Demands on Nurses Grow as Hospital Quality Improvement Activities Increase

Nurses Pivotal to Quality Improvement Efforts, but Shortages Could Curtail Involvement

News Release
March 20, 2008

Alwyn Cassil (202) 264-3484 or

WASHINGTON, DC—Hospitals face growing tensions and trade-offs when allocating nurses between the competing priorities of direct patient care and quality improvement efforts, according to a study released today by the Center for Studying Health System Change (HSC).

Commissioned by the Robert Wood Johnson Foundation (RWJF), the study included interviews with hospital leaders in Detroit, Memphis, Minneapolis-St. Paul and Seattle to examine the role of nurses in hospital quality improvement activities.

"Nursing has the biggest impact on a patient’s experience in the hospital, so involving nurses in quality improvement is critical," said John Lumpkin, M.D., M.P.H., senior vice president and director of the Health Care Group at RWJF. "We commissioned this study to gain a better understanding of the role that nurses play in quality improvement and the challenges nurses face when balancing the competing priorities of direct patient care and quality improvement efforts."

RWJF has been on the forefront of efforts to involve nurses and other front-line staff in quality improvement. Its Transforming Care at the Bedside program, a joint initiative with the Institute for Healthcare Improvement, has significantly improved the quality and safety of patient care on medical and surgical units, increased retention of nurses in hospital-based jobs and helped to improve the effectiveness of the entire health care team.

According to the HSC study, hospital organizational cultures set the stage for quality improvement, including nurses’ involvement. Hospitals with supportive leadership; a philosophy of quality as everyone’s responsibility; individual accountability; physician and nurse champions; and effective feedback reportedly offer greater promise for successfully involving nurses in quality improvement activities.

Even when hospitals are committed to including nurses in quality improvement, they often face various problems, including a shortage of nurses; growing demands to participate in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving role in today’s contemporary hospital setting, the study found.

"The stakes for hospitals to demonstrate high quality are increasing at the same time that resources—especially nurses—are in short supply," said Debra A. Draper, Ph.D., HSC associate director and coauthor of the study with Laurie Felland, M.S., an HSC health researcher; Allison Liebhaber, an HSC health research assistant; and RWJF Senior Program Officer Lori Melichar, Ph.D.

"While quality improvement isn’t solely the domain of nurses, they are critical because of their day-to-day patient responsibilities, and hospitals will need to guard against diminishing nurses’ involvement in quality improvement activities," Draper said

The study’s findings are detailed in a new HSC Research Brief—The Role of Nurse in Hospital Quality Improvement—available online at

Other key study findings include:

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.