Agency for Health Care Policy and Research: Proposed Research Agenda

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[Federal Register: November 13, 1996 (Volume 61, Number 220)]
[Page 58194-58195]
From the Federal Register Online via GPO Access []



Agency for Health Care Policy and Research

Proposed Research Agenda

AGENCY: Agency for Health Care Policy and Research, with the National
Institute for Nursing Research and Health Resources and Services
Administration, Division of Nursing.

ACTION: Notice of request for comments.


SUMMARY: The Agency for Health Care Policy and Research (AHCPR), the
National Institute for Nursing Research (NINR), and the Division of
Nursing (DN) of the Health Resources and Services Administration (HRSA)
invite comments and suggestions of priority research topics related to
the impact of nurse staffing on the quality of care in hospitals. These
comments and suggestions will be considered by AHCPR, NINR, and DN of
HRSA in planning for future research initiatives to benefit health care
for the public and the health of the nation. Comments and suggestions
on the proposed research agenda will be considered by the three
Agencies in developing research priorities, but they will not be
responded to individually.

DATES: Comments and suggestions must be postmarked by December 30,

ADDRESSES: Written comments and suggestions should be submitted to
Kelly Morgan, Program Analyst, Center for Primary Care Research, Agency
for Health Care Policy and Research, Suite 502, 2101 East Jefferson
Street, Rockville, Maryland 20852. Respondents should provide a clear
rationale and supporting evidence of the importance of the suggested
    All responses will be available for public inspection at the Center
for Primary Care Research. Telephone 301-594-1357 ext. 1335, weekdays
between 8:30 a.m. and 5:00 p.m.

SUPPLEMENTARY INFORMATION: In response to a congressional directive,
the Department requested the Institute of Medicine (IOM) to conduct a
study on nurse staffing levels in hospitals and nursing homes. The IOM
issued a report in January 1996, Nursing Staff in Hospitals and Nursing
Homes--Is It Adequate? \1\ (the Report). The Report notes a paucity of
objective research on the relationships among restructuring, nurse
staffing, and quality in hospitals. One of the recommendations of the
Report is that the National Institute of Nursing Research and other
appropriate agencies fund scientifically sound research on the
relationships between quality of care and nurse staffing levels and
skill mix, taking into account organizational variables. The Report
further recommends that NINR, along with AHCPR and private
organizations, develop a research agenda on staffing and quality of
care (See page 122 of the Report).

    \1\ Wunderlich, Gooloo S. & Davis, Carolyne K. (1996). Nursing
Staff in Hospitals and Nursing Homes--Is It Adequate? Washington,
D.C.: National Academy Press.

    In July 1996, AHCPR, DN (HRSA), and NINR jointly convened a group
of research experts to discuss methodological issues and key research
questions on nurse staffing and quality of care in hospitals. Also
discussed were selected outcomes from a conference held by the American
Academy of Nursing in June 1996, sponsored by AHCPR, the American
Nurses' Association, and the American Organization of Nurse Executives,
entitled ``Outcome Measures and Care Delivery Systems.''

Nurse Staffing

    Research efforts in this area will require refinement and
standardization of conceptual as well as operational definitions of
variables such as nurse staffing level and nursing skill mix. Included
in this process must be an evaluation of the characteristics of the
nurses providing care, such as level of education and psychological
factors (e.g., nurse satisfaction with work). What nurses actually do
(clinical vs administrative vs other duties), how nursing care is
provided (staffing models used in each unit), and organizational
characteristics (such as management or leadership style) are also
important considerations.

Quality of Nursing Care

    The concept of health care quality is extremely complex and usually
includes a consideration of the structure and process as well as the
outcomes of care. Research focusing on nurse staffing and quality of
care in hospitals may, therefore, be expected to include an evaluation
of the organization and delivery of nursing care in the hospital

Proposed Research Agenda

    Based on the expert discussions, the IOM Report, and a review of
the published literature, the overarching questions to be addressed by
research related to nurse staffing and quality of care in hospitals
are: What is the contribution of nursing to the quality of care in
hospitals, and what are the cost implications of this contribution?
Within this area, a high research priority

[[Page 58195]]

continues to be identifying patient outcomes that are sensitive to
nursing care.
    The primary areas proposed for future research focusing on the
impact of nurse staffing on the quality of care in hospitals include:
     What is the relationship between the organization and
delivery of nursing care and patient outcomes? What are the key
organizational variables that influence staff performance and outcomes?
     What are the unique skills and the mix of registered
nurses and other nursing and ancillary staff that impact on outcomes?
This includes understanding what work needs to be done for patients to
impact patient outcomes and who are the best people to do it.
     What specific organizational variables and delivery of
care variables are related to specific patient outcomes? Specific
questions within this category include: What is the relationship
between nursing skill mix and achievement of outcomes such as
appropriate self-care? What are the relative contributions of nurse,
patient, other clinicians (e.g., M.D.), and organizational factors to
specific patient outcomes?
     What is the impact of computer technology on patient
outcomes? Included in this area are questions about the use of decision
support that may extend off-site clinical expertise to hospital nursing
staff. Also included are questions about the data elements about
nursing and nurses that should be routinely collected.
     What is costworthy in an era when limited resources are
available for hospital care? Although a nursing intervention may work
for a clinical problem and even be more effective than other
interventions, there may be other diseases or clinical problems that
affect more people and also have cost-effective interventions.
    At the AAN Conference, the following patient outcomes were
identified for further refinement by research teams: achievement of
appropriate self-care, demonstration of health-promoting behaviors,
health-related quality of life, perception of being well cared for
(broadened beyond patient satisfaction), symptom management, and
adverse outcomes. Other outcomes of interest relate to the patient's
family and community.
    In line with the recommendations of the IOM Report the specific
focus of this proposed research agenda is the relationship between
nurse staffing and quality of care in hospitals. However, comments and
suggestions about research pertaining to nurse staffing and quality in
other types of delivery settings are welcome by AHCPR, NINR, and DN
    Dated: November 6, 1996.
Clifton R. Gaus,
[FR Doc. 96-28997 Filed 11-12-96; 8:45 am]