The Quadruple Aim: care, health, cost and meaning in work Rishi Sikka,1 Julianne M Morath,2 Lucian Leape3 1Advocate Health Care, Downers Grove, Illinois, USA 2Hospital Quality Institute, Sacramento, California, USA 3Harvard School of Public Health, Boston, Massachusetts, USA Correspondence to Dr Rishi Sikka, Advocate Health Care, 3075 Highland Avenue, Suite 600, Downers Grove, Il 60515, USA; [email protected] Received 5 March 2015 Revised 6 May 2015 Accepted 16 May 2015 To cite: Sikka R, Morath JM, Leape L. BMJ Qual Saf 2015;24:608–610. In 2008, Donald Berwick and colleagues provided a framework for the delivery of high value care in the USA, the Triple Aim, that is centred around three over- arching goals: improving the individual experience of care; improving the health of populations; and reducing the per capita cost of healthcare.1 The intent is that the Triple Aim will guide the redesign of healthcare systems and the transition to population health. Health systems glo- bally grapple with these challenges of improving the health of populations while simultaneously lowering healthcare costs. As a result, the Triple Aim, although ori- ginally conceived within the USA, has been adopted as a set of principles for health system reform within many organi- sations around the world. The successful achievement of the Triple Aim requires highly effective healthcare organisations. The backbone of any effective healthcare system is an engaged and productive workforce.2 But the Triple Aim does not explicitly acknow- ledge the critical role of the workforce in healthcare transformation. We propose a modification of the Triple Aim to acknow- ledge the importance of physicians, nurses and all employees finding joy and meaning in their work. This ‘Quadruple Aim’ would add a fourth aim: improving the experience of providing care. The core of workforce engagement is the experience of joy and meaning in the work of healthcare. This is not synonym- ous with happiness, rather that all members of the workforce have a sense of accomplishment and meaning in their contributions. By meaning, we refer to the sense of importance of daily work. By joy, we refer to the feeling of success and fulfilment that results from meaning- ful work. In the UK, the National Health Service has captured this with the notion of an engaged staff that ‘think and act in a positive way about the work they do, the people they work with and the organ- isation that they work in’.3 The evidence that the healthcare work- force finds joy and meaning in work is not encouraging. In a recent physician survey in the USA, 60% of respondents indicated they were considering leaving practice; 70% of surveyed physicians knew at least one colleague who left their practice due to poor morale.2 A 2015 survey of British physicians reported similar findings with approximately 44% of respondents reporting very low or low morale.4 These findings also extend to the nursing profession. In a 2013 US surv.

1. The Quadruple Aim: care, health,
cost and meaning in work
Rishi Sikka,1 Julianne M Morath,2 Lucian Leape3
1Advocate Health Care, Downers
Grove, Illinois, USA
2Hospital Quality Institute,
Sacramento, California, USA
3Harvard School of Public
Health, Boston, Massachusetts,
USA
Correspondence to
Dr Rishi Sikka, Advocate
Health Care, 3075 Highland
Avenue, Suite 600, Downers
Grove, Il 60515, USA;
[email protected]
Received 5 March 2015
Revised 6 May 2015
Accepted 16 May 2015
To cite: Sikka R, Morath JM,
Leape L. BMJ Qual Saf
2015;24:608–610.
In 2008, Donald Berwick and colleagues
provided a framework for the delivery of
high value care in the USA, the Triple
Aim, that is centred around three over-
arching goals: improving the individual

2. experience of care; improving the health
of populations; and reducing the per
capita cost of healthcare.1 The intent is
that the Triple Aim will guide the redesign
of healthcare systems and the transition to
population health. Health systems glo-
bally grapple with these challenges of
improving the health of populations while
simultaneously lowering healthcare costs.
As a result, the Triple Aim, although ori-
ginally conceived within the USA, has
been adopted as a set of principles for
health system reform within many organi-
sations around the world.
The successful achievement of the
Triple Aim requires highly effective
healthcare organisations. The backbone of
any effective healthcare system is an
engaged and productive workforce.2 But
the Triple Aim does not explicitly acknow-
ledge the critical role of the workforce in
healthcare transformation. We propose a
modification of the Triple Aim to acknow-
ledge the importance of physicians, nurses
and all employees finding joy and
meaning in their work. This ‘Quadruple
Aim’ would add a fourth aim: improving
the experience of providing care.
The core of workforce engagement is
the experience of joy and meaning in the
work of healthcare. This is not synonym-
ous with happiness, rather that all
members of the workforce have a sense
of accomplishment and meaning in their

3. contributions. By meaning, we refer to
the sense of importance of daily work.
By joy, we refer to the feeling of success
and fulfilment that results from meaning-
ful work. In the UK, the National Health
Service has captured this with the notion
of an engaged staff that ‘think and act in
a positive way about the work they do,
the people they work with and the organ-
isation that they work in’.3
The evidence that the healthcare work-
force finds joy and meaning in work is
not encouraging. In a recent physician
survey in the USA, 60% of respondents
indicated they were considering leaving
practice; 70% of surveyed physicians
knew at least one colleague who left their
practice due to poor morale.2 A 2015
survey of British physicians reported
similar findings with approximately 44%
of respondents reporting very low or low
morale.4 These findings also extend to
the nursing profession. In a 2013 US
survey of registered nurses, 51% of
nurses worried that their job was affect-
ing their health; 35% felt like resigning
from their current job.5 Similar findings
have been reported across Europe, with
rates of nursing job dissatisfaction
ranging from 11% to 56%.6
This absence of joy and meaning experi-
enced by a majority of the healthcare
workforce is in part due to the threats of
psychological and physical harm that are

4. common in the work environment.
Workforce injuries are much more frequent
in healthcare than in other industries. For
some, such as nurses’ aides, orderlies and
attendants, the rate is four times the indus-
trial average.7 More days are lost due to
occupational illness and injury in health-
care than in mining, machinery manufac-
turing or construction.7
The risk of physical harm is dwarfed
by the extent of psychological harm in
the complex environment of the health-
care workplace. Egregious examples
include bullying, intimidation and phys-
ical assault. Far more prevalent is the psy-
chological harm due to lack of respect.
This dysfunction is compounded by pro-
duction pressure, poor design of work
flow and the proportion of non-value
added work.
The current dysfunctional healthcare
work environment is in part a by-product
of the gradual shift in healthcare from a
public service to a business model that
occurred in the latter half of the 20th
EDITORIAL
608 Sikka R, et al. BMJ Qual Saf 2015;24:608–610.
doi:10.1136/bmjqs-2015-004160
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9. http://qualitysafety.bmj.com/
century.8 Complex, intimate caregiving relationships
have been reduced to a series of transactional demand-
ing tasks, with a focus on productivity and efficiency,
fuelled by the pressures of decreasing reimbursement.
These forces have led to an environment with lack
of teamwork, disrespect between colleagues and lack
of workforce engagement. The problems exist from
the level of the front-line caregivers, doctors and
nurses, who are burdened with non-caregiving work,
to the healthcare leader with bottom-line worries and
disproportionate reporting requirements. Without joy
and meaning in work, the workforce cannot perform
at its potential. Joy and meaning are generative and
allow the best to be contributed by each individual,
and the teams they comprise, towards the work of the
Triple Aim every day.
The precondition for restoring joy and meaning is
to ensure that the workforce has physical and psycho-
logical freedom from harm, neglect and disrespect.
For a health system aspiring to the Triple Aim, fulfill-
ing this precondition must be a non-negotiable, endur-
ing property of the system. It alone does not
guarantee the achievement of joy and meaning,
however the absence of a safe environment guarantees
robbing people of joy and meaning in their work.
Cultural freedom from physical and psychological
harm is the right thing to do and it is smart economics
because toxic environments impose real costs on the
organisation, its employees, physicians, patients and
ultimately the entire population.
An organisation focused on enabling joy and

10. meaning in work and pursuit of the Triple Aim needs
to embody shared core values of mutual respect and
civility, transparency and truth telling and the safety
of the workforce. It recognises the work and accom-
plishments of the workforce regularly and with high
visibility. For the individual, these notions of joy and
meaning in healthcare work are recognised in three
critical questions posed by Paul O’Neill, former chair-
man and chief executive officer of Alcoa. This is an
internal gut-check, that needs to be answered affirma-
tively by each worker each day:2
1. Am I treated with dignity and respect by everyone,
everyday, by everyone I encounter, without regard to
race, ethnicity, nationality, gender, religious belief, sexual
orientation, title, pay grade or number of degrees?
2. Do I have the things I need: education, training, tools,
financial support, encouragement, so I can make a con-
tribution this organisation that gives meaning to my life?
3. Am I recognised and thanked for what I do?
If each individual in the workforce cannot answer
affirmatively to these questions, the full potential to
achieve patient safety, effective outcomes and lower
costs is compromised.
The leadership and governance of our healthcare
systems currently have strong economic and outcome
motivations to focus on the Triple Aim. They also
need to feel a parallel moral obligation to the
workforce to create an environment that ensures joy
and meaning in work. For this reason, we recommend

11. adding a fourth essential aim: improving the experi-
ence of providing care. The notion of changing the
objective to the Quadruple Aim recognises this focus
within the context of the broader transformation
required in our healthcare system towards high value
care. While the first three aims provide a rationale for
the existence of a health system, the fourth aim
becomes a foundational element for the other goals to
be realised.
Progress on this fourth goal in the Quadruple Aim
can be measured through metrics focusing on two
broad areas: workforce engagement and workforce
safety. Workforce engagement can be assessed through
annual surveys using established frameworks that
allow for benchmarking within industry and with
non-healthcare industries.9 Measures should also be
extended to quantify the opposite of engagement,
workforce burn-out. This could include select ques-
tions from the Maslach Burnout Inventory, the gold
standard for measuring employee burn-out.10 In the
realm of workforce safety, metrics should include
quantifying work-related deaths or disability, lost time
injuries, government mandated reported injuries and
all injuries. Although these measures do not com-
pletely quantify the experience of providing care, they
provide a practical start that is familiar and allow for
an initial baseline assessment and monitoring for
improvement.
The rewards of the Quadruple Aim, achieved within
an inspirational workplace could be immense. No
other industry has more potential to free up resources
from non-value added and inefficient production
practices than healthcare; no other industry has more
potential to use its resources to save lives and reduce

12. human suffering; no other industry has the potential
to deliver the value envisioned by The Triple Aim on
such an audacious scale. The key is the fourth aim:
creating the conditions for the healthcare workforce
to find joy and meaning in their work and in doing
so, improving the experience of providing care.
Contributors All authors assisted in the drafting of this
manuscript.
Competing interests None declared.
Provenance and peer review Not commissioned; externally
peer reviewed.
REFERENCES
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http://qualitysafety.bmj.com/The Quadruple Aim: care, health,
cost and meaning in workReferences
Original Article
Predictors of Evidence-Based Practice
Implementation, Job Satisfaction, and Group
Cohesion Among Regional Fellowship
Program Participants
Son Chae Kim, RN, PhD • Jaynelle F. Stichler, DNS, RN, NEA-
BC, FACHE, FAAN •
Laurie Ecoff, RN, PhD, NEA-BC • Caroline E. Brown, DEd,
CNS •
Ana-Maria Gallo, PhD, CNS, RNC-OB • Judy E. Davidson,
DNP, RN, FCCM
Keywords
evidence-based
practice,
fellowship,
EBP beliefs,
EBP
implementation,
job satisfaction,

24. group cohesion,
group attractiveness
ABSTRACT
Background: A regional, collaborative evidence-based practice
(EBP) fellowship program utiliz-
ing institution-matched mentors was offered to a targeted group
of nurses from multiple local
hospitals to implement unit-based EBP projects. The Advancing
Research and Clinical Practice
through Close Collaboration (ARCC) model postulates that
strong EBP beliefs result in high EBP
implementation, which in turn causes high job satisfaction and
group cohesion among nurses.
Aims: This study examined the relationships among EBP
beliefs, EBP implementation, job satis-
faction, group cohesion, and group attractiveness among the
fellowship program participants.
Methods: A total of 175 participants from three annual cohorts
between 2012 and 2014 com-
pleted the questionnaires at the beginning of each annual
session. The questionnaires included
the EBP beliefs, EBP implementation, job satisfaction, group
cohesion, and group attractiveness
scales.
Results: There were positive correlations between EBP beliefs
and EBP implementation (r = 0.47;
p <.001), as well as EBP implementation and job satisfaction (r
= 0.17; p = .029). However, no
statistically significant correlations were found between EBP
implementation and group cohesion,
or group attractiveness. Hierarchical multiple regression models

25. showed that EBP beliefs was a
significant predictor of both EBP implementation (β = 0.33; p
<.001) and job satisfaction (β =
0.25; p = .011). However, EBP implementation was not a
significant predictor of job satisfaction,
group cohesion, or group attractiveness.
Linking Evidence to Action: In multivariate analyses where
demographic variables were taken
into account, although EBP beliefs predicted job satisfaction, no
significant relationship was
found between EBP implementation and job satisfaction or
group cohesion. Further studies are
needed to confirm these unexpected study findings.
BACKGROUND
The adoption and implementation of evidence-based practice
(EBP) in nursing and other healthcare disciplines are recog-
nized as essential in ensuring optimal patient outcomes and
quality of care (Aarons, Ehrhart, & Farahnak, 2014). Although
EBP is considered to be the gold standard in nursing practice,
the actual implementation of EBP has been inconsistent due
to barriers related to nursing workload, lack of organizational
support, lack of EBP knowledge and skills, and poor attitudes
toward EBP (Brown et al., 2010; Ramos-Morcillo, Fernandez-
Salazar, Ruzafa-Martinez, & Del-Pino-Casado, 2015; Squires,
Estabrooks, Gustavsson, & Wallin, 2011). Although many hos-
pitals have used professional development courses individually
to encourage nurses’ implementation of EBP through im-
proved nurses’ knowledge and attitudes about EBP, successful
outcomes have been elusive (Melnyk, Gallagher-Ford, Long,
& Fineout-Overholt, 2014; Pryse, McDaniel, & Schafer, 2014;
Underhill, Roper, Siefert, Boucher, & Berry, 2015).
A regional, collaborative EBP fellowship program, the EBP

26. Institute, was founded in 2006 by nurse leaders from multi-
ple hospitals and academia in San Diego County, California, to
promote implementation of EBP by hospital nurses. The fel-
lowship program utilized institution-matched mentors to assist
in executing unit-based EBP projects, and included didactic as
well as interactive learning experiences in six daylong educa-
tional sessions over a 9-month period. A formal graduation day
340 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–
348.
C© 2016 Sigma Theta Tau International
Original Article
completed the learning experience, with the fellows present-
ing their EBP projects in poster and podium presentations. A
previous report on this program showed improvements in the
participants’ knowledge, attitudes, and practice associated with
EBP, as well as a reduction in barriers to EBP implementation
(Kim et al., 2013).
LITERATURE REVIEW
The literature is replete with evidence and opinions that ef-
forts to educate nurses regarding EBP have improved nurses’
knowledge and attitudes. However, these efforts have not nec-
essarily resulted in actual improvements in EBP implementa-
tion, nor have they changed clinical practices (Aarons et al.,
2014; Melnyk et al., 2014; Pryse et al., 2014). Although barri-
ers to EBP implementation have been well-documented, some
authors have also cited the importance of organizational cul-
ture and leadership in reducing barriers and fostering EBP
implementation.
Organizational Culture and Leadership for EBP
An organizational culture that emphasizes making clinical de-

27. cisions based on evidence is critical for improving and sus-
taining safe and high-quality patient care (Melnyk, Fineout-
Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010). Al-
though leaders influence the organizational culture, they also
play an important role in supporting implementation of EBP
and other innovative practices. Supportive leaders obtain fund-
ing, provide resources, allow the time necessary for nurses
to engage in EBP implementation, and reward those nurses
who participate in evidence-based change projects in perfor-
mance evaluations (Aarons et al., 2014; Ehrhart, Aarons, &
Farahnak, 2015). Ehrhart, Aarons, and Farahnak (2015) have
reported that clinical nurses with the greatest clinical exper-
tise and EBP knowledge were most helpful in advancing EBP
skills and positive EBP attitudes among their coworkers. This
finding supports the importance of mentorship in improving
nurses’ knowledge, attitudes, and practice of EBP (Abdullah
et al., 2014; Green et al., 2014; Magers, 2014).
Furthermore, organizations that engage in the Magnet
Recognition Program have been recognized for nurse engage-
ment in EBP and implementation of clinical practice changes.
The Magnet journey transforms organizational cultures, and
ensures leadership support and resources necessary to facili-
tate nurses’ engagement in EBP (American Nurses Credential-
ing Center, 2014; Black, Balneaves, Garossino, Puyat, & Qian,
2015; Wilson et al., 2015).
Educational Processes to Enhance EBP in
Healthcare Settings
A number of studies have described the structures, processes,
and outcomes of programs to enhance nurses’ appreciation,
knowledge, competencies, and practice of EBP (Kim et al.,
2013; Magers, 2014; Mollon et al., 2012; Ramos-Morcillo et al.,
2015; Underhill et al., 2015; Wong & Myers, 2015). Although
most EBP educational programs emphasize EBP contents re-

28. lated to asking relevant clinical questions, and searching for
and appraising forms of evidence, less emphasis is put on
actual EBP implementation (Wyer, Umscheid, Wright, Silva,
& Lang, 2015). The Advancing Research and Clinical Practice
through Close Collaboration (ARCC) model emphasizes EBP
implementation as the final focal point of the entire model,
through which all of the beneficial outcomes of EBP diffusion
flow (Melnyk et al., 2010). These outcomes include benefits
to patients with improved patient outcomes as well as bene-
fits to nurses such as higher job satisfaction and group cohe-
sion, along with lower nurse turnover, with the ultimate out-
come of decreased hospital costs. Using the ARCC model to
educate nurses, previous studies have reported that partici-
pants’ beliefs about EBP were significantly correlated with
perceived organizational culture for EBP, implementation of
EBP, group cohesion, and job satisfaction (Melnyk et al., 2010;
Wallen et al., 2010). However, there has not been a full ex-
amination of the strength of relationships among EBP beliefs,
EBP implementation, job satisfaction, and group cohesion that
takes the demographic variables into account.
The purpose of the study was to examine the relation-
ships among EBP beliefs, EBP implementation, job satisfac-
tion, group cohesion, and group attractiveness among nurses
participating in a regional, collaborative EBP fellowship pro-
gram. The specific aims were to examine: (a) EBP beliefs as a
predictor of EBP implementation; and (b) EBP beliefs and EBP
implementation as predictors of job satisfaction, group cohe-
sion, and group attractiveness above and beyond the influence
of demographic variables.
METHODS
Design and Participants
Three annual cohorts of nurses attending the 9-month re-
gional, collaborative EBP fellowship program in San Diego,
California, from 2012 to 2014 were invited to participate in

29. the study. The program attendees were selected nurses repre-
senting each participating institution as a dyad of mentor and
fellow. The fellows, in general, were staff nurses who would be
implementing unit-based EBP projects under the mentorship
of advanced practice nurses, nurse educators, or other nurses
with experience in implementing EBP projects.
Instruments
EBP beliefs scale. This 16-item scale measures respondents’
beliefs about the importance of EBP and their EBP competence
in a five-point Likert response format, ranging from strongly
disagree ( = 1) to strongly agree ( = 5). Possible total scores
range from 16 to 80, with higher scores indicating stronger
EBP beliefs. The internal consistency reliability was reported
as Cronbach’s alpha of 0.90, and validity testing has also been
reported in the previous study (Melnyk, Fineout-Overholt, &
Mays, 2008). The Cronbach’s alpha for the instrument in this
study was 0.87.
Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348.
341
C© 2016 Sigma Theta Tau International
Predictors of EBP Implementation, Job Satisfaction, and Group
Cohesion
EBP implementation scale. This 18-item scale assesses the
frequency of performing EBP-related activities in the past
8 weeks (Melnyk et al., 2008). Examples of items include
gener-
ating a PICO question, critically appraising research evidence,
and collecting data, as well as sharing EBP guidelines with oth-
ers. Response options range from 0 times ( = 0) to greater than
or equal to 8 times ( = 4), and the total summation score ranges

30. from 0 to 72, with a higher score indicating greater participa-
tion in EBP-related activities. The internal consistency reliabil-
ity was Cronbach’s alpha of 0.96, and validity testing was also
reported. The Cronbach’s alpha in this study was 0.96.
Job satisfaction scale. Respondents are asked to rate their
perception of job satisfaction in a five-point Likert response
format, ranging from strongly disagree ( = 1) to strongly agree
( = 5). This scale contains four items and the total summation
score ranges from 4 to 20, with a higher score indicating higher
job satisfaction (Mueller, Boyer, Price, & Iverson, 1994). The
Cronbach’s alpha was reported as 0.88 in the previous study
and it was 0.89 in this study.
Group cohesion and attractiveness scales. These are two
scales that measure group cohesion and group attractiveness
in a seven-point Likert response format (Good & Nelson, 1973).
The four-item Group Cohesion scale rates respondents’ percep-
tion about their work group’s productivity, efficiency, feeling
of belongingness, and morale from very much above average
( = 1) to very much below average ( = 7). The two-item Group
Attractiveness scale assesses respondents’ perception of their
enjoyment in working with the group. Responses range from
like/enjoy very much ( = 1) to dislike very much ( = 7). In this
study, the scores were reversed so that higher scores indicate
positive perceptions. The reported split-half reliabilities were
0.77 and 0.82, whereas the Cronbach’s alphas in this study
were 0.90 and 0.85, respectively.
Demographic data form. General demographic information,
such as age, educational background, ethnicity, years of RN
experience, and nursing position, was obtained.
Data Collection Procedures
This study was approved by the institutional review boards
of the participating academic and healthcare institutions. A

31. consent letter was provided to and reviewed by all potential
participants. Written documentation of consent was waived,
because minimal risk was involved in this study and partici-
pants’ anonymity was protected. Completion of the study ques-
tionnaires indicated consent to participate in the study. The
participants completed the study questionnaires at the begin-
ning of each 9-month program.
Data Analyses
Descriptive statistics, including mean, standard deviation, fre-
quency, and percentage, were calculated. Independent t-tests
were performed to compare the mean scores of EBP be-
liefs, EBP implementation, job satisfaction, group cohesion,
and group attractiveness between the mentors and the fel-
lows. Bivariate Pearson’s correlations were performed to exam-
ine the relationships among demographic variables and other
variables. To examine EBP beliefs as a predictor of EBP im-
plementation, the demographic variables that had significant
correlations with EBP implementation were entered in the first
step of the hierarchical multiple regression model. The EBP be-
liefs was then entered in the second step as a predictor of EBP
implementation above and beyond the demographic variables.
To examine EBP beliefs and EBP implementation as pre-
dictors of job satisfaction, group cohesion, and group attrac-
tiveness, the demographic variables that correlated with job
satisfaction, group cohesion, or group attractiveness were en-
tered in the first step of the hierarchical multiple regression
models. This was followed by entry of the EBP beliefs and
EBP implementation in the second step as predictors above
and beyond the demographic variables. The assumptions of
normality, linearity, and homoscedasticity in the hierarchical
multiple regression models were met. SPSS version 21.0 (IBM
SPSS Statistics, Armonk, NY) was used for data analyses and
the level of significance was set at p < .05.

32. RESULTS
Sample Characteristics
A total of 175 participants (101 fellows and 74 mentors) from
the three annual cohorts between 2012 and 2014 completed the
questionnaires at the beginning of the program. The fellows
comprised 57.7% of all participants. A majority of the partic-
ipants were white (69.7%) and had graduate degrees (52%).
The mean age was 42 years and average RN experience was
15 years (Table 1).
The mentors had statistically significant higher scores for
EBP beliefs (66.6 vs. 59.3; p < .001) and EBP implementation
(24.2 vs. 11.0; p < .001) in comparison with the fellows. How-
ever, there were no statistically significant differences in job
satisfaction, group cohesion, or group attractiveness between
the mentors and the fellows (Table 2).
Bivariate Correlations among Demographics and
Other Variables
Table 3 shows that the demographic variables of being a
mentor, clinical nurse specialist, nurse educator, or nurse
practitioner, as well as having a graduate-level education, had
statistically significant positive correlations with both EBP
beliefs and EBP implementation. Length of RN experience also
correlated with EBP implementation and having a graduate-
level education was the only demographic variable that corre-
lated with job satisfaction. None of the demographic variables
had positive correlations with either group cohesion or group
attractiveness.
For EBP implementation, positive correlations were ob-
served with EBP beliefs (r = 0.47; p < .001) and job satisfaction
(r = 0.17; p = .029). However, no statistically significant cor-
relations were found between EBP implementation and group

33. 342 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–
348.
C© 2016 Sigma Theta Tau International
Original Article
Table 1. Demographic Characteristics (N = 175)
Total Fellows Mentors
Variables (N = 175) (n = 101) (n = 74)
Cohorts
2012 cohort 42 (24.0) 20 (19.8) 22 (29.7)
2013 cohort 60 (34.3) 40 (39.6) 20 (27.0)
2014 cohort 73 (41.7) 41 (40.6) 32 (43.2)
Age,mean (year), range 42 (23-68) 39 (23-68) 46 (27-67)
Ethnicity
White (non-Hispanic) 122 (69.7) 66 (65.3) 56 (75.7)
Black 5 (2.9) 3 (3.0) 2 (2.7)
Hispanic 11 (6.3) 6 (5.9) 5 (6.8)
Asian/Pacific Islanders 29 (16.6) 19 (18.8) 10 (13.5)
Other 8 (4.5) 7 (6.9) 1 (1.4)
Educational level

34. Diploma/associate 8 (4.6) 8 (7.9) 0 (0.0)
Baccalaureate 76 (43.4) 70 (69.3) 6 (8.1)
Master/doctorate 91 (52.0) 23 (22.8) 68 (91.9)
Nursingposition
Clinical nurse 73 (41.7) 67 (66.3) 6 (8.1)
Leadnurse 20 (11.4) 13 (12.9) 7 (9.5)
Nursemanager 12 (6.9) 1 (1.0) 11 (14.9)
CNS/nurse educator/NP 64 (36.6) 15 (14.9) 49 (66.2)
Non-nursing 6 (3.4) 5 (5.0) 1 (1.4)
RNexperience,mean (year), range 15 (1, 42) 12 (1, 35) 20 (2,
42)
ANCCcertification in specialty 94 (53.7) 48 (47.5) 46 (62.2)
Note. Values are expressed as n (%) unless otherwise indicated.
Percentagesmay not add up to 100% because of missing data or
rounding. ANCC = American
NursesCredentialingCenter; CNS = clinical nurse specialist; NP
= nursepractitioner; RN = registerednurse.
cohesion or group attractiveness. For job satisfaction, there
were positive correlations with EBP beliefs (r = 0.26; p = .01)
and group attractiveness (r = 0.23; p = .003). There was also a
positive correlation between group cohesion and group attrac-
tiveness (r = 0.49; p < .001; Table 3).
Multivariate Analysis: EBP Beliefs as a Predictor of

35. EBP Implementation
In the first step of a hierarchical multiple regression model,
the demographic variables, including being a mentor, edu-
cational level, years of RN experience, and nursing position
accounted for 22.5% of the variance in EBP implementation
(R2 = 0.225; Table 4). The entry of the EBP beliefs in the
second step increased the R2 by .075, indicating that the EBP
beliefs explained a small fraction of the variance in the EBP
implementation above and beyond the demographic variables
(7.5%). Being a mentor (β = 0.27; p = .012) and EBP beliefs
(β = 0.33; p < .001) were statistically significant predictors of
EBP implementation.
Multivariate Analyses: Predictors of Job Satisfac-
tion, Group Cohesion, and Group Attractiveness
Table 5 shows that demographic variables in the first step
of a hierarchical multiple regression model accounted for 6.2%
Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348.
343
C© 2016 Sigma Theta Tau International
Predictors of EBP Implementation, Job Satisfaction, and Group
Cohesion
Table 2. Comparison of Mean (± SD) of Variables
Between Mentors and Fellows (N = 170)
P value
Fellows Mentors independent
(n = 98) (n = 72) (t test)

36. EBPbeliefs 59.3 (6.38) 66.6 (6.91) < .001***
EBP implementation 11.0 (10.6) 24.2 (16.9) < .001***
Job satisfaction 16.6 (2.18) 17.0 (2.34) .215
Groupcohesion 20.1 (4.39) 20.6 (4.67) .479
Groupattractiveness 11.7 (1.67) 11.8 (1.83) .653
Note. ***p < 0.001. SD = standard deviation. The higher the
scores,
the higher the EBP beliefs, EBP implementation, job
satisfaction, group
cohesion, andgroupattractiveness.
of the variance in job satisfaction (R2 = 0.062). The entry of
EBP beliefs and EBP implementation in the second step in-
creased the R2 by 0.050, indicating that these two variables ex-
plained a small fraction of the variance in job satisfaction above
and beyond demographic variables (5.0%). EBP beliefs was
a statistically significant positive predictor of job satisfaction
(β = 0.25; p = .011), but EBP implementation was not a
predictor of job satisfaction.
For group cohesion, the demographic variables in the
first step explained 1.8% of the variance of group cohesion
(R2 = 0.018). The EBP beliefs and EBP implementation in the
second step explained 0.2% of the variance of group cohesion
(R2 = 0.002), indicating that these two variables explained
only a minimal fraction of variance in group cohesion above
and beyond the demographic variables.
For group attractiveness, the first entry of demographic
variables accounted for 1.0% of the variance of the group at-
tractiveness (R2 = 0.010). The entry of EBP beliefs and EBP

37. implementation in the second step changed the R2 by 0.038,
indicating that they explained a minimal fraction of the vari-
ance in group attractiveness (3.8%). EBP implementation was
a statistically significant negative predictor for group attractive-
ness (β = -0.22; p = .021; Table 5).
Table 3. Bivariate Correlations Among Variables
EBP
beliefs
EBP
implementation
Job
satisfaction
Group
cohesion
Group
attractiveness
Mentors 0.48*** 0.43*** 0.10 0.06 0.04
Educational level
Diploma/associate −0.19* −0.03 −0.02 −0.19* 0.01
Baccalaureate −0.43*** −0.37*** −0.15* −0.002 −0.06
Master/doctorate 0.51*** 0.38*** 0.16* 0.01 0.07
Years of RNexperience 0.13 0.16* 0.02 0.04 0.04
Nursingposition
Clinical nurse −0.33*** −0.28*** 0.04 −0.01 −0.07

38. Leadnurse −0.02 −0.001 −0.19* −0.04 −0.02
Nursemanager 0.07 −0.02 −0.07 0.11 0.04
CNS/nurse educator/NP 0.34*** 0.32*** 0.09 −0.02 0.01
EBPbeliefs 1 0.47*** 0.26** −0.02 0.09
EBP implementation 0.47*** 1 0.17* −0.02 −0.11
Job satisfaction 0.26** 0.17* 1 0.09 0.23**
Groupcohesion −0.02 −0.02 0.09 1 0.49***
Groupattractiveness 0.09 −0.11 0.23** 0.49*** 1
Note. *p < .05; ** p < .01; *** p < .001 byPearson’s
correlations.
344 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–
348.
C© 2016 Sigma Theta Tau International
Original Article
Table 4. Multivariate Analysis: Predictors of EBP Im-
plementation
EBP implementation
Predictors B β
Step 1
Constant demographic variables a 15.4
R2 = 0.225***
Step2

39. Constant −27.0
Mentor 8.25* 0.27*
EBPbeliefs 0.66*** 0.33***
R2 � = 0.075***
F� (1, 160) = 17.22***
Note. *p < 0.05; *** p < 0.001. aDemographic variables of
being amen-
tor, educational level, years of RN experience, and nursing
position were
entered.
DISCUSSION
The study findings indicate that EBP beliefs had a signifi-
cant correlation with EBP implementation in bivariate anal-
ysis, and was a positive predictor of EBP implementation in
multivariate analysis. In addition, EBP beliefs showed a signif-
icant correlation with job satisfaction in bivariate analysis and
was also a positive predictor of job satisfaction in multivariate
analysis. These results are consistent with previous findings
and support the ARCC model, which postulates that strong
EBP beliefs result in high levels of EBP implementation
(Melnyk et al., 2010).
Although these study findings indicate that EBP implemen-
tation has some correlation with job satisfaction in a bivariate
analysis, the multivariate analysis showed a surprising finding
that EBP implementation was not a predictor of job satisfac-
tion. In addition, EBP implementation was not a significant
predictor of group cohesion or group attractiveness in mul-
tivariate analyses. Furthermore, EBP implementation was a
significant negative predictor of group attractiveness, indicat-

40. ing that high levels of EBP implementation are associated with
lower group attractiveness. These unexpected findings from
multivariate analyses appear to conflict with the ARCC model,
which postulates that high levels of EBP implementation re-
sult in high job satisfaction as well as high group cohesion
(Melnyk et al., 2010). However, these findings are consistent
with a previous report showing no statistically significant cor-
relations between EBP implementation and job satisfaction or
group cohesion (Melnyk et al., 2010). Also, an interventional
study of implementing the ARCC model showed no signifi-
cant effect on job satisfaction, in spite of improvements in EBP
implementation (Levin, Fineout-Overholt, Melnyk, Barnes, &
Vetter, 2011). It is possible that these findings showing no
significant relationship between EBP implementation and job
satisfaction or group cohesion are due to small sample sizes,
which could have prevented detection of small effects. Further
studies are needed to confirm this study findings.
Table 5. Multivariate Analyses: Predictors of Job Satisfaction,
Group Cohesion, and Group Attractiveness
Job satisfaction Groupcohesion Groupattractiveness
Predictors B β B β B β
Step 1
Constant 17.0 19.3 12.1
demographic variables a
R2 = 0.062 R2 = 0.018 R2 = 0.010
Step2
Constant 12.2 20.9 10.2

41. EBP implementation 0.01 0.06 −0.01 −0.03 −0.03* −0.22
EBPbeliefs 0.07* 0.25* −0.02 −0.04 0.04 0.16
R2 � = 0.050* R2 � = 0.002 R2 � = 0.038*
F� (2, 157) = 4.47* F� (2, 162) = 0.16 F� (2, 157) = 3.12*
Note. *p < 0.05. aDemographic variables of being amentor,
educational level, years of RNexperience,
andnursingpositionwere entered.
Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348.
345
C© 2016 Sigma Theta Tau International
Predictors of EBP Implementation, Job Satisfaction, and Group
Cohesion
It was not surprising that mentors, given their longer years
of RN experience, higher levels of education, and nursing
positions as advanced practice nurses (clinical nurse special-
ists, nurse educators, or nurse practitioners), had significantly
stronger EBP beliefs and greater EBP implementation. These
findings are consistent with previous reports showing that
higher levels of education correlated with higher EBP be-
liefs and EBP implementation (Underhill et al., 2015). It is
interesting that the mentors did not have higher job satis-
faction, group cohesion, or group attractiveness, in spite of
having higher EBP implementation. This is consistent with
the aforementioned findings from this study, as well as previ-
ous reports that EBP implementation is not necessarily asso-
ciated with higher job satisfaction or group cohesion (Melnyk
et al., 2010).

42. Since its inception in 2006, our regional collaborative EBP
fellowship program has been in continuous operation, and has
successfully educated more than 400 nurses and nurse lead-
ers from 12 local hospitals to date. With solid and consistent
organizational support from local hospitals and academic insti-
tutions, the fellowship program has been able to pool resources
and expertise from these organizations to empower participat-
ing nurses to execute unit-based EBP projects (Kim et al.,
2013).
The fellows and mentors, equipped with EBP knowledge and
skills, along with strong EBP beliefs, become EBP champi-
ons in their own hospital units and serve as role models for
their colleagues (Melnyk, 2007). We believe that our regional
EBP fellowship program in Southern California can serve as
a template for other regional organizations to come together
and collaborate in fostering EBP implementation across mul-
tiple hospitals in their own regions, with the ultimate aim of
improving quality of care and patient outcomes.
Limitations
There are several limitations to this study. First, the study find-
ings of EBP beliefs as a significant predictor of EBP implemen-
tation and job satisfaction should not be taken as cause-and-
effect relationships in this descriptive cross-sectional study.
Second, the subjective self-reporting methods of the study
questionnaire may have overestimated respondents’ percep-
tions about their beliefs in the value of EBP, EBP implemen-
tation, and job satisfaction. Third, the fellowship participants
were selected from a group of staff nurses who had already
demonstrated high motivation for EBP adoption. Due to the
potential sample selection bias, the study findings may not be
generalizable to other nursing staff. Fourth, although the in-
struments used in this study have been validated previously,
the items may not have fully captured the intended concepts.
Further refinements of the instruments could show differ-
ent results. Finally, even though the study population came

43. from multiple institutions, the findings are from one region
in Southern California and may not be generalizable to other
regions.
Future studies are needed to conduct an interventional
study to evaluate the beneficial effects of regional fellowship
programs on EBP beliefs, EBP implementation, job satisfac-
tion, and group cohesion. There is a need for further empir-
ical research evidence to support relationships in the ARCC
model.
CONCLUSIONS
The baseline data collected from the participants of a regional
collaborative fellowship program involving multiple local hos-
pitals and academic institutions over a 3-year period indicated
that strong EBP beliefs was a positive predictor of EBP imple-
mentation and job satisfaction. However, no significant rela-
tionships were found between EBP implementation and job
satisfaction or group cohesion when demographic variables
were taken into account. Further studies are needed to evalu-
ate the impact of regional collaborative fellowship programs on
EBP beliefs, EBP implementation, job satisfaction, and group
cohesion among the participants, as well as to generate addi-
tional evidence for the ARCC model. WVN
LINKING EVIDENCE TO ACTION
� A regional, collaborative EBP fellowship program
utilizing institution-matched mentors should be
encouraged to advance EBP because such pro-
grams may be effective in improving EBP beliefs,
EBP implementation, and job satisfaction.
� Support from participating institutions is essential
for the success of a regional, collaborative EBP

44. fellowship program.
� Strong beliefs in the value of EBP appear to be
associated with high levels of EBP implementation
and job satisfaction among the fellowship program
participants.
� No significant relationship was found between
EBP implementation and job satisfaction or group
cohesion when demographic variables were taken
into account; further studies are needed to confirm
these unexpected study findings.
Author information
Son Chae Kim, Professor, St. David’s School of Nursing, Texas
State University, Round Rock, TX; Jaynelle F. Stichler, Pro-
fessor Emerita, San Diego State University; Consultant, Re-
search and Professional Development, Sharp Memorial Hos-
pital and Sharp Mary Birch Hospital for Women & Infants, San
Diego, CA; Laurie Ecoff, Director of Research, Education, and
Professional Practice, Sharp Memorial Hospital, San Diego,
CA; Caroline E. Brown, Research Consultant, Bonita Springs,
FL; Ana-Maria Gallo, Director of Nursing Education, Research
and Professional Practice, La Mesa, CA; Judy E. Davidson,
346 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–
348.
C© 2016 Sigma Theta Tau International
Original Article
EBP/Research Nurse Liaison, University of California San
Diego Health System, San Diego, CA

45. Address correspondence to Dr. Son Chae Kim, Professor, St.
David’s School of Nursing, Texas State University, 1555
Univer-
sity Blvd., Round Rock, TX 78665; [email protected]
Accepted 14 November 2015
Copyright C© 2016, Sigma Theta Tau International
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ASSIGNMENT

51. Evidence-Based Practice and the Quadruple Aim
Healthcare organizations continually seek to optimize
healthcare performance. For years, this approach was a three-
pronged one known as the Triple Aim, with efforts focused on
improved population health, enhanced patient experience, and
lower healthcare costs.
More recently, this approach has evolved to a Quadruple Aim
by including a focus on improving the work life of healthcare
providers. Each of these measures are impacted by decisions
made at the organizational level, and organizations have
increasingly turned to EBP to inform and justify these
decisions.
To Prepare:
· Read the articles by Sikka, Morath, & Leape (2015); Crabtree,
Brennan, Davis, & Coyle (2016); and Kim et al. (2016)
provided in the Resources.
· Reflect on how EBP might impact (or not impact) the
Quadruple Aim in healthcare.
· Consider the impact that EBP may have on factors impacting
these quadruple aim elements, such as preventable medical
errors or healthcare delivery.
To Complete:
Write a brief analysis (no longer than 2 pages) of the connection
between EBP and the Quadruple Aim.
Your analysis should address how EBP might (or might not)
help reach the Quadruple Aim, including each of the four
measures of:
· Patient experience
· Population health
· Costs
· Work life of healthcare providers
MORE INFORMATION
Module 1: Evidence Based Practice (EBP) and the Quadruple
Aim
There are two objectives for this module:
• Evaluate healthcare organization for evidence based

52. practices
• Analyze the relationship between evidence based practice
and the Quadruple Aim in healthcare organizations.
Keep these goals in mind as you complete your readings,
discussion, and assignment this module.
Watch the video introduction to the course. Watch the video in
the Module. Read as many of the learning resources as possible
for the week.
Choose a professional healthcare organization and review their
website. Explore the website to determine where and how EBP
is evidence. Write your initial discussion post and post it no
later than Wednesday, Day 3.
What should be included in your initial post?
1. A description of the organization website that you
reviewed.
2. Where does EBP appear ( mission, philosophy, goals of the
organization, or other locations). Don’t just list them-explain
your choice
3. Answer the question: Did the information you found on the
website change your perception of the healthcare organization.
4. Be very specific and provide examples. Use AT LEAST
THREE credible resources to support your findings and ideas.
Once you have posted an initial post, come back to the
discussion and review the posts made by your peers. Review the
websites they shared. You will post two responses to peers on
two different days. (You will have three posts on three days in
total for the week.)
What should be included in the responses:
1. Offer additional examples of EBP
2. Alternative views or interpretations to those shared by your
peers.
3. Be specific and use at least two credible resources to
support your findings and ideas.
The discussion posts should be completed no later than
Saturday, Day 6. Responses will not be graded after day 6.

53. Be sure to review the grading rubric so that you know how you
will be graded and can post accordingly.