Quality and Safety in Nursing: Recommendations From a Systematic Review

Supplemental Digital Content is Available in the Text.

ABSTRACT

As a consistent 24-hour presence in hospitals, nurses play a pivotal role in ensuring the quality and safety (Q&S) of patient care. However, a comprehensive review of evidence-based recommendations to guide nursing interventions that enhance the Q&S of patient care is lacking. Therefore, the purpose of our systematic review was to create evidence-based recommendations for the Q&S component of a nursing professional practice model for military hospitals. To accomplish this, a triservice military nursing team used Covidence software to conduct a systematic review of the literature across five databases. Two hundred forty-nine articles met inclusion criteria. From these articles, we created 94 recommendations for practice and identified eight focus areas from the literature: (1) communication; (2) adverse events; (3) leadership; (4) patient experience; (5) quality improvement; (6) safety culture/committees; (7) staffing/workload/work environment; and (8) technology/electronic health record. These findings provide suggestions for implementing Q&S practices that could be adapted to many healthcare delivery systems.

Introduction

Estimates suggest that 250,000–400,000 lives may be lost because of medical errors in American hospitals each year.^1,2 We now approach the 25th anniversary of the publication To Err is Human, which steered healthcare into an era of concern with quality and safety.³ Ten years after this report, an overall grade of “B-” was awarded for progress toward improved patient safety.⁴ However, more recent assessments are less optimistic, suggesting the focus on safety has declined in healthcare settings.⁵

Nurses are a critical part of any healthcare team. The World Health Organization estimates that almost 60% of the world's healthcare workforce comprised nurses; therefore, nurses play an important role in improving patient outcomes.⁶ The role of nurses in patient care is unique, particularly in hospitals, because they spend the most time with patients.⁷ This frequent contact means that they likely provide the majority of direct patient care, they are able to assess patients more frequently, and this positions nurses to be the first healthcare team member to identify when something is amiss with a patient. Therefore, the way nurses practice becomes central to ensuring quality and safety (Q&S) in patient care.

A nursing professional practice model helps define how nurses identify as professionals and, therefore, how they practice nursing care delivery.⁸ Many PPMs include a focus on providing safe, high-quality patient care.⁹ When recent legislation led to the need to merge the separate nursing PPMs of the three service branches of the U.S. military (Army, Navy, and Air Force) into one triservice model, Q&S was deemed a critical element to include.^10,11 Other components that make up this triservice professional practice model are Leadership Development, Healthy Work Environment, Evidence-Based Practice, and Operational Readiness.¹¹

The purpose of our systematic review was to create evidence-based recommendations for the Q&S component of the U.S. military nursing's Joint Professional Practice Model (JPPM). The purpose of this article was to share recommendations from the literature that informed the Q&S component of the JPPM.

Methods

The reporting of this review follows the guidelines of the PRISMA 2020 Statement.¹² We conducted a systematic literature review for the period from January 2001 to December 2020. Five research databases (CINAHL, Embase, Joanna Briggs, PubMed, and Scopus) were used to search for relevant literature. Key words used in the search strategy included “patient safety and quality,” “patient safety,” and “quality care.” The search string was developed to include the interchangeable synonyms and keywords to ensure the search captured as many relevant sources as possible that described the variables of interest. The team used Covidence software to facilitate the systematic review.¹³ This web-based software enables team collaboration to accomplish literature reviews.¹³ Senior team members, who are all nurse scientists, held weekly meetings during this phase to train team members on which articles to include, how and what data to extract, and to answer any questions that arose during the article review process.

Before performing the literature search, we outlined the inclusion and exclusion criteria for the review. We included articles focusing on patient safety through nursing interventions, measurement of nurse quality indicators, systematic reviews related to healthcare Q&S, and both quantitative and qualitative research. We excluded articles based on the following criteria: opinion pieces, patient populations uncommon to the military healthcare system (e.g., long-term care and hospice facilities), and articles primarily related to other disciplines (e.g., physicians, pharmacists, and radiology). Because of a potential lack of generalizability, we also excluded articles from international settings that may provide healthcare in a significantly different way than the United States.

All articles were imported into Covidence. During the title/abstract screen and full-text screen stages, two team members voted to keep or dismiss each article based on the predetermined inclusion/exclusion criteria. A third team member resolved any conflicts.

After all included articles were identified, a standardized form for data extraction was created within Covidence. Two individuals extracted data from each article; any disagreements were adjudicated by a third individual. Examples of some of the extracted data included sample, setting, organizational level (e.g., unit, hospital, and system), purpose, variables, intervention, instrumentation, findings, and implications. To ensure a rigorous and standardized approach among data extractors, an interrater reliability estimate was performed on 10% of the extracted articles (n = 25). We obtained an interrater reliability of 0.88, suggesting the extractors were achieving consistency in data extraction.¹⁴ Finally, the team synthesized the extracted data to create actionable recommendations, which were later used to create Q&S standards for implementing the JPPM. Additionally, each reviewer assigned every article a primary focus area, determined by the repetitive themes found in the articles during the initial title and abstract screen. The focus areas were later aggregated and condensed into what we present in the findings.

We evaluated the quality of articles with the John Hopkins Nursing Evidence-Based Rating Scale¹⁵ and assigned each article a rating of “low-,” “good-,” or “high-” quality evidence. Additionally, we rated the level of evidence of each article from a Level I (systematic or meta-analytic review) to Level VII (expert opinion or report of committee).¹⁶ When we created each individual recommendation, we assigned each recommendation a quality rating, considering the quality and level of evidence of the articles used to inform the recommendation.

Results

The comprehensive literature search yielded a total of 13,597 articles. After duplicate removal, 11,435 articles remained for title and abstract screen. After this screen, 325 papers underwent a full-text review. At the end, 249 articles were included for synthesis. Figure 1 contains a flow chart of the review processes. Supplemental Digital Content 1 (see http://links.lww.com/JHQ/A216) contains a list of all articles included in the review.

Figure 1.

Flowsheet of article selection process

Six articles (2%) were studies from the military population. Forty-nine articles (20%) were literature reviews. To organize the findings, we ordered the resulting recommendations into eight focus areas: (1) communication; (2) adverse events; (3) patient experience; (4) leadership; (5) quality improvement; (6) safety culture, committees, and councils; (7) staffing, workload, and work environment; and (8) technology and the electronic health record.

After the literature review, 94 recommendations were created to inform the Q&S component of the JPPM. A complete listing of these recommendations, as well as implementation ideas, evaluation metrics, and supporting references may be found in Supplemental Digital Content 2 (see Table, http://links.lww.com/JHQ/A217). Table 1 lists each quality and safety focus area and broad recommendations. Tables 2–4 include only those recommendations that were determined to have a “high” level of evidence, supported by (1) a meta-analysis, (2) two or more systematic reviews, or (3) at least one systematic review and a combination of other reviews and studies. The focus area with the highest level of evidence was adverse events (e.g., medication errors, patient complications/mortality) (Table 2). The “high-quality” focus areas of nurse staffing, workload, and the nurse work environment contained no tested intervention or implementation ideas for improving these areas (Table 3). The focus areas of communication, patient experience, leadership, and safety culture all had one or two recommendations achieving a high level of evidence. The following section will highlight each of the eight focus areas and provide a brief overview of some of the recommendations.

Table 1.

Quality and Safety Focus Areas and Broad Recommendations^a

	Broad recommendations
Q&S focus area: Communication
Communication: Shift report/handovers	Create standardized shift reports/handover strategies
Communication: Discharges	Consider a standardized discharge process
Communication: Reducing readmissions	Develop a protocoled EBP process for hospital discharges, potentially including phone calls and home visits to reduce readmissions
Communication: Patient and family participation	Consider ways for patients and family to actively communicate about care
Communication: Nursing communications	Build relationships between RNs and nursing assistants
Communication: Improving patient safety through communication	Improve patient safety through communication interventions for both nurses and the multidisciplinary team
Communication: Patient to nurse satisfaction or nurse perception of patient satisfaction	Consider ways to balance patient satisfaction with nurse satisfaction in communication/handover processes
Communication: Quality improvement initiative	Standardize heparin administration to reduce communication errors and regulate care
Q&S focus area: Adverse events
Falls	Create a comprehensive, multicomponent, patient-centered, interdisciplinary falls prevention strategy
Falls	Increase RN job satisfaction to reduce patient falls
Falls	Consider technological advances to reduce falls
Falls	Include point-of-care staff from the unit level to plan and design the fall prevention program
Falls	Improve interdisciplinary and patient/family communication regarding mobility status
Falls	Create a standardized method to collect data about fall events
Hospital-acquired infections	Use the CAUTI Guide to Patient Safety Assessment Tool
Hospital-acquired infections	Use physician champions to reduce CAUTIs
Hospital-acquired infections	Ensure multiple component interventions to reduce adverse events and hospital-acquired infections
Hospital-acquired infections	Screen early for hospital-acquired infections, such as sepsis, with an EHR screening tool
Hospital-acquired infections	Ensure favorable nursing work environments and staffing to reduced hospital-acquired infections
Hospital-acquired infections	Consider skills training using a mastery rather than traditional approach
Hospital-acquired infections	Be aware that Hospital Survey on Patient Safety Culture may not necessarily be indicative of actual hospital infection rates (CAUTI and CLABSI)
Medication errors	Reduce interruptions and distractions during medication preparation and administration
Medication errors	Ensure nurses are well rested to reduce medication errors
Medication errors	Ensure adequate staffing and appropriate workload to reduce medication errors
Medication errors	Use technology to reduce errors (i.e., bar coded medication administration)
Medication errors	Reduce medication reconciliation discrepancies at discharge by beginning a time-out process
Medication errors	Perform a daily interprofessional “medication time outs”
Medication errors	Create a standard operating procedure for reducing SmartPump Infusion errors due to the prevalence of this errors
Medication errors	Use interdisciplinary communication and training to reduce medication errors
Medication errors	Engage leadership to ensure optimal staff performance in system-wide improvement initiatives
Medication errors	If staffing and workload are issues, combat medics may be trained to perform medication administration
Patient complications/mortality	Create policies and procedures to reduce negative maternal fetal health outcomes
Patient complications/mortality	Create a microsystem level patient safety program
Patient complications/mortality	Choose relevant measures for hospital and nursing safety indicators—need for further study for best measures
Patient complications/mortality	Create multicomponent sepsis protocols
Patient complications/mortality	Implement rapid response system, create clear parameters for their activation, and enhance observation of patients at risk for deterioration
Patient complications/mortality	Allow for caregivers to remain at the bedside during patient hospitalizations for psychosocial support, as well as modest improvements in length of stay and discharge time
Patient complications/mortality	Initiate early mobility in the ICU
Patient complications/mortality	Ensure adequate nurse staffing for better patient outcomes, particularly on weekends
Patient complications/mortality	Place frontline nurses in leadership roles to improve outcomes for QI endeavors and other improvement projects
Patient complications/mortality	Continue to study surgical quality improvement in the military health system
Patient complications/mortality	Use checklists to reduce negative patient outcomes
Patient complications/mortality	Use consensus statement for adhesive skin injuries
Patient complications/mortality	Focus safety efforts on drug management and surgical procedures because these areas have the highest rates of prevalence among preventable harm errors
Patient complications/mortality	Create an interdisciplinary nutrition program to reduce malnutrition among hospital patients
Patient complications/mortality	Integrate warning systems into the electronic health record
Patient complications/mortality	Create multicomponent and a nurse managed early identification and management policy for delirium
Patient complications/mortality	Create a virtual collaborative series to reduce certain outcomes, such as postoperative respiratory failure
Patient complications/mortality	Create care pathways to improve the quality of care provided to patients with heart failure
Patient complications/mortality	If creating a toolkit, include components evidenced to be effective and useful to patient outcomes
Patient complications/mortality	Consider incorporation of responsiveness technology for improved patient sedation in the ICU
Pressure injuries	Use multicomponent interventions to prevent pressure injuries
Restraints	Use a personalized approach for decreasing agitation in patients who require sitters
Patient experience	Use evidence-based methods for improving patient experience
Patient experience	Monitor patient experience as an indicator of clinical effectiveness
Patient experience	Use established patient safety measures
Q&S focus area: Leadership
Leadership	Leadership must be engaged to improve and sustain improvement in patient outcomes
Leadership	Facilitate greater continuity between nursing house supervisors, other nursing leadership roles, and other hospital leaders
Leadership	Emphasize the transformational leadership style for its association with better patient outcomes, improvement in structurally empowering work conditions, and enhanced staff nurse clinical leadership
Leadership	Build in the ability of staff nurses to assume clinical leadership roles because of its association with better perceptions of patient care and job satisfaction
Leadership	Create well-defined job roles and descriptions for nursing house supervisors
Q&S focus area: QI
QI	Initiate QI projects and engage staff members in QI because QI projects can improve patient outcomes and reduce costs
QI	Create multidisciplinary opportunities for QI
QI	Use an effective approach for collecting data to determine effectiveness of QI initiatives
QI	Ensure effective communication and transparency in QI initiatives
QI	Standardize processes of care when possible
QI	Mature QI programs may produce better patient outcomes
QI	Include the following components to enhance the success of QI programs: leadership promotion and engagement, easy data access, and personnel who has experience with measurement
Q&S focus area: Safety committees, councils, and culture
Safety committees and councils	Incorporate clinical communities, nurse peer review programs, and EBP councils into regular operations
Safety committees and councils	When creating committees, include nurses at the level of the intervention to be sure the interventions are feasible and useful
Safety culture and patient safety indicators	Choose relevant measures to examine safety culture and indicators
Safety culture	Make efforts to create a positive safety culture
Q&S focus area: Staffing, workload, and the NWE
Staffing, NWE, workload	Create a nursing-driven sitter protocol, potentially using video monitoring
Staffing, NWE, workload	Use appropriate metrics for measuring staffing and efficiency
Staffing, NWE, workload	Ensure adequate nurse staffing and appropriate workload because of their favorable association with more positive patient outcomes
Staffing, NWE, workload	Ensure a more favorable work environment for better nurse and patient outcomes
Staffing, NWE, workload	Participate in further study for determining best models for nurse staffing, such as supply and demand models or staffing ratios
Staffing, NWE, workload	Magnet hospital status may not be enough to ensure quality patient care
Staffing, NWE, workload	Monitor staff burnout and well-being because of its association with patient safety
Staffing, NWE, workload	Measure staffing and workload at the unit rather than hospital level
Staffing, NWE, workload	Monitor unfinished nursing care because of its association with nurse and patient outcomes
Staffing, NWE, workload	Create clinic programs to improve work–life and work conditions to reduce negative clinician outcomes
Staffing, NWE, workload	Incorporate methods of reporting and documenting that show the financial value of nursing care
Staffing, NWE, workload	Ensure supportive nursing leadership for improved healthcare and human resource outcomes
Staffing, NWE, workload	Support nursing certifications for improved patient outcomes
Staffing, NWE, workload	Use care technicians in creative ways to reduce nurse workload and improve patient safety experience
Staffing, NWE, workload	Further study is needed to determine the necessary frequency of vital sign assessment in the emergency department
Q&S focus area: Technology and the EHR
Technology and EHR: Alarm management	Create an alarm management strategy to monitor and decrease alarm sounds to reduce alarm fatigue
Technology and EHR: Electronic health record interoperability	Enhance operability of EHR to detect/capture adverse events more quickly and accurately than traditional reporting methods and enhance adherence to best practice guidelines
Technology and EHR: Electronic health record adoption and adverse events	Ensure EHR adoption (if not already done) to facilitate improvements in patient safety. Also monitor EHR concerns
Technology and EHR: Implementation of tele-critical nursing care	Consider incorporation of telehealth or Tele-ICU nurse
Technology and EHR: Nurse sensitive indicators	Use of the EHR to find areas pertinent to nurse sensitive indicators
Technology and EHR: Nurses call system/Missed nursing care	Consider new approaches for nurse call systems and consider monitoring missed nursing care
Technology and EHR: Nurses' use of computerized clinical guidelines	Consider use of computerized clinical guidelines with follow-up assessments to ensure the guidelines relevance to patient outcomes

^aThe broad recommendations are synthesized from multiple sources. A complete listing of references supporting these recommendations, as well as implementation ideas and evaluation metrics may be found in Supplemental Digital Content 2 (see Table, http://links.lww.com/JHQ/A217).

CAUTI, catheter-associated urinary tract infection; CLABSI, central line associated bloodstream infection; EBP, evidence-based practice; EHR, electronic health record; ICU, intensive care unit; NWE, nurse work environment; QI, quality improvement; Q&S, quality and safety.

Table 2.

Recommendations Labeled a “High” Quality of Evidence Pertaining to Adverse Events

Recommendation	Intervention/implementation ideas	Supporting articles	Metrics to operationalize the recommendations
Reduce interruptions and distractions during medication preparation and administration	“Red Zone initiatives” or “SAFE Zones”; lighted lanyards for the “no interruption zone”; clerk triage of calls and pages during peak medication times, patient and family education, scripting cards, multidisciplinary communication/education, UAP rounding and responding to alarms; safety vests; e-learning module (in addition to other interventions-as this was non-significant by itself); checklist; use data to drive decisions; redesign medication room	21-30	Number of medication events (via report); medication errors measured by sequential audits;30 perceived number of interruptions;29 number of med errors per 1,000 days;29 Medication Administration Distraction Observation Sheet29
Use technology to reduce errors (i.e., bar coded medication administration)	None specified	25,31,32	Number of med errors per 1,000 days;29 sequential audits for medication errors30
Implement rapid response system, create clear parameters for their activation, and enhance observation of patients at risk for deterioration	Create threshold vital sign abnormality criteria33 Increase vital signs assessment/documentation by policy change; education, ward observation chart, a track and trigger system34 Policy and procedures for identifying at-risk patients after surgery for additional monitoring35 Use of a national early warning score if sepsis is suspected36 Education for continuous patient monitoring, appropriate alarm thresholds; continuous noninvasive vital sign monitoring37 Early warning systems38	33-41	Rapid response activation (no. of activations); rapid response activation per threshold vital sign abnormality;33 unplanned ICU admissions, adverse events, daily frequency of vital sign measurement, documented communication and medical review after clinical instability;34 number of alarms per patient day37
Initiate early mobility in the ICU	A goal may be to ambulate 100 feet (30 m) before ICU discharge	42,43	Distance walked
Ensure adequate nurse staffing for better patient outcomes, particularly on weekends	None specified	44,45	The American Society of PeriAnesthesia Nurses Practice Recommendation for determining number of nurses needed44
Use of checklists to reduce negative patient outcomes	None specified	46,47	None specified
Focus safety efforts on drug management and surgical procedures because these areas have the highest rates of prevalence among preventable harm errors	None specified	48,49	None specified
Create care pathways to improve the quality of care provided to patients with heart failure	None specified	50	Readmission rates, length of stay, mortality, and cost50
Use multicomponent interventions to prevent pressure injuries	Prevention is most-cost effective strategy for reducing pressure injuries;51 using a certified wound care nurse can help reduce pressure injuries;52 use auditors to reduce pressure injury occurrence53	51-56	None specified

Table 4.

Additional Recommendations Labeled a “High” Quality of Evidence

Recommendation	Intervention/implementation ideas	Supporting Articles	Metrics to operationalize the recommendations
Create standardized shift reports/handover strategies	Educational toolkit and gather feedback from practicing nurses77 A new handover process, education (video and written materials, script, flowchart, posters, and lanyard cards)78 ISBAR (identification, situation, background, assessment and actions, responsibility and referral) structured communication handoffs79 Incorporate handoffs into nursing education, and develop standardized guidelines80 Integrated Nursing Handover System structured content for handover and electronic tool in the EHR; education sessions81 Training session, new handover form, educational interventions, communication skills training interventions17	17,77-91	Semi-structured research developed interview guide, EMR-based handoff tool and structured interview for communication tool87 Transfer delay time, ICU readmissions within 72 hr, mortality after ICU discharge83 Researcher developed: “A bedside handover audit tool; patient experience survey; family experience survey; nursing staff experience survey; and an Excel spreadsheet incorporating the number, type and severity of patient adverse events (falls, pressure injuries and medication errors).”78 (p. 12) Handover Evaluation Scale, translated in Dutch in original article82
Develop a protocoled EBP process for hospital discharges, potentially including phone calls and home visits to reduce readmissions	Consideration of sociodemographic characteristics, location of hospital, and surgical patient status, and inpatient teaching to reduce hospital readmissions92	92-95	Health Care Failure Mode and Effects Analysis were used for readmission rates, compliance rates for calls95 AHRQ Patient Safety Indicators rates, CMS/Yale Hospital-Wide All-Cause Unplanned Readmission Measure92
Use evidence-based methods for improving patient experience	Emphasize teamwork, adequate staffing, and learning culture96 Use data to drive improvement, nursing rounds, intensive discharge preparation and planning97 Encourage active patient participation in care98 Consideration for patient-centered care, relational care, assessing patient feelings of safety99 Encourage ICU nurses to be active in promoting patient perception of safety100 Consideration of hourly rounding in the ED; hourly rounding by nurses and daily rounding by nurse leaders; use of Lewin's Planned Change Theory, creation of a standard policy involvement of stakeholders101 Ready-to-go cards for discharge preparation102 Incorporation of elements of the acuity adaptable model (methods for allowing patients to feel safe, facilitate continuity of care, and valuing family)103	96-108	HCAHPS survey97 AHRQ staff safety culture survey and HCAHPS patient satisfaction survey96 5 HCAHPS survey questions: (1) Response to concerns/complaints during your stay; (2) degree to which hospital staff worked as a team; (3) staff identified themselves to patients; (4) overall rating of institution; (5) likelihood to recommend101 HCAHPS data102 Researcher developed semi-structured interview guide103
Engage leadership to improve and sustain improvement in patient outcomes	Education and communication, use of coaches, data monitoring and analysis with quarterly updates;109 walk-rounds;47,110 ensure they have resources111	47,109,110,112-115	Joint Commission Composite Score115
Create a positive safety culture	Encourage safe speaking up;116 create psychological safety (O'Donovan, 2020);117 leader walk rounds, education, team-based intervention, surgical checklists;47 for ambulatory care: rounds, blog, just culture training, medication reconciliation118	47,73,92,106,116-122	Safety Attitudes Questionnaire, AHRQ PSI; Hospital Survey of Patient Safety Culture Other: single item for speaking up116

AHRQ, Agency for Healthcare Research and Quality; CMS, Centers for Medicaid and Medicaid Services; ED, emergency department; EHR, electronic health record; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems; PSI, patient safety indicators.

Table 3.

Recommendations Labeled a “High” Quality of Evidence Pertaining to Nurse Staffing, Workload, and the Work Environment

Recommendation	Intervention/implementation ideas	Supporting articles	Metrics to operationalize the recommendations
Ensure a more favorable work environment for better nurse and patient outcomes	None specified	57-70	Practice Environment Survey of the Nursing Work Index;63-67 Nursing Work Index-Revised69
Monitor unfinished nursing care due to its association with nurse and patient outcomes	None specified	18,60,71-76	Care Left Undone Survey,72 MISSCARE survey73,75

Communication

The first focus area we identified was communication. This involved a wide range of communication strategies dispersed across the healthcare team and the patient or family. Eight recommendations are found in this focus area and include standardization of regularly occurring events requiring communication from different healthcare team members.

Adverse Events

The second focus area we identified was adverse events. These included a range of potentially harmful patient events, such as falls, hospital-acquired infections, and medication errors. This area had the most recommendations, encompassing 45 of the 94 recommendations we identified from the literature.

Patient Experience

Focus area 3 pertained to the way patients perceived their time in the hospital or other health care setting and primarily aimed toward improving it. Much of this involved data or metric tracking. Interestingly, several of the interventions identified within this area tie back to communication strategies, providing an indication of how recommendations from different focus areas sometimes overlap. This was the smallest focus area, with only three recommendations.

Leadership

Focus area 4 centered around leadership and its importance to Q&S. Leadership is found at all levels of nursing care and is associated with patient outcomes. Recommendations pertaining to nursing leadership's role in Q&S included an emphasis on leadership engagement and leadership style, specifically transformational leadership. Five recommendations make up this focus area.

Quality Improvement

Focus area 5 highlighted the role of quality improvement and its ability to contribute to better Q&S. Again, there was overlap between the recommendations in quality improvement and recommendations from other focus areas. For example, standardization of care processes is a consistent theme seen in the communication recommendations but was also identified within the quality improvement literature. Seven recommendations are found in this focus area.

Safety Culture, Committees, and Councils

Focus area 6 involves how committees, councils, or other teams are formed and are able to make improvements to Q&S. Some recommendations include which councils to include, e.g., EBP councils or nurse peer review programs, and methods for creating a positive patient safety culture. Four recommendations make up this focus area.

Staffing, Workload, and the Nurse Work Environment

Focus area 7 pertains to nurse staffing, workload, and the nurse work environment in general. Some recommendations pertain to the way nurses or nursing support personnel practice, such as ensuring adequate staffing or considering the use of nurse-driven sitter protocols. Other recommendations focus on metrics and the general improvement of the overall work environment. This focus area has 15 recommendations.

Technology and the Electronic Health Record

Finally, focus area 8 examined the role of both technology and the electronic health record and its influence on nursing Q&S. Examples of recommendations involve the consideration of alarm management in healthcare settings, or monitoring electronic health record data for concerns or opportunities to enhance the detection of adverse events. This last focus area contains seven recommendations.

Limitations

The vast scope of Q&S literature makes it likely that relevant articles were unintentionally omitted. However, the articles included here remain particularly informative toward the current state of various Q&S practices. Additionally, because of the timeframe in which articles were included, much of the COVID-19 literature was omitted. The pandemic has changed healthcare in many ways; however, long-term effects have not yet been identified. Furthermore, this article was intended to share the evidence-based recommendations that informed the development of the Q&S component of the JPPM, not necessarily to provide a comprehensive review on all nursing Q&S literature. However, the JPPM implementation plan includes the recommendations because they were derived from current literature that supports their usefulness.

Discussion

This review used 249 articles to form 94 recommendations that will be used to guide the Q&S component of the JPPM for the U.S. military. The sheer number of articles included in this review demonstrate how wide and vast the area of Q&S is in the scientific literature.

Most systematic reviews in the Q&S realm focus on a specific safety area; for example, interventions for nurse communication skills,¹⁷ nursing care left undone,¹⁸ or nursing ratios.¹⁹ These reviews are helpful for answering specific questions or identifying evidence-based solutions for specific issues. For purposes of this review, however, we needed to identify a broad range of recommendations from current literature to inform aspects that would create the Q&S component of the JPPM. After synthesizing the 249 articles, we believed our findings may be helpful to a larger nursing audience as well.

This comprehensive review of the literature and resulting recommendations also demonstrate how complex and intertwined Q&S are within the healthcare environment. For example, the communication focus area alone highlights the need to build relationships with the interdisciplinary team, use standardized tools to support accurate and thorough information exchange, and enhance the patient discharge process with additional patient/healthcare staff touchpoints before and after discharge. The communication focus area also suggests that this needs to be done while considering both staff and patient satisfaction. Although none of the six recommendations for preventing falls were graded as high-quality evidence, those that were considered “good” were comprehensive and multifaceted interventions, and ensuring accurate data are available to assess fall events and a focus on nurse satisfaction. Much of the high-quality evidence demonstrates a need to have data to understand the problem as an organization, i.e., systematic indicator collection, and data to alert nursing to patient status or concern as quickly as possible, i.e., standardized reporting or early detection, and a multicomponent and whole hospital investment in improving the specific outcome, i.e., multidisciplinary prevention strategies and leadership engagement.

Within Military Treatment Facilities adopting the JPPM, these recommendations led to the development of a condensed set of standards. The standards will be implemented and adhered to, based on the resources and needs of each individual facility, making them tailorable rather than prescriptive. The Military Health System serves 9.6 million beneficiaries, including active-duty military service members, their dependents, and service member retirees.²⁰ Providing care for such a large number of recipients, particularly given that many of these individuals are responsible for American national security, highlights the absolute necessity of providing them with the highest quality care and assurance of patient safety.

Conclusions

A focus on Q&S is essential at all levels of healthcare. This review identified 94 recommendations based on the current literature for ways nurses may be able to achieve improved Q&S. The findings in this review provide many strategies that hospitals, clinics, or other healthcare facilities can consider when making changes for the improvement of Q&S for their patients.

Implications

Q&S interventions are essential to nursing practice. This article provides the findings from a comprehensive review of current literature on the status of Q&S strategies. However, we recognize that no health system could implement these interventions simultaneously. Instead, we assert that the 94 recommendations can serve as a guide for healthcare systems or settings unsure where to begin with quality initiatives. For example, organizations could use these recommendation tables to assess what their facility may be doing well already and where there may be gaps that could be addressed.

We expect the JPPM to be fully implemented in all military treatment facilities by mid-2024. Our team has used the recommendations shared here to develop standards that will be expected of each military treatment facility. An important aspect of these standards is their propensity to be tailored to each individual facility's resources and capabilities. Therefore, we aimed to provide information that our facilities could use whether they are in small, remote locations or are large academic medical facilities. Continued observation and data collection from implementation of the JPPM will help inform our team of where improvements can be made to the JPPM and what aspects are already functioning well.

Authors' Biographies

Patricia A. Patrician, PhD, RN, FAAN, is an endowed professor at the University of Alabama at Birmingham School of Nursing in Birmingham, AL. Her research focuses on the nursing workforce and patient safety.

Caitlin M. Campbell, PhD, RN, is a research assistant at the University of Alabama at Birmingham School of Nursing in Birmingham, AL. Her research interest focuses on the nurse work environment and enabling nurses to provide better quality patient care.

Mariyam Javed, Pharm-D, MPH, is a research assistant at the University of Alabama at Birmingham School of Nursing in Birmingham, AL. She is a dedicated and highly skilled Clinical Research Coordinator with a passion for public health projects. With a proven track record of successful project coordination and a strong commitment to improving community health, she continues to contribute to the advancement of public health research and evidence-based interventions.

Kathy M. Williams, MSN, RN-BC, ACNS-BC, is a Master Clinician at the 96th Medical Group at Eglin Air Force Base in Florida. She oversees the #1 Air Force Nurse Resident Program, guiding 25 novice nurses annually while ensuring 879 clinical tasks/400 teaching hours, and 28 educational requirements are met for graduation. She provides expert opinion and direct clinical care on a 35-bed medical–surgical and specialty nursing unit covering 22 specialties for 3.5K patient population ranging from newborn through geriatrics, including over 300 postpartum couplets averting divert/saving greater than $300K annually.

Lozay Foots III, DNP, RN, FACHE, is a contractor for the Defense Health Agency, San Antonio, TX. He has served in many positions during his career in the Army, including Deputy Chief of the Army Nurse Corps; CNO/Director for Nursing for Walter Reed National Military Medical Center; and Assistant Deputy for Medical Affairs for the Assistant Secretary of the Army for Manpower and Reserve Affairs (ASA M&RA) at the Pentagon. His focus and passion is on developing and growing future nurse leaders.

Wendy M. Hamilton, DNP, APRN, AGCNS-BC, RN-BC, is a Clinical Nurse Specialist and the Director of Nursing Professional Practice at Tripler Army Medical Center in Honolulu, HI, a 229-bed military treatment facility providing care for over 264,000 beneficiaries and 171,000 referrals throughout the Pacific Region. She is responsible for assessing, planning, implementing, evaluating, and leading activities within patient care services related to nursing professional development, education, practice, care delivery systems, evidence-based practice, and patient/nursing outcome improvement at the enterprise level. She provides strategic direction to deliver safe, high-quality, reliable care reflective of professional standards, policies/procedures/guidelines, regulatory compliance, and quality measures. She advances professional nursing practice by providing administrative direction to strengthen and sustain the shared governance structure.

Sherita House, is an Assistant Professor at the University of North Carolina Greensboro. Her program of research focuses on health systems interventions to improve care processes and staff outcomes among healthcare professionals in civilian and military hospitals. Her research addresses improving care coordination among healthcare professionals with interdependent task and complex work processes. She has experience in quantitative and qualitative research methods, and her work has been funded by private foundations and the Tri-Service Nursing Research Program. She is currently developing and testing relational coordination training interventions to improve staff outcomes with multidisciplinary teams in the clinical setting.

Pauline A. Swiger, is the Chief of the Center for Nursing Science and Clinical Inquiry at Madigan Army Medical Center and the Consultant to the Army Surgeon General for Nursing Research in Tacoma, Washington, DC. Her primary research interests are the nursing workforce, the nursing practice environment, nursing care quality, and improving outcomes. She is a certified Clinical Nurse Leader and a Certified Medical Surgical Registered Nurse.

Supplementary Material

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Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at www.nahq.org/journal/ce. This continuing education offering, JHQ 308 May (46.3 May/June 2024), will provide 1 hour to those who complete it appropriately. 46.3 May/June 2024

Core CPHQ Examination Content Area

Domain 1—Management and Leadership

CE Objectives and Posttest Questions: Quality and Safety in Nursing: Recommendations from a Systematic Review

Learning objectives

1. Identify the focus areas to consider in improving the quality and safety of patient care in health care organizations.

2. Describe the processes for conducting a systematic review.

3. Identify the main recommendations for implementing quality and safety into a nursing professional practice model.

Questions

1. When addressing quality and safety which focus areas should be included

   1. Communication, adverse events, nurse staffing, and technology

   2. Quality improvement, implementation science, nurse staffing, and technology

   3. Communication, adverse events, violence, and the electronic health record

   4. Pressure injuries, violence, systemic racism, and technology

2. A nursing professional practice model:

   1. Defines the nurse-to-patient ratios and skill mix in all units in the hospital

   2. Describes nursing competencies and values

   3. Defines how nurses identify as professionals and how they practice nursing care delivery

   4. Is a picture that does not represent reality in health care settings

3. Covidence is a system that:

   1. Performs your literature search

   2. Performs your literature reviews

   3. Allows teams to collaborate on reviews

   4. Allows teams to check up on each other’s work

4. A PRISMA diagram is a representation of a:

   1. Professional practice model

   2. Covidence matrix

   3. Literature review strategy

   4. Literature search strategy

5. Which focus area had the highest level of evidence?

   1. Communication

   2. Nurse staffing

   3. Skill mix

   4. Adverse events

6. The common adverse events include:

   1. Falls, hospital acquired infections, and medication errors

   2. Falls, hospital acquired infections, and wrong site surgery

   3. Falls, pressure injuries, and retained surgical instruments

   4. Hospital acquired infections, medication errors, and wrong site surgery

7. A consistent theme in the quality improvement recommendations was:

   1. Use of iterative PDSA cycles

   2. Use of implementation science frameworks

   3. Standardization of care processes

   4. Standardization of terminology

8. The focus of the technology and the electronic health record included the following recommendation:

   1. Alarm management in healthcare settings

   2. Charting by exception

   3. Voice activated charting systems

   4. Nurse tracking devices

9. The limitations of this review include:

   1. Exclusion of editorial and opinion articles

   2. Exclusion of COVID-related literature

   3. Inclusion of COVID-related literature

   4. Consideration of only 5 years of literature

10. The authors recommend that organizations use which of the following:

    1. Implement all immediately to ensure high quality, safe patient care

    2. Randomly assign a group of nurses to tackle each recommendation

    3. Assess what their facility may be doing well already, and where there may be gaps that could be addressed