Nursing standards, language and age as variables associated with clinical competence for nurses in long-term care facilities: A cross-sectional study.

AIM: To identify and examine the explanatory variables associated with clinical competence among registered nurses (RNs) and practical nurses (PNs) working in long-term care facilities (LTCF) for older adults. DESIGN AND METHODS: This was a cross-sectional study. The competence test, 'the Ms. Olsen test', was used for data collection. A convenience sample of 337 nursing staff working in LTCFs for older adults was selected between December 2020 and January 2021. A quantitative, non-experimental approach with multiple linear regression analysis examined the explanatory variables associated with clinical competence and the outcome variables. RESULTS: The main findings of the linear regression analysis show that the nursing staff's increasing age, use of Swedish as a working language and use of the Finnish nursing practice standards had statistically significant relationships with clinical competence among the participating nursing staff. CONCLUSION: This is the first knowledge test that has been developed to test nursing staff's clinical competence in elderly care. In this study in Finland, the highest clinical competence was among the nursing staff who were Swedish-speaking RNs working in institutional care homes caring for patients according to national practice standards. IMPLICATIONS: These results may be useful to nursing staff and managers working in elderly care to understand the explanatory variables associated with clinical competence in elderly care in Finland and in bilingual settings. The study highlights the importance of using national nursing standards in elderly nursing care. Knowing the explanatory variables associated with clinical competence can provide guidance for the further education of nursing staff in these settings. IMPACT: Caring according to national practice standards and caring for severely ill patients are associated with clinical competence. REPORTING METHOD: The authors adhered to the EQUATOR network guidelines Appendix S1 STROBE to report observational cross-sectional studies. PATIENT OR PUBLIC CONTRIBUTION: Registered and PNs completed a questionnaire for the data collection.

Addiction Nursing Competencies: A Comprehensive Toolkit for the Addictions Nurse.

With the increased role of nurses in caring for patients with substance addiction, there was a clear need to develop the Addiction Nursing Competencies to guide and support the nursing workforce. A literature search revealed a lack of formal instruments to assess and guide nurses in caring for persons with substance use disorders. The Addiction Nursing Competencies were created using existing nursing education frameworks and addiction nurse care manager clinical guidelines.

Reforming nursing registration: Lessons from pandemics.

A nimble and flexible regulatory response regarding the nursing workforce is essential to a fully integrated public health approach to national crises and pandemics. The COVID-19 pandemic has drawn many comparisons to the 1918 Flu Pandemic. Some of them are well-reasoned and grounded in evidence. Other are not. This study provides a historically contextualized analysis of how the 1918 flu pandemic helped shape Pennsylvania nursing's current regulatory apparatus. We conclude that the state-based solutions that nursing registration represents are inadequate to deal with pandemics and crises with national, if not global, reach. We need to move immediately toward the national COMPACT system, while mindful of how regulatory processes and procedures can reinforce structural inequities.

Cultural competence among nurses and its influencing factors: A cross-sectional study.

The purpose of this study was to investigate the level of cultural competence and its influencing factors among Chinese nurses by using a cross-sectional design. Participants were recruited from four tertiary hospitals in Jiangsu, China, and 325 nurses completed the Cultural Competence Inventory for Nurses in China. Data were analyzed using stepwise multiple regression to identify factors influencing cultural competence. The results showed that Chinese nurses self-rated cultural competence at a moderate level (mean value of 101.7 out of 145), which indicates that cultural training is necessary to improve their cultural competence. Nurses who were younger and had fewer years of working experience, had lower educational backgrounds, seldom learned about different cultures via mass media, and rarely resided in or visited places with different cultures tended to have lower cultural competence levels, and should be provided more opportunities for cultural training. By considering demographic characteristics that influence cultural competence among Chinese nurses, educators can specifically design cultural training content at an appropriate level, targeting trainees' needs and thereby enhance training effectiveness.

Development and content validation of the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey.

AIM: To develop a validated tool to measure nursing and midwifery documentation burden. BACKGROUND: While an important record of care, documentation can be burdensome for nurses and midwives and may remove them from direct patient care, resulting in decreased job satisfaction, associated with decreased patient satisfaction. The amount of documentation is increasing at a time where staff rationalisation results in decreasing numbers of clinicians at the bedside. No instrument is available to measure staff perceptions of the burden of clinical documentation. DESIGN: Survey development, followed by rwo rounds of content validation (April and May 2019). METHODS: Based on the literature a 28 item survey, with items in 6 subscales, representing key areas of documentation burden was developed. Item (I-CVI), subscale (S-CVI/Ave by subscale) and overall content validity indexes (S-CVI/Ave) were calculated following two review rounds by an expert panel of clinical and academic nurses and midwives. RESULTS: Level of agreement for the first iteration of the survey was low, with many items failing to reach the critical I-CVI threshold of 0.78. No subscale reached a S-CVI/Ave above 0.8 and the overall scale only achieved a S-CVI/Ave score of 0.67. Thirteen items were removed, seven were edited and five new items added, based on the expert panel feedback, substantially improving the content validity. All individual items achieved an I-CVI ≥0.78, the S-CVI/Ave was above 0.85 for all subscales and the total S-CVI/Ave was 0.94. CONCLUSION: The Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey can be considered as content valid, according to the content validity analysis by an expert panel. IMPACT: The BurDoNsaM survey may be used by nurse leaders and researchers to measure the burden of documentation, providing the opportunity to review practice and implement strategies to decrease documentation burden, potentially improving patient satisfaction with the care received.

Nursing strike, America, 2019: Concept analysis to guide practice.

BACKGROUND: In 2018 a nursing 'sympathy strike' occurred. Although unionized nurses were directed to participate, many expressed questions about what a strike or sympathy strike was. Literature revealed no seminal article to define the term. A concept analysis for the nursing workforce was created. METHOD: The Hybrid Method of Concept Analysis, (theoretical literature analysis, qualitative stakeholder interviews; applicability) was used. 33 articles and 7 books were reviewed. Nine interviews took place. RESULTS: The literature and interviews agreed on the definition, antecedents, and consequences of a nursing strike. Strikes in the United States were defined as "a last resort effort, after significant bargaining on the issue between nurses and management has not allowed for agreement, where a work stoppage occurs and nurses leave the bedside." Interviews alone introduced the concept of duty to patients. A model case, contrary case and borderline case are offered. CONCLUSION: This study contains recommendations for practice.

Methods of nursing certification in North America-A scoping review.

BACKGROUND: Definitions of nursing certification are lacking in the research literature and research on certification in nursing is remarkably limited. METHODS: A six-stage scoping review framework was used to identify the nature, extent, and range of certification within the nursing literature. FINDINGS: Thirty-six articles were included in this scoping review. Most originated in the United States (89%), were classified as research articles (56%), and used a quantitative approach (90%). The majority focused on initial certification (50%), and written examination was the most prevalent approach to certification (39%). Missing and incomplete data were prevalent. DISCUSSION: The overall lack of nursing certification origin, focus, methodological rigor, and clear certification mastery criteria have hindered meaningful study of the relationship between nursing certification and patient outcomes. Common data elements, reporting standards, and observational studies linking common data elements and patient outcomes could guide future research and improve the transparency of certification processes and reporting.

Sample size calculation for stepped-wedge cluster-randomized trials with more than two levels of clustering.

BACKGROUND/AIMS: Power and sample size calculation formulas for stepped-wedge trials with two levels (subjects within clusters) are available. However, stepped-wedge trials with more than two levels are possible. An example is the CHANGE trial which randomizes nursing homes (level 4) consisting of nursing home wards (level 3) in which nurses (level 2) are observed with respect to their hand hygiene compliance during hand hygiene opportunities (level 1) in the care of patients. We provide power and sample size methods for such trials and illustrate these in the setting of the CHANGE trial. METHODS: We extend the original sample size methodology derived for stepped-wedge trials based on a random intercepts model, to accommodate more than two levels of clustering. We derive expressions that can be used to determine power and sample size for p levels of clustering in terms of the variances at each level or, alternatively, in terms of intracluster correlation coefficients. We consider different scenarios, depending on whether the same units in a particular level are repeatedly measured as a cohort sample or whether different units are measured cross-sectionally. RESULTS: A simple variance inflation factor is obtained that can be used to calculate power and sample size for continuous and by approximation for binary and rate outcomes. It is the product of (1) variance inflation due to the multilevel structure and (2) variance inflation due to the stepped-wedge manner of assigning interventions over time. Standard and non-standard designs (i.e. so-called "hybrid designs" and designs with more, less, or no data collection when the clusters are all in the control or are all in the intervention condition) are covered. CONCLUSIONS: The formulas derived enable power and sample size calculations for multilevel stepped-wedge trials. For the two-, three-, and four-level case of the standard stepped wedge, we provide programs to facilitate these calculations.

Appropriateness of transferring nursing home residents to emergency departments: a systematic review.

BACKGROUND: Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable. METHODS: Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract. RESULTS: Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital. CONCLUSIONS: The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient's autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

Nurses' knowledge, behaviour and compliance concerning hand hygiene in nursing homes: a cross-sectional mixed-methods study.

BACKGROUND: Effective hand hygiene is one of the most important measures for protecting nursing home residents from nosocomial infections. Infections with multi-resistant bacteria's, associated with healthcare, is a known problem. The nursing home setting differs from other healthcare environments in individual and organisational factors such as knowledge, behaviour, and attitude to improve hand hygiene and it is therefore difficult to research the influential factors to improve hand hygiene. Studies have shown that increasing knowledge, behaviour and attitudes could enhance hand hygiene compliance in nursing homes. Therefore, it may be important to examine individual and organisational factors that foster improvement of these factors in hand hygiene. We aim to explore these influences of individual and organisational factors of hand hygiene in nursing home staff, with a particular focus on the function of role modelling by nursing managers. METHODS: We conducted a mixed-methods study surveying 165 nurses and interviewing 27 nursing managers from nursing homes in Germany. RESULTS: Most nurses and nursing managers held the knowledge of effective hand hygiene procedures. Hygiene standards and equipment were all generally available but compliance to standards also depended upon availability in the immediate work area and role modelling. Despite a general awareness of the impact of leadership on staff behaviour, not all nursing managers fully appreciated the impact of their own consistent role modelling regarding hand hygiene behaviours. CONCLUSION: These results suggest that improving hand hygiene should focus on strategies that facilitate the provision of hand disinfectant materials in the immediate work area of nurses. In addition, nursing managers should be made aware of the impact of their role model function and they should implement this in daily practice.

Change Over Time in Ratings of New Nurses on the Appraisal of Nursing Practice.

OBJECTIVE: To examine changes in new nurses' competencies across the 1st year of practice. BACKGROUND: Competency assessment is a challenge for nurse residency programs and often focuses on skills checklists and confidence self-reports. The Appraisal of Nursing Practice, an observational rating based on Quality and Safety in Nursing Education standards, was developed to help evaluate an RN residency program. METHODS: Preceptors, nurse educators, and/or unit managers from various units rated new nurse residents. Ratings were compared for 353 nurses at 3 points: within the 1st month in the program (T1), at 5 months (T2), and at month 11 (T3). RESULTS: Competency ratings increased significantly for all subscales from T1 to T2. Ratings continued to increase significantly from T2 to T3, although at a slightly slower rate. Teamwork and evidence-based practice increased the most. CONCLUSIONS: Future studies should explore factors affecting the trajectory in developing nursing competencies within various settings.

Psychosocial work environment and cross-cultural competence among native and foreign-born registered nurses.

Cross-cultural competence is an essential component of the nursing profession, but little is known about the specific psychosocial work characteristics that potentially promote or hinder such competence. In the present study, psychosocial work characteristics were based on Karasek's Job Demand-Control Model. The researchers examined whether Karasek's psychosocial work characteristics, such as high-strain jobs, high-strain isolated jobs, active jobs, and active collective jobs, are associated with cross-cultural competence (empathy, skills, positive attitudes, and motivation), and whether there are differences between native and foreign-born registered nurses (RN) in these potential associations. A random sample of 744 native RNs (91.0% women) and a total sample (n = 212) of foreign-born RNs (94.3% women) working in Finland were used. Data were collected using a questionnaire and analyzed with a series of multiple linear regression analyses. High-strain and high-strain isolated jobs were negatively associated with all four dimensions of cross-cultural competence. Active collective jobs, but not active jobs, were positively associated with cross-cultural skills. There were no differences between native and migrant nurses in these associations. The psychosocial work environment is associated with cross-cultural competence in both native and migrant nurses. Improvements in psychosocial working conditions, especially minimizing negative factors in the work environment, such as high-strain and high-strain isolated jobs, may need to be considered as a part of the efforts aimed to enhance cross-cultural competence among nursing personnel.

Nursing knowledge of essential maternal and newborn care in a high-mortality urban African setting: A cross-sectional study.

AIMS: To assess the knowledge of nurses of national guidelines for emergency maternity, routine newborn and small and sick newborn care in Nairobi County, Kenya. BACKGROUND: The vast majority of women deliver in a health facility in Nairobi. Yet, maternal and neonatal mortality remain high. Ensuring competency of health workers, in providing essential maternal and newborn interventions in health facilities will be key if further progress is to be made in reducing maternal and neonatal mortality in low-resource settings. DESIGN: Cross-sectional survey. METHODS: Questionnaires comprised of clinical vignettes and direct questions and were administered in 2015-2016 to nurses (n = 125 in 31 facilities) on duty in maternity and newborn units in public and private facilities providing 24/7 inpatient neonatal services. Composite knowledge scores were calculated and presented as weighted means. Associations were explored using regression. STROBE guidelines were followed. RESULTS: Nurses scored best for knowledge on active management of the mother after birth and immediate routine newborn care. Performance was worst for questions on infant resuscitation, checking signs and symptoms of sick newborns, and managing hypertension in pregnancy. Overall knowledge of care for sick newborns was particularly low (score 0.62 of 1). Across all areas assessed, nurses who had received training since qualifying performed better than those who had not. Poorly resourced and low case-load facilities had lower average knowledge scores compared with better-resourced and busier facilities. CONCLUSION: Overall, we estimate that 31% of maternity patients, 3% of newborns and 39% of small and sick newborns are being cared for in an environment where nursing knowledge is very low (score <0.6). RELEVANCE TO CLINICAL PRACTICE: Focus on periodic training, ensuring retention of knowledge and skills among health workers in low-case load setting, and bridging the know-do gap may help to improve the quality of care delivered to mothers and newborns in Kenya.

Factors Related to Health Informatics Competencies for Nurses-Results of a National Electronic Health Record Survey.

In 2015, the Finnish Ministry of Social Affairs and Health published an eHealth and eSocial strategy with key objectives that by 2020 health information systems will be smart and providers will be able to maximize their use. Measures include improving system usability and decision support, involving professionals in system and service development, and increasing professionals' training in information management, electronic documentation, data protection, and data security. The aim of this study was to explore the level of nurses' informatics competencies and sufficiency of in-house training regarding technology-induced changes in work practices. An electronic questionnaire produced by the National Institute of Health and Welfare was sent in February to April 2017 to 29 283 Finnish working-age nurses, community nurses, and midwives; 3607 replies were received. Respondents rated their overall informatics competency relatively high, with the lowest competency scores on terminology-based documentation (Finnish Care Classification) and patient-related digital work. Education, electronic health record system used, experience using electronic health record systems, sufficiency of training, higher levels of technical functionality, ease of use, and usefulness were all associated with competency and remained significant after all adjustments. One-third of the respondents felt that they had not received sufficient training. Age and participation in system development were associated with experiences of sufficiency of training.

Practice and Training Needs of Staff Nurses Caring for Patients With Intestinal Ostomies in Primary and Secondary Hospitals in China: A Cross-Sectional Survey.

PURPOSE: The purpose of this study was to describe staff nurses' intestinal ostomy care practice in primary and secondary hospitals in China and their ostomy-related training needs. SUBJECTS AND SETTING: The target population for this study was first-line staff nurses working in general surgical departments in primary and secondary care hospitals in Luzhou, located in Sichuan Province, Southwest China. Hospitals in China are divided into 3 tiers; first tier facilities are usually located in townships and have fewer than 100 inpatients beds; secondary hospitals are usually found in medium-sized cities or districts and have between 100 and 500 inpatient beds. DESIGN: Descriptive, cross-sectional. METHODS: Participants were recruited through a stratified cluster sampling method based on hospital tier and the presence of general surgical department. Data were collected via a questionnaire that comprised 3 sections; the first section queried demographic and professional practice data, the second queried practice related to patients with intestinal ostomies, and the third queried nurses' stoma-related training needs. Links to the electronic survey were distributed through e-mail. RESULTS: Three hundred and eighteen nurses were invited to participate in the survey, and 280 questionnaires were returned, yielding a response rate of 88.05%. Review of data found that 214 questionnaires were sufficiently complete to be used in our data analysis. The mean intestinal ostomy practice score was 26.61 ± 7.98, indicating less than optimal engagement in ostomy care. Lack of manpower in the workplace and heavy workload of daily nursing were identified as leading barriers to continuing education in this area of practice. CONCLUSIONS: The ostomy-related practice of first-line staff nurses in Chinese primary and secondary hospitals showed less than optimal engagement in ostomy practice. We recommend creating additional ostomy-related continuing education targeted for nurses practicing in primary and secondary tier hospitals and removal of barriers to this education in order to improve ostomy care in primary and secondary tier hospitals in China.

Impact of using data from electronic protocols in nursing performance management: A qualitative interview study.

AIM: To explore the impact of using electronic data in performance management to improve nursing compliance with a protocol. BACKGROUND: Electronic data are increasingly used to monitor protocol compliance but little is known about the impact on nurses' practice in hospital wards. METHOD: Seventeen acute hospital nursing staff participated in semi-structured interviews about compliance with an early warning score (EWS) protocol delivered by a bedside electronic handheld device. RESULTS: Before electronic EWS data was used to monitor compliance, staff combined protocol-led actions with clinical judgement. However, some observations were missed to reduce noise and disruption at night. After compliance monitoring was introduced, observations were sometimes covertly omitted using a loophole. Interviewees described a loss of autonomy but acknowledged the EWS system sometimes flagged unexpected patient deterioration. CONCLUSIONS: Introducing automated electronic systems to support nursing tasks can decrease nursing burden but remove the ability to record legitimate reasons for missing observations. This can result in covert resistance that could reduce patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Providing the ability to log legitimate reasons for missing observations would allow nurses to balance professional judgement with the use of electronic data in performance management of protocol compliance.

Preparing nursing professionals fit for the evolving healthcare landscape.

The revised Nursing and Midwifery Council education curriculum, which came into force in January, has the potential to revolutionise nursing, says Barry Hill, Senior Lecturer, Northumbria University ( barry.hill@northumbria.ac.uk ).

The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study.

BACKGROUND: Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either "generally", "sometimes" or "exceptionally" appropriate for NH residents with severe dementia. METHODS: A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents' families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran's-Q tests. RESULTS: The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a "sometimes appropriate" medication post-intervention were 0.81 (95% CI: 0.71-0.92) and 0.83 (95% CI: 0.74-0.94), respectively. CONCLUSION: A simple KE intervention using a medication review guidance tool categorizing medications as being either "generally", "sometimes" or "exceptionally" appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.

Failure to Meet Nurse Staffing Standards: A Litigation Case Study of a Large US Nursing Home Chain.

Large for-profit nursing home chains in the United States have generally reported low nurse staffing levels. This historical case study examined a class action litigation case regarding staffing levels, resident rights, and quality outcomes in 12 Arkansas nursing homes owned by a large for-profit chain. The questions were as follows: (1) How did the residents' care needs compare with actual nurse staffing levels? (2) How did the staffing levels compare with federal and state nurse staffing requirements and professional staffing standards? (3) Did the facilities comply with state and federal residents' rights and quality of care requirements? The findings showed staffing levels marginally above state minimum standards, staffing shortages that violated state standards, staffing levels not adjusted for resident acuity, and shortages that resulted in omitted care. Staffing levels were lower than needed according to nursing directors, lower than average facilities in the state, and lower than professional standards. The findings showed many resident grievances regarding basic care and residents' rights, clinical measures of poor quality, and state deficiencies. A large settlement was agreed on to compensate the residents. The case shows that chain's management, as well as the regulatory system, failed to ensure adequate staffing levels that took into account regulatory requirements and professional standards and resulted in violations of residents' rights, health, safety, and well-being.

Key considerations for selecting instruments when evaluating healthcare professionals' evidence-based practice competencies: A discussion paper.

AIM: A discussion of key considerations related to selecting instruments and tools for evaluating healthcare professionals' evidence-based practice (EBP) competencies. DESIGN: A discussion paper. DATA SOURCES: Articles published in international peer-reviewed journals from January 2000 - November 2017 on validated instruments for assessing healthcare professionals' performance-based EBP competencies. IMPLICATIONS FOR NURSING: Validated EBP competency instruments based on actual performance to evaluate the EBP competencies of healthcare professionals are currently available in the field of medicine. Although some of these instruments have already been adapted for use in physical and occupational therapy, their modification for use in nursing has begun only in the last few months. CONCLUSION: A concerted effort on modifying and validating objective measures of actual performance for use in nursing should be commenced to evaluate directly measurable EBP competencies, instead of continuing to rely on nurses' self-assessments. Future studies focusing on development and validation of objective instruments to evaluate EBP competencies based on actual performance and exploring the modification of currently available objective instruments from medicine are urgently needed in nursing. IMPACT: Instead of measuring actual EBP competencies, the majority of competency evaluations in nursing are still being conducted via self-assessments, despite growing evidence of their poor accuracy in evaluating directly measurable constructs such as evidence-based practice knowledge and skills. Accurate measurement of nurses' EBP competencies is essential to increasing systematic implementation of EBP in healthcare organizations, thus promoting the attainment of improved care quality and patient outcomes in healthcare delivery.