official position or belief about specific periop-
erative nursingerelated topics. In particular,
several position statements convey and support
the importance of the
relationship among peri-
operative nurses, patients,
and their family members
during the perioperative
period. A number of AORN
tool kits also provide re-
sources for engaging pa-

tients and their family
members. These resources
include the following:
n AORN Position
Statements
n Care of the Older Pa-
tient in Perioperative
Settings (https://
www.aorn.org/Wo
rkArea/DownloadAsse
t.aspx?id¼21926)
n Creating a Practice
Environment of Safety
(http://www.aorn.org/
WorkArea/Download
Asset.aspx?id¼21919)
n Patient Safety (http://
www.aorn.org/Work
Area/DownloadAsse

t.aspx?id¼21930)
Resources: Partnership for Patient Affinity Groups
Information shared via the Partnership for Patients hospital
engagement networks often comes from Affinity Groups with
clinical focuses, such as health careeassociated infections,
medi-
cation safety and pharmacist engagement, patient and family
member engagement, and product safety and resource manage-
ment. AORN, the American College of Surgeons, the American
Society of Anesthesiologists, and the American Association of
Nurse Anesthetists collaborated with the Partnership to create
the
Procedural Harm Affinity Group,
1
which endorses successful
practices related to surgical safety, such as use of the World
Health
Organization’s Surgical Safety Checklist.
2
Members of the Part-
nership and the Affinity Group make information available to
the

Partnership’s hospital engagement networks (eg, through web
events, conference calls, shared tools), so that health care pro-
fessionals have direct access to resources that can be used in
providing optimal preoperative, intraoperative, and
postoperative
care to the surgical patient.
1. Procedural Harm Affinity Group. Healthcare Communities.
http://www.health
carecommunities.org [membership required]. Accessed February
12, 2014.
2. AANA, ACS, AORN, ASA and the Council on Surgical and
Perioperative
Safety (CSPS) endorses the use of the World Health
Organization’s Safe
Surgery Checklist and the implementation of The Joint
Commission’s
Universal Protocol [news release]. Denver, CO: AORN, Inc;
2012. http://
www.aorn.org/uploadedFiles/Main_Navigation/Advocacy/Suppo
rting_
Documents/Issues/PfP%20Affinity%20Group%20Joint%20State
ment.pdf.

Accessed February 6, 2014.
526 j AORN Journal
https://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21926
http://www.aorn.org/WorkArea/DownloadAsset.aspx?id=21919
http://www.healthcarecommunities.org
http://www.healthcarecommunities.org
http://www.aorn.org/uploadedFiles/Main_Navigation/Advocacy/
Supporting_Documents/Issues/PfP%20Affinity%20Group%20Jo
int%20Statement.pdf
int%20Statement.pdf
int%20Statement.pdf
n Perioperative Care of Patients with Do Not
Resuscitate Orders (http://www.aorn.org/

WorkArea/DownloadAsset.aspx?id¼21917)
n AORN Tool Kits
n Correct Site Surgery Tool Kit (http://www
.aorn.org/Secondary.aspx?id¼20846)
n Workplace Safety Tool Kit (http://www.aorn
.org/Clinical_Practice/ToolKits/Workplace_
Safety/Workplace_Safety_Tool_Kit.aspx)
n Just Culture Tool Kit (http://www.aorn.org/
Secondary.aspx?id¼20848)
n Patient Hand Off Tool Kit (http://www.aorn
.org/Secondary.aspx?id¼20849)
Additional resources are available from the
Nursing Alliance for Quality Care (http://www
.naqc.org), of which AORN is a member. This
alliance comprises 22 national organizations and
consumer advocacy groups that are committed to
improving the quality and safety of health care
for all Americans. Goals of the alliance include
the active engagement of patients, family members,
and others to improve quality and to reduce

medical errors and harm to patients; a second
goal is that nurses at all levels of education and
across all health care settings must play a central
role in fostering successful patient and family
member engagement. To meet these goals, the
Nursing Alliance for Quality Care created
the following:
n guiding principles
25
to support nurses’ efforts
in fostering patient engagement and
n the Fostering Successful Patient and Family
Engagement white paper
8
to propose a strategic
plan that both encourages nurses’ support of
patient engagement and identifies how organi-
zations and individual nurses can be active in
implementing the plan.

AORN believes that patients and their family
members are essential partners in the care that
health care professionals provide to perioperative
patients. In addition, involving patients in aspects
of their care is necessary to developing a safe
perioperative culture. AORN president Victoria
M. Steelman, PhD, RN, CNOR, FAAN, has em-
braced the concept of patient engagement by ap-
pointing a task force to make recommendations
for infusing the principles of relationship-based
care into new and existing resources to aid in
the care of the perioperative patient. Members
of the Patient Engagement Task Force will share
their results at the AORN Surgical Conference &
Expo 2015.
LINDA K. GROAH
MSN, RN, CNOR, NEA-BC, FAAN
EXECUTIVE DIRECTOR AND CHIEF EXECUTIVE
OFFICER

AORN, INC
DENVER, CO
Editor’s note: Ask Me 3 is a registered trade-
mark of the National Patient Safety Foundation,
Boston, MA.
References
1. A New Definition of Patient Engagement: Why is Patient
Engagement Important? Washington, DC: Center for
Advancing Health; 2010. http://www.cfah.org/pdfs/
CFAH_Engagement_Behavior_Framework_current.pdf.
Accessed January 13, 2014.
Figure 1. AORN Perioperative Patient Focused
Model. Reprinted with permission from aorn.org.
Copyright ª 2014, AORN, Inc, Denver, CO. All rights
reserved.
AORN Journal j 527
http://www.aorn.org/Secondary.aspx?id=20846
http://www.aorn.org/Clinical_Practice/ToolKits/Workplace_Saf
ety/Workplace_Safety_Tool_Kit.aspx

http://www.naqc.org
http://www.naqc.org
http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Frame
work_current.pdf
http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Frame
work_current.pdf
http://aorn.org
2. Kish L. The blockbuster drug of the year: an engaged
patient. HL7Standards.com e-newsletter. 2012. http://
www.hl7standards.com/blog/2012/08/28/drug-of-the
-century/. Accessed January 13, 2014.
3. Malik M. Advocacy in nursingda review of the litera-
ture. J Adv Nurs. 1997;25(1):130-138.
4. AORN position statements. AORN J. 2011;93(5):545-549.
5. Schroeter K. Advocacy in perioperative nursing practice.
AORN J. 2000;71(6):1207-1222.

6. McGowan R. A surgical patient’s perception of trust.
AORN J. 2011;93(4):493-497.
7. A Leadership Resource for Patient and Family Engage-
ment Strategies. Chicago, IL: Health Research & Educa-
tional Trust; 2013. http://www.hpoe.org/Reports-HPOE/
Patient_Family_Engagement_2013.pdf. Accessed
January 13, 2014.
8. Shoshanna S, Schumann MJ. Fostering Successful Pa-
tient and Family Engagement: Nursing’s Critical Role
[white paper]. Silver Spring, MD: Nursing Alliance for
Quality Care; 2013. http://www.naqc.org/Main/Resources/
Publications/March2013-FosteringSuccessfulPatientFami
lyEngagement.pdf. Accessed February 10, 2014.
9. Schillinger D, Piette J, Grumback K, et al. Closing the
loop: physician communication with diabetic patients
who have low health literacy. Arch Intern Med. 2003;
163(1):83-90.
10. Shojania KG, Duncan BW, McDonald KM, Wachter RM,

eds. Making Health Care Safer: A Critical Analysis of
Patient Safety Practices. Rockville, MD: Agency for
Healthcare Research and Quality; 2001. http://psnet
.ahrq.gov/resource.aspx?resourceID¼1599. Accessed
January 13, 2014.
11. Ask Me 3. National Patient Safety Foundation. http://
www.npsf.org/for-healthcare-professionals/programs/
ask-me-3/. Accessed January 13, 2014.
12. Pelletier LR, Stichler JF. Action brief: patient engage-
ment and activation: a health reform imperative and
improvement opportunity for nursing. Nurs Outlook.
2013;61(1):51-54.
13. Institute of Medicine. Kohn LT, Corrigan JM,
Donaldson MS, eds. To Err Is Human: Building
a Safer Health System. Washington, DC: National
Academy Press; 2000.
14. Coulter A. Patient engagementdwhat works? J Ambul
Care Manage. 2012;35(2):80-89.
15. McLeod S. Maslow’s hierarchy of needs. Simple-

Psychology. 2007. http://www.simplypsychology.org/
maslow.html. Accessed January 13, 2014.
16. Duffy WJ. The value of our practice. AORN J. 2004;
79(6):1125-1127.
17. Brendle TA. Surgical care improvement project and the
perioperative nurse’s role. AORN J. 2007;86(1):94-101.
18. Costa MJ. The lived perioperative experience of ambu-
latory surgery patients. AORN J. 2001;74(6):874-881.
19. Establishment of Center for Medicare and Medicaid
Innovation within CMS. Patient Protection and Afford-
able Care Act (Pub. L. 111e148) x 3021(2010). http://
www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW
-111publ148.pdf. Accessed February 6, 2014.
20. ANA Policy & Provisions of Health Reform Law. Silver
Spring, MD: American Nurses Association; 2010. http://
www.nursingworld.org/MainMenuCategories/Policy-
Advocacy/HealthSystemReform/Policy-and-Health-Reform-
Law.pdf. Accessed February 6, 2014.

21. Health care transformation: the Affordable Care Act and
more. American Nurses Association. http://nursingworld
.org/MainMenuCategories/Policy-Advocacy/HealthSystem
Reform/AffordableCareAct.pdf. Published March 23,
2012. Accessed February 6, 2014.
22. The CMS Innovation Center. Centers for Medicare &
Medicaid Services. http://innovations.cms.gov/. Accessed
February 6, 2014.
23. About the Partnership for Patients. CMS.gov. http://partner
shipforpatients.cms.gov/about-the-partnership/aboutthe
partnershipforpatients.html. Accessed February 6, 2014.
24. Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2014.
25. Guiding principles for patient engagement. In: The
Nursing Alliance for Quality Care National Consensus
Conference program. Nursing Alliance for Quality Care.
http://www.naqc.org/Main/Resources/Publications/2012
-NursesContributionsFosteringSuccessfulPatientEngage

ment.pdf. Accessed February 10, 2014.
The authors of this article have no declared
affiliations that could be perceived as posing
potential conflicts of interest in the publication
of this article.
The AORN Journal is seeking contributors for the Table Talk
column. Interested authors can contact
Charlotte Guglielmi, column coordinator, by sending topic ideas
to [email protected]
528 j AORN Journal
http://www.hl7standards.com/blog/2012/08/28/drug-of-the-
century/
century/
century/
http://refhub.elsevier.com/S0001-2092(14)00166-5/sref2
http://www.hpoe.org/Reports-
HPOE/Patient_Family_Engagement_2013.pdf
http://www.hpoe.org/Reports-

HPOE/Patient_Family_Engagement_2013.pdf
http://www.naqc.org/Main/Resources/Publications/March2013-
FosteringSuccessfulPatientFamilyEngagement.pdf
http://psnet.ahrq.gov/resource.aspx?resourceID=1599
me-3/
me-3/
me-3/
http://www.simplypsychology.org/maslow.html
http://www.simplypsychology.org/maslow.html

http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-
111publ148.pdf
111publ148.pdf
111publ148.pdf
http://www.nursingworld.org/MainMenuCategories/Policy-
Law.pdf
Law.pdf
Law.pdf
Law.pdf
http://nursingworld.org/MainMenuCategories/Policy-
Advocacy/HealthSystemReform/AffordableCareAct.pdf
http://innovations.cms.gov/
http://partnershipforpatients.cms.gov/about-the-
partnership/aboutthepartnershipforpatients.html

http://www.naqc.org/Main/Resources/Publications/2012-
NursesContributionsFosteringSuccessfulPatientEngagement.pdf
mailto:[email protected]
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HomeANA PeriodicalsOJINTable of ContentsVol.12 -
2007No3:Sept'07Nursing Quality Indicators
The National Database of Nursing Quality Indicators®
(NDNQI®)
^md
Isis Montalvo, MS, MBA, RN
Abstract
The National Database of Nursing Quality IndicatorsTM
(NDNQI®) is the only national nursing database that provides
quarterly and annual reporting of structure, process, and
outcome indicators to evaluate nursing care at the unit level.
Linkages between nurse staffing levels and patient outcomes
have already been demonstrated through the use of this
database. Currently over 1100 facilities in the United States
contribute to this growing database which can now be used to
show the economic implications of various levels of nurse
staffing. The purpose of this article is to describe the work and

accomplishments related to the NDNQI as researchers utilize its
nursing-sensitive outcomes measures to demonstrate the value
of nurses in promoting quality patient care. After reviewing the
history of evaluating nursing care quality, this article will
explain the purpose of the NDNQI and describe how the
database has been operationalized. Accomplishments and future
plans of the NDNQI will also be discussed.
Citation: Montalvo, I., (September 30, 2007) "The National
Database of Nursing Quality IndicatorsTM (NDNQI®)" OJIN:
The Online Journal of Issues in Nursing. Vol. 12 No. 3,
Manuscript 2.
DOI: 10.3912/OJIN.Vol12No03Man02
Key Words: nursing-sensitive indicators, quality, nurse staffing,
patient outcomes, nursing outcomes, performance measurement
Quality is a broad term that encompasses various aspects of
nursing care. Various health care measures have been identified
over the years as indicators of health care quality (American
Nurses Association, 1995; Institute of Medicine, 1999, 2001,
2005; Joint Commission, 2007). In 2004, the National Quality
Forum (NQF), via its voluntary consensus standards process,
endorsed 15 national standards to be used in evaluating nursing-
sensitive care. These standards are now known as the NQF 15
(Kurtzman & Corrigan, 2007). The purpose of this article is to
describe the work and accomplishments related to the National
Database of Nursing Quality IndicatorsTM (NDNQI®) as
researchers utilize its nursing-sensitive outcomes measures to
demonstrate the value of nurses in promoting quality patient
care. After reviewing the history of evaluating nursing care
quality, this article will explain the purpose of the NDNQI and
describe how the database has been operationalized.
Accomplishments and future plans of the NDNQI will also be
discussed.
History of Evaluating Nursing Care Quality
Evaluating the quality of nursing practice began when Florence
Nightingale identified nursing's role in health care quality and
began to measure patient outcomes. She used statistical methods

to generate reports correlating patient outcomes to
environmental conditions (Dossey, 2005; Nightingale,
1859/1946). Over the years, quality measurement in health care
has evolved. The work done in the 1970s by the American
Nurses Association (ANA), the wide dissemination of the
Quality Assurance (QA) model (Rantz, 1995), and the
introduction of Donabedian's structure, process, and outcomes
model (Donabedian, 1988, 1992) have offered a comprehensive
method for evaluating health care quality.
The workforce restructuring and redesign prevalent in the early
1990s demonstrated the need for the ANA to evaluate nurse
staffing and identify linkages between nurse staffing and patient
outcomes.The workforce restructuring and redesign prevalent in
the early 1990s demonstrated the need for the ANA to evaluate
nurse staffing and identify linkages between nurse staffing and
patient outcomes. In 1994 the ANA Board of Directors asked
ANA staff to investigate the impact of these changes on the
safety and quality of patient care. In 1994, ANA launched the
Patient Safety and Quality Initiative (ANA, 1995). A series of
pilot studies across the United States were funded by ANA to
evaluate linkages between nurse staffing and quality of care
(ANA, 1996a, 1997, 2000a, 2000b, 2000c). Multiple quality
indicators were identified initially. Evidence of the
effectiveness of these indicators was used to adopt a final set of
10 nursing-sensitive indicators to use in evaluating patient care
quality (Gallagher & Rowell, 2003). Implementation guidelines
were subsequently published (ANA, 1996b, 1999).
Nursing-sensitive indicators identify structures of care and care
processes, both of which in turn influence care outcomes.
Nursing-sensitive indicators are distinct and specific to nursing,
and differ from medical indicators of care quality. For example,
one structural nursing indicator is nursing care hours provided
per patient day. Nursing outcome indicators are those outcomes
most influenced by nursing care.
Purpose of the NDNQI®
In 1998, the National Database of Nursing Quality Indicators

was established by ANA so that ANA could continue to collect
and build on data obtained from earlier studies and further
develop nursing's body of knowledge related to factors which
influence the quality of nursing care. Linkages between nurse
staffing and patient outcomes had already been identified, but
continued data collection and reporting was necessary to
evaluate nursing care quality at the unit level and thus fulfill
nursing's commitment to evaluating and improving patient care.
Nursing's foundational principles and guidelines identify that as
a profession, nursing has a responsibility to measure, evaluate,
and improve practice. This is stated in two of nursing's guiding
documents:
The Code of Ethics for Nurses with Interpretative Statements
states: The nurse promotes, advocates for, and strives to protect
the health, safety, and rights of the patient (ANA, 2001, p.12).
Nursing: Scope & Standards of Practice, Standard 7 states: The
registered nurse systematically enhances the quality and
effectiveness of nursing practice (ANA, 2004. p. 33).
The Utilization Guide for the ANA Principles for Nurse Staffing
recognizes that in order to measure sufficiency of staffing on an
ongoing basis, at a minimum, unit level nursing-sensitive
structure, process, and outcome indicators need to be collected
(ANA, 2005). NDNQI's mission is to aid the nurse in patient
safety and quality improvement efforts... NDNQI's mission is to
aid the nurse in patient safety and quality improvement efforts
by providing research-based, national, comparative data on
nursing care and the relationship of this care to patient
outcomes.
Operationalization of the National Database
The NDNQI® database is managed at the University of Kansas
Medical Center (KUMC) School of Nursing under contract to
ANA with fiscal and legal support provided by KUMC Research
Institute (KUMCRI). A health care facility that is interested in
joining the NDNQI submits a signed contract and fee, based on
hospital size, to KUMCRI, along with information on the person
who will be the facility's NDNQI® primary point of contact.

This person is then identified as the NDNQI Site Coordinator.
The NDNQI Site Coordinator serves as the interface between
the participating facility and the NDNQI liaisons working at the
University of Kansas. The NDNQI® liaisons provide ongoing
assistance and support to health care facilities at multiple
levels. For example they provide help in identifying nursing
units appropriately for data entry; offer web-based, data-entry
tutorials; conduct pilot testing; and answer questions about
definitions and the reading of reports. NDNQI® researchers are
also available to answer questions related to the database or the
nursing measures.
Education on NDNQI and nursing-sensitive indicators has been
ongoing for participating facilities since 1999. Facilities have
quarterly conference calls with NDNQI® staff to review any
changes or updates to the indicators or database. They also have
the opportunity to participate in pilot studies performed when
an indicator is being evaluated for implementation.
Once access to the database has been provided, the facility
NDNQI® Site Coordinator will work with NDNQI staff from
the University of Kansas to correctly classify the nursing units.
This is an important step to ensure nursing units are classified
appropriately prior to data entry. The facility NDNQI Site
Coordinator and other authorized hospital staff also complete
web-based tutorials to learn about each indicator prior to initial
data submission.The facility NDNQI Site Coordinator has
continuous access to the indicator definitions and is responsible
for aligning the hospital data collected to NDNQI definitions.
The facility NDNQI Site Coordinator has continuous access to
the indicator definitions and is responsible for aligning the
hospital data collected to NDNQI definitions. On average, it
takes three months to join the database and start data
submission. The NDNQI is then dependent on hospitals
correctly submitting the data on a quarterly basis. All data is
submitted electronically via the intranet in a secure website or
by XML submission. Data checks and error reports are
conducted on an ongoing basis by participating facilities and by

NDNQI staff to ensure data integrity.
As of the writing of this article, the NDNQI has implemented
six of the ten original ANA-endorsed NDNQI indicators (See
Table 1). The initial set of indicators used in establishing the
database was selected based on feasibility testing. These
indicators included: Falls, Falls with Injury, Nursing Care
Hours per Patient Day, Skill Mix, Pressure Ulcer Prevalence,
and Hospital-Acquired Pressure Ulcer Prevalence. The RN job
satisfaction indicator was pilot tested in 2001 and subsequently
implemented in 2002. The RN satisfaction survey is an
important indicator to assist nursing leaders and staff in
evaluating the work environment so as to facilitate nursing
retention and recruiting efforts.
Table 1. NDNQI Indicators
Indicator
Sub-indicator
Measure(s)
1. Nursing Hours per Patient Day1,2
a. Registered Nurses (RN)
b. Licensed Practical/Vocational Nurses (LPN/LVN)
c. Unlicensed Assistive Personnel (UAP)
Structure
2. Patient Falls1,2
Process & Outcome
3. Patient Falls with Injury1,2
a. Injury Level
Process & Outcome
4. Pediatric Pain Assessment, Intervention, Reassessment (AIR)
Cycle
Process
5. Pediatric Peripheral Intravenous Infiltration Rate
Outcome

6. Pressure Ulcer Prevalence1
a. Community Acquired
b. Hospital Acquired
c. Unit Acquired
Process & Outcome
7. Psychiatric Physical/Sexual Assault Rate
Outcome
8. Restraint Prevalence2
Outcome
9. RN Education /Certification
Structure
10. RN Satisfaction Survey Options1,3
a. Job Satisfaction Scales
b. Job Satisfaction Scales – Short Form
c. Practice Environment Scale (PES)2
Process & Outcome
11. Skill Mix: Percent of total nursing hours supplied by1,2
<="">
a. RN’s
b. LPN/LVN’s
c. UAP
d. % of total nursing hours supplied by Agency Staff
Structure
12. Voluntary Nurse Turnover2
Structure
13. Nurse Vacancy Rate
Structure
14. Nosocomial Infections(Pending for 2007)
a. Urinary catheter-associated urinary tract infection (UTI)2
b. Central line catheter associated blood stream infection
(CABSI)1,2

c. Ventilator-associated pneumonia (VAP)2
Outcome
1 Original ANA Nursing-Sensitive Indicator
2 NQF Endorsed Nursing-Sensitive Indicator “NQF-15”
3 The RN Survey is annual, whereas the other indicators are
quarterly
Pediatric and psychiatric indicators have been added more
recently because participating hospitals requested indicators for
these areas. Additional NQF endorsed measures (Table 1) were
then added to the database because these represented additional
nursing measures available that had already gone through a
consensus measure approval process. ANA supported the
addition of these measures to the database because they were of
interest nationally to the nursing profession and were in concert
withANA's seminal work and ongoing support of nursing
measures.
Implementing an indicator is a multi-step process (Table 2) that
includes evaluating the evidence that a specified indicator is
nurse sensitive and then pilot testing (Table 3) of the indicator
by participating facilities. In addition, ...there is ongoing
monitoring and testing for validity and reliability per NDNQI
standard operating procedure. there is ongoing monitoring and
testing for validity and reliability per NDNQI standard
operating procedure. An outcome indicator is deemed to be
nursing sensitive if there is a correlation or multivariate
association between some aspect of the nursing workforce or a
nursing process and the outcome. The NDNQI utilizes state-of-
the-science methods, such as the hierarchical mixed model, to
assess the strength of correlation between nursing workforce
characteristics and outcomes (Gajewski et al., 2007; Hart, et al.,
2006).
Table 2. Indicator Development Process
1. Review scientific literature for: (a) evidence that some aspect
of nursing case has an effect on a patient outcome; (b) specific
definitions of the indicators; and (c) evidence that the indicators

can be validly and reliably measured
2. Collect information from researchers in the field on threats to
reliability and validity
3. Conduct expert review of draft indicator definitions, data
collection guidelines, and data collection forms
4. Distribute revised definitions, guidelines, and forms to
clinical experts for comments on face validity and feasibility of
reliable data collection
5. Incorporate clinical expert feedback and develop revised
versions of definitions, guidelines, and forms
6. Conduct a pilot study (Table 3) using the draft data collection
materials and review data; also interview hospital study
coordinators to identify additional threats to reliability and
validity
7. Finalize definitions, data collection guidelines, and forms
8. Train database participants in standardized data collection
practices
Table 3. Pilot Testing Process
1. Develop the indicator with draft guidelines and data
collection instruments
2. Recruit pilot testers via e-mail and phone
3. Select pilot sites from those interested. Sites are selected for
hospital/unit diversity
4. Guide pilot sites in collecting data according to the draft
guidelines
5. Analyze data submitted by pilot sites
6. Collect written and telephone evaluations to assess for
clarity, feasibility, and assessment of threats to validity and
reliability
7. Analyze pilot data for indicator refinement
8. Finalize guidelines and instruments for dissemination
Quarterly Reports are downloaded electronically from the web
by participating facilities. Reports can be downloaded in Adobe
PDF, or Microsoft Excel format to facilitate data sharing and
dissemination within a given institution. Figure 1 provides a

sample of two tables from the report. The reports range from
25-200+ pages based on the number of nursing units and
indicators for which hospitals submit data. The reports provide
the most current eight quarters worth of data and a rolling
average of those eight quarters with national comparisons at the
unit level based on patient type, unit type, hospital bed size, and
statistical significance of unit performance. For example,
patient falls with injury could be reported for each adult
medical unit of a 100-199 bed facility. The means for all
medical units in a given-size facility can be compared with
national standards for a given, nursing-sensitive indicator. The
process measures associated with falls are collected and
reported as well as the outcome measure of a patient fall.
Figure 1 – Sample Tables from NDNQI Reports
The significance of offering the reports at the unit level is that
such reports provide data regarding the specific site where the
care occurs and provides a better comparison among like units.
The significance of offering the reports at the unit level is that
such reports provide data regarding the specific site where the
care occurs and provides a better comparison among like units.
Nursing leaders at participating facilities have used the
information to advocate for more staff or a different mix of staff
based on their comparisons of units in comparable facilities
nation wide. Staff are also able to identify whether their
performance improved after they intervened in an area needing
improvement, e.g., a decrease in the fall rate due to
implementation of a new protocol.
Some facilities join NDNQI as part of their MagnetTM Journey
to report nursing-sensitive indicators. The Magnet facilities
represent about 20% of the database. The remaining 80% of
NDNQI-participating facilities join because they believe in the
value of evaluating the quality of nursing care and improving
outcomes, activities which are both basic responsibilities of the
profession. NDNQI is also used to aid in the recruitment and

retention of nurses by hospitals that use the annual RN Survey
data and quarterly data to improve work environments, to staff
based on patient outcomes, and to meet regulatory or state
reporting requirements.
Broad Accomplishments
NDNQI accomplishments include development of nationally
accepted measures to assess the quality of nursing care,
improvements in training procedures for data submission,
identification of nursing workforce structures and processes that
influence outcomes, and sharing best practices for improving
outcomes. Each will be discussed in turn. Nursing leaders at
participating facilities have used the information to advocate for
more staff...
To date the NDNQI has already developed a number of
standards. Four of the 15 standard nursing measures endorsed
by the NQF have been NDNQI measures. Thirteen indicators
already have been implemented in NDNQI, and at the time of
this writing three additional measures, which are also NQF-
endorsed measures, are scheduled for implementation. Of the 13
implemented indicators, eight are NQF consensus measures.
NQF uses a consensus process to endorse measures. This
process includes (a) consensus standard development, (b)
widespread review, (c) member voting and member council
approval, (d) board of directors action, and (e) evaluation. The
importance of the NQF-endorsed indicators is that they provide
a standard measure for evaluating nursing care and are the only
nursing measures that have been endorsed for public reporting.
Data training procedures and submissions have advanced from a
telephone call for 1:1 training and submission using a CD, to
use of comprehensive, web-based tutorials training participants
to submit data using electronic means. Data submission now
involves specification of unit types and various patient types,
such as adult, pediatric, neonatal, psychiatric, and rehabilitation
patient populations.
Research on the database has yielded meaningful information on
both workforce characteristics which influence quality outcomes

and the importance of evaluating the data based on unit type.
Identification of important correlations between structures and
processes and observed nursing outcomes can help facilities
improve their nursing care outcomes.Dunton et al. (2004)
evaluated nurse staffing and patient falls and noted important
correlations. They observed that lower fall rates were associated
with higher staffing on certain types of units, and noted a strong
relationship between fall rates, nursing hours, and skill mix.
Hart, et al.(2006) studied the incidence of pressure ulcers
among NDNQI hospitals, and reported a difference in quality
outcomes based on the nursing workforce element of
certification. As a result of the Hart et al. study an additional,
web-based tutorial on pressure ulcers was created by NDNQI to
educate the staff nurse on wound assessment. It is available
publicly on the NDNQI web-site for any nurse to complete.
Both of these studies demonstrated the value of reporting
nursing-sensitive indicator data at the unit level, recognizing
that variability of outcomes occurs at the unit level based on
patient type, nurse staffing, and the nursing workforce
characteristics. The NDNQI database enables researchers to
identify various nursing workforce elements that can impact
patient outcome, such as nurse staffing, skill mix, and specific
nursing processes. It also enables researchers to identify process
elements that can influence patient outcomes. Identification of
important correlations between structures and processes and
observed nursing outcomes can help facilities improve their
nursing care outcomes. The database provides the end user with
a powerful tool to aid in decision making related to improving
the nursing work environment and patient outcomes.
...80% of NDNQI-participating facilities join because they
believe in the value of evaluating the quality of nursing care
and improving outcomes, activities which are both basic
responsibilities of the profession. NDNQI staff have also helped
facilities improve patient care by sharing best practices. In 2006
NDNQI staff identified facilities that had sustained an
improvement in a given nursing-sensitive indicator. These

facilities were asked to share what they had done to bring about
this improvement. Fourteen facilities were profiled in a
monograph identifying their experience with the database, their
use of the data, and improvement strategies they had
implemented to improve nursing performance in a given
measure (Montalvo & Dunton, 2007). For example, in one
facility the hospital-acquired pressure ulcer (HAPU) rate
dropped from 6.31 to 3.04 after implementing a quality
improvement process that included assigning wound/ostomy/
continence specialists to specific nursing units to help all staff
improve their surveillance for HAPUs and adopt a zero
tolerance for HAPU. The opportunity for varying-size facilities
to share these best practices adds to nursing's knowledge base
and helps nurses nation wide to improve nursing practice and
patient outcome. The First Annual NDNQI Data Use Conference
was held in January 2007 and was highly successful with 900
attendees being able to walk away with practical tools and tips
in utilizing NDNQI data and to improve nursing-sensitive
indicator outcomes. The monograph by Montalvo and Dunton,
along with the annual national conference, have aided in
disseminating such helpful information to all interested parties.
The current consumer-driven health care environment requires
accountability for the health care decisions made and the impact
of these decisions on patients. Although direct financial
cost/benefits have not been fully calculated with NDNQI
globally, the staff nurses and nurse leaders now have a valuable
nursing tool to aid them in decision making about staffing, skill
mix, patient care processes, and workforce characteristics that
affect patient outcomes, thus influencing directly and indirectly
the cost of patient care. The facility now has the data necessary
to calculate their cost/benefit ratio based on their improvements
and outcomes.
Future Plans and Goals for NDNQI®
The NDNQI database continues to grow in the number of
facilities participating and in methodological sophistication.
The database has grown from the original 30 facilities to over

1100 facilities in 2007, and ongoing investment and database
enhancements continue. Two key developments are slated to
begin in 2007. One is to develop methods for measuring unit-
level acuity. This will provide mixed acuity units (units having
more than 10% of patients representing a different patient
population, such as rehabilitation patients on medical units
[NDNQI operational definition, 2007]) and universal bed units
(those having patient rooms equipped to care for any patient
regardless of acuity [Brown, 2007]) with the ability to receive
comparisons from NDNQI.
The second enhancement is to improve reporting features of
NDNQI, so that more finite or granular comparisons of a very
specific type of unit can be made. An example of a more finite
comparison for particular facilities would be comparing
coronary critical care units in the 100-bed to 199-bed hospitals.
More enhanced reporting will provide more specific
comparisons, the ability to download and post different sections
of the report, new color graphics, single report cards, and
hospital-level summaries. These value-added enhancements will
provide the end user with a more powerful tool to evaluate
nursing care, improve quality, and influence outcomes for both
the patient and the nursing staff alike.
New indicators are added to the database on an annual basis.
Additionally, over the next 18 months, existing indicators in the
database will become available for all appropriate nursing units.
For example, the current psychiatric assault indicator could be
pertinent in the Emergency Department (ED) because the ED is
a point of entry for these patients. As the demand for data
increases, expanding existing indicators to relevant areas will
facilitate the ability of facilities to respond to patient and staff
needs.
Researchers will also continue to benefit from these
enhancements. These developments will enable researchers to
fine-tune their research questions and identify additional
associations between nursing workforce characteristics and
processes and the observed patient outcomes.

Conclusion
The NDNQI has made considerable progress since the ANA
Board of Directors asked ANA staff to investigate the impact of
workforce restructuring and redesign on patient care and to
quantify the relationship between nurse staffing and patient
outcomes. Today's national spotlights on patient safety and
public reporting have increased the need for nursing to collect
and monitor data related to patient outcomes. It is also critical
to continue these efforts to ensure nursing has the appropriate
workforce to render the care necessary to optimize patient
outcomes at the unit level. NDNQI studies have demonstrated
the value of nursing care and the significance of nursing's
contribution to positive patient outcomes. NDNQI data now has
the validity and reliability to be used to evaluate nursing care,
improve patient outcomes, and identify the linkages between
nurse staffing and patient outcomes at the unit level. NDNQI
has indeed become the seminal nursing database that is used to
influence nursing policy and improve nursing care.
Author
Isis Montalvo, MS, MBA, RN
E-mail: [email protected]
Isis Montalvo is Manager, Nursing Practice & Policy at the
American Nurses Association (ANA). She is primarily
responsible for providing oversight to the National Database of
Nursing Quality Indicators™ (NDNQI®) in which over 1100
hospitals currently participate (www.nursingquality.org). Ms.
Montalvo has over 20 years experience in multiple areas of
clinical and administrative practice with a focus in critical care
and performance improvement. As a former NDNQI Site
Coordinator, Quality Specialist, and Nursing Research Chair at
a large urban facility she brings expertise in data analysis,
performance improvement, and nursing care evaluation. In
1996, she received her Master’s in Business Administration
from the University of Baltimore in Maryland and her Master’s
of Science in Nursing Administration from the University of
Maryland . She is a Critical Care Registered Nurse (CCRN)

Alumnus and a member of the American Association of Critical
Care Nurses, the American Society of Association
Executives/The Center for Association Leadership, the National
Association for Healthcare Quality, and Phi Kappa Phi and
Sigma Theta Tau honor societies.
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Article published September 30, 2007
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Workplace empowerment and nurses’ job satisfaction: a
systematic literature review
GIANCARLO CICOLINI R N , M S N , P h D
1
, DANIA COMPARCINI R N , M S N

2
and VALENTINA
SIMONETTI R N , M S N 2
1Nurse Director and 2PhD Student, Center of Excellence on
Aging, Clinical Research Center CRC-CeSI,
‘G.d’Annunzio’ University, Chieti Scalo, Italy
Correspondence
Giancarlo Cicolini
Center of Excellence on Aging,
Clinical Research Center CRC-
CeSI
University of ‘G. d’Annunzio’
Chieti - Via dei Vestini 31
66013 Chieti Scalo
Italy
E-mail: [email protected]
CICOLINI G., COMPARCINI D. & SIMONETTI V. (2014)
Journal of Nursing Management
22, 855–871.
Workplace empowerment and nurses’ job satisfaction: a
systematic
literature review

Aims This systematic review aimed to synthesize and analyse
the studies that
examined the relationship between nurse empowerment and job
satisfaction in
the nursing work environment.
Background Job dissatisfaction in the nursing work environment
is the primary
cause of nursing turnover. Job satisfaction has been linked to a
high level of
empowerment in nurses.
Evaluation We reviewed 596 articles, written in English, that
examined the
relationship between structural empowerment, psychological
empowerment and
nurses’ job satisfaction. Twelve articles were included in the
final analysis.
Key issue A significant positive relation was found between
empowerment and
nurses’ job satisfaction. Structural empowerment and
psychological empowerment
affect job satisfaction differently.
Conclusion A satisfying work environment for nurses is related
to structural and
psychological empowerment in the workplace. Structural
empowerment is an
antecedent of psychological empowerment and this relationship
culminates in
positive retention outcomes such as job satisfaction.
Implication for nursing management This review could be

useful for guiding
leaders’ strategies to develop and maintain an empowering work
environment
that enhances job satisfaction. This could lead to nurse retention
and positive
organisational and patient outcomes.
Keywords: job satisfaction, psychological empowerment,
review, structural
empowerment, workplace
Accepted for publication: 18 September 2012
Background
Nursing shortage is increasing because nurses are
leaving the profession, particularly as a result of diffi-
cult working conditions (Buerhaus et al. 2000, 2006)
and unsatisfying workplaces (Hayes et al. 2006, Pur-
dy et al. 2010). A recent study showed that the fac-
tors causing this desertion could be: a high nurse
turnover (Hauck et al. 2011), heavy workloads and
lack of development opportunities (Laschinger et al.
2009a).
Job satisfaction is defined as the degree of affect

toward a job and its main components (Adams &
Bond 2000) and can be considered to be a positive
concept describing work behaviours in work settings
(Utriainen & Kyngas 2009). Nurses’ job satisfaction is
DOI: 10.1111/jonm.12028
ª 2013 John Wiley & Sons Ltd 855
Journal of Nursing Management, 2014, 22, 855–871
related to professional, personal and organisational
variables (Lu et al. 2005) and is influenced by both
nurses’ working environment and nurses’ personal
characteristics (Adams & Bond 2000).
Nurse managers have to maintain high-quality stan-
dards of care and job satisfaction among nurses, often
with a lack of human and financial resources (Lee &
Cummings 2008). Transformational leadership style
is based on principles of empowerment, and it is able to
support these organisational conditions. To date, trans-

formational leadership is the most effective model of
management in the healthcare system for developing a
positive relationship between managers and nursing
staff, to promote nurse satisfaction and organisational
commitment (Ellefsen & Hamilton 2000, Falk-Rafael
2001, Laschinger et al. 2001a).
Workplace structures can support healthier nurses,
reduce stress and increase commitment and job
satisfaction, and also improve organisational and
patient outcomes (Wagner et al. 2010). Nurse leaders
need to carry out evidence-based approaches for
empowering work environments that ensure satisfac-
tion, which in turn could ensure high quality care
(Laschinger 2008).
The term ‘empowerment’ in the organisational con-
text is used in two different perspectives: psychological
empowerment and structural empowerment. Structural
empowerment refers to the application of management

(Kanter 1977) and occurs when employees have access
to empowerment structures (Laschinger et al. 2004).
The psychological empowerment (Spreitzer 1995) deals
with ways in which these applications are experienced
and understood by workers (Cavus & Demir 2010)
and occurs when there is a sense of motivation in rela-
tion to the workplace environment (Manojlovich &
Laschinger 2007).
Based on previous studies on psychological empow-
erment (Conger & Kanungo 1988, Thomas & Velt-
house 1990), Spreitzer (1995, 1996) developed a
multidimensional instrument to measure the psycho-
logical empowerment in the workplace through four
cognitive dimensions reflecting why employees feel
empowered.
The first cognitive dimension is meaning, referring
to how much employees feel that their work is impor-
tant in relation to the congruence between workplace

requirements and one’s own beliefs, values and behav-
iours. The second is competence, referring to the level
of one’s capability to perform job requirements
successfully. The third is self-determination, referring
to the sense of autonomy that people have towards
their own work. The fourth dimension is impact,
referring to the level to which people feel that they are
able to have an influence on the workplace.
Kanter (1977) defined an empowering work environ-
ment as a workplace in which employees have access to
the four empowerment structures. The first structure is
information, referring to the data, technical knowledge
and expertise that are necessary effectively to fulfil
someone’s professional requirements (Laschinger &
Havens 1996). The second is resources, referring to
material, money, time, requirement and equipment
needed to accomplish the organisational goals. The
third is support, referring to feedback, leadership and

guidance received from superiors, peer and subordi-
nates. The last is opportunities referring to autonomy,
self-determination, a feeling of challenge and the oppor-
tunity to learn and grow. The access to these structures
is facilitated by two specific sources of power in organi-
sations: formal power (specific job characteristics) and
informal power (interpersonal relationships with supe-
riors, peers and subordinates) (Miller et al. 2000).
Chandler (1986) was the first to test Kanter’s theory
of organisational empowerment in nursing settings.
Based on Kanter’s (1977) theory and Chandler’s
(1986) work, the University of Western Ontario
Workplace Empowerment Research Programme has
been created. To date, the main studies testing Kan-
ter’s model of empowerment in health care settings
have been conducted by Laschinger and colleagues
(Laschinger and others, 2000–2011). Further research
(Laschinger et al. 2001a,c,d) has been carried out to

expand Kanter’s model with the addition of Spreitzer’s
(1995) model of psychological empowerment.
In the past two decades, researchers have integrated
both the structural and the psychological perspectives
of empowerment (Spreitzer 2007) in order to under-
stand empowerment at work.
Both perspectives are correlated with measurable
positive workplace outcomes, particularly with job
satisfaction (Stewart et al. 2010, Wagner et al. 2010),
which is essential to support changes at all levels of
the organisation and to achieve long-term outcomes
for managers, staff and patients (Laschinger & Havens
1996, Manojlovich & Laschinger 2002). Nurse manag-
ers have to incorporate empowerment techniques
into management strategies (Chang et al. 2011) to
increase nurse satisfaction within the work environment
(Upenieks 2003).
Significance

Many factors contribute to the current nursing short-
age, high nurse turnover is considered one of the main
ª 2013 John Wiley & Sons Ltd
856 Journal of Nursing Management, 2014, 22, 855–871
G. Cicolini et al.
contributors (Hauck et al. 2011) while job dissatisfac-
tion is the primary cause of nursing turnover (Lautizi
et al. 2009).
Nursing retention is related to workplace variables
and to job satisfaction (Coomber & Barriball 2007).
Furthermore, nurses’ perceptions of workplace empow-
erment is related to intent to stay, independently of
individual factors (Nedd 2006).
Recent studies show that workplace empowerment
has a strong relationship with nurse retention and an
important impact on factors related to recruitment,
particularly on job satisfaction (Laschinger et al.
2001a, Faulkner & Laschinger 2008) and commit-

ment (McDermott et al. 1996).
The aim of the review was to identify and synthesize
recent studies on the relationship between nurse
empowerment and job satisfaction and to make rec-
ommendations for further research.
The following research questions guided this review:
● Can structural and psychological empowerment pro-
mote job satisfaction in nurses’ work environment?
● What is the relationship between structural empow-
erment and job satisfaction in nurses’ work environ-
ment?
● What is the relationship between psychological
empowerment and job satisfaction in nurses’ work
environment?
Methods
Design
A systematic literature review with narrative synthesis
was performed, because the methodologies of the
included studies were not appropriate for a statistical

summary of the studies. The integrative method pro-
posed by Whittemore and Knalf (2005) was used. This
method allows a combination of different method-
ologies to understand the varied perspectives on a spe-
cific phenomenon of concern better (Whittemore &
Knalf 2005).
Search strategy
The search included the following on-line databases:
MEDLINE (through PubMed), CINAHL (through EB-
SCOhost) and SCOPUS (through EBSCOhost). The
search period included articles published between
1998 and 2012 in order to select recent studies that
may have more relevance to the current nursing work-
place. The MeSH headings and free text terms were
combined to research the specific topic. Key search
terms included: workplace empowerment, nurse*,
structural empowerment, psychological empowerment,
job satisfaction and work satisfaction. Two web sites

were searched for additional studies: Laschinger H.K.S.,
http://publish.uwo.ca/~hkl and Spreitzer G., http://webuser.
bus.umich.edu/spreitze/Empowerment_Research.htm.
For the search and retrieval process see Figure 1.
Inclusion criteria
The inclusion criteria for the studies were: (1) papers
published in English language, (2) with a study sample
that included nurses (no student nurses, no nurse edu-
cators, no nurse managers or assistant nurse managers),
(3) studies investigating the impact of empowerment
on job satisfaction and/or the relationship between
workplace empowerment and job satisfaction, (4) stud-
ies reporting direct measures of empowerment (struc-
tural and/or psychological) and job satisfaction, (5)
studies using CWEQ or CWEQ-II for measuring struc-
tural empowerment and studies using PES for measur-
ing psychological empowerment, (6) quantitative or
qualitative research designs, (7) peer reviewed research.

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