[Federal Register Volume 61, Number 220 (Wednesday, November 13, 1996)]
[Notices]
[Pages 58194-58195]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-28997]


=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

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, 
1996.

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 
topic.
    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 
setting.

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 
(HRSA).
    Dated: November 6, 1996.
Clifton R. Gaus,
Administrator.
[FR Doc. 96-28997 Filed 11-12-96; 8:45 am]
BILLING CODE 4160-90-M