Portal de Periódicos da CAPES

A picture worth a thousand words

2025; Lippincott Williams & Wilkins; Linguagem: Inglês

10.1097/nmg.0000000000000215

1538-8670

Lisa Young, Alisha Johnson, Blaine Reeder, Amy Vogelsmeier,

Primary Care and Health Outcomes

FigureHospital-acquired conditions (HAC), such as falls or infections, develop during a patient's hospitalization and are unintended events that often result in harm. For example, hospital-acquired infections (HAIs) are associated with increased morbidity and mortality and are estimated to cost $28.4 billion annually in the US.1,2 The prevention of HACs is a priority, and nurse managers can play a vital role in leading quality and performance improvement initiatives aimed to influence patient outcomes at the bedside. Hospital nurse managers are responsible for involving direct care staff in quality improvement (QI) at the front line, which requires resources to ensure continuous enhancements in the care delivery process.3-5 Additionally, as members of the hospital's leadership team, nurse managers are accountable for upholding their unit's performance by accurately identifying problems, prioritizing initiatives, making decisions, and communicating opportunities to improve patient outcomes. Thus, to serve in this dual role, nurse managers can benefit from tools summarizing their unit's information, such as dashboards.6-8 Dashboards are commonly used tools to improve patient care in hospital settings.9,10 Dashboards serve as a report card that synthesizes large amounts of data into a single visual display, and healthcare leaders and clinicians use dashboards to inform decisions, communicate information, increase compliance with care protocols, monitor performance against benchmarks, and identify patterns or outliers requiring practice changes.6,11,12 Used in QI, dashboards display performance metrics of aggregated patient data (such as infection rates) intended to support operational decision-making.6,9 And to be effective in QI, users should be able to select relevant performance indicators to be displayed on dashboards, so nurse managers can make a meaningful impact on patient care.6 Dashboards are widely used by nurses and nurse managers in hospital patient-care units.7,13 However, much of the available research has focused on user-centered design, where users participate in selecting, designing, and evaluating dashboards for ease of use and usefulness.10,14-17 Although managers play a vital role in identifying and prioritizing key quality indicators for successful dashboard implementation, there's a gap from the nurse managers' perspectives on how they integrate and optimize their use of dashboards for unit QI initiatives.8,9 Therefore, the aim of this study was to describe how hospital nurse managers use dashboards to support their role in unit-level quality and performance improvement efforts. METHODS Ethical considerations The institutional review boards (IRBs) from the university and the health system study site approved the study as exempt. Verbal consent was obtained prior to the study, and any identifiable information was redacted in preparation for data analysis. Study data were stored in a secure, password-protected cloud storage platform. Design, sample, and recruitment A descriptive qualitative design was used. Participants were full-time hospital nurse managers with direct supervision and accountability over at least one hospital unit or patient-care area. Inclusion criteria were nurse managers who 1) supervised direct care staff, 2) had at least 3 months of managerial experience, and 3) participated in QI. Exclusion criteria were 1) nurses in direct care, administration, or director or higher roles, and 2) nurse managers overseeing nonclinical hospital departments (such as education) or nonhospital units (such as outpatient clinics). Purposive sampling was used to recruit from one not-for-profit health system with 11 hospitals (ranging from 25 to more than 900 beds) in the Midwestern US serving a metropolitan city and surrounding suburbs. A representative from each hospital's quality department sent an email recruitment flyer and consent form with study details and participant expectations to their respective hospital's nurse managers. Interested participants completed an online eligibility screening form to ensure inclusion criteria were met. The principal investigator (PI) (LY) contacted qualified individuals for enrollment. All participants received a $25 gift card. Data collection Recruitment and data collection began after IRB approval and were completed when data saturation was reached, which was when no new codes emerged from data analysis.18 The PI conducted one-on-one, semistructured interviews over videoconferencing scheduled for approximately 60 minutes. An interview guide was used to ask participants about their role in QI and experiences with using dashboards for QI on their units (see Figure 1). Probing was used to clarify or expand on participant responses. Interviews were audio-recorded with transcription and reviewed for accuracy. Participants were deidentified with a pseudonym. Demographic data were collected for race, ethnicity, gender, age group, years as a nurse, years as a nurse manager, and highest education level. Data analysis Data were analyzed using Braun and Clarke's six phases of thematic analysis.19 First, the PI became familiar with the data by reading each transcript twice after transcription. The PI then independently generated initial codes for each transcript, and those codes were continuously reviewed and revised by the PI and the senior author (AV) throughout data collection and analysis. Next, the PI searched for themes by continuously grouping codes into categories and categories into themes. The PI and senior author then reviewed and defined themes, respectively, before two additional team members (AJ, BR) conducted a final consensus review of codes, coded data, and themes. Finally, the PI completed a write-up of findings. Ensuring trustworthiness Four steps were followed to ensure trustworthiness of findings. First, participant responses were validated throughout and at the end of each interview to confirm accurate interpretation of findings. Second, codes and themes were reviewed with research team members to assure objective and consistent findings. Third, the PI maintained a detailed audit trail from data collection through data analysis. Fourth, the PI practiced bracketing and reflexivity by maintaining a journal to minimize personal biases and assumptions.20 RESULTS Eleven nurse managers from seven hospitals participated. Interviews averaged 52 minutes (range of 40 to 63 minutes). Participants were non-Hispanic White (91%, n = 10), female (82%, n = 9), and in the Generation X age group (74%, n = 8). Nine (82%) had more than 15 years of nursing experience, but managerial experience varied, with 64% (n = 7) having more than 6 years. All held a bachelor's degree or higher. A variety of unit types were included: critical care, medical-surgical, obstetrics, ED, oncology, and rehabilitation. Table 1 shows participant demographics.Figure 1:: Interview guide Table 1: - Participant demographics (N = 11) Measure Item Frequency % Race White 10 91 Black 1 9 Other 0 0 Ethnicity Non-Hispanic 11 100 Hispanic 0 0 Gender Female 9 82 Male 2 18 Age group Millennial (26-41 years) 2 18 Generation X (42-57 years) 8 73 Baby boomer (> 58 years) 1 9 Years as RN < 1 year 0 0 1-2 years 0 0 3-5 years 0 0 6-10 years 1 9 11-15 years 1 9 > 15 years 9 82 Years as manager < 1 year 1 9 1-2 years 2 18 3-5 years 1 9 6-10 years 4 36 11-15 years 1 9 > 15 years 2 18 Highest level of education Bachelor's 5 45 Master's 5 45 Doctorate 1 9 Unit type Critical care 2 18 Medical-surgical 3 27 Obstetrics 2 18 ED 1 9 Rehabilitation 2 18 Oncology 1 9 Themes Themes were based on how nurse managers perceived that dashboards were used to positively support their role as QI leaders responsible for unit outcomes. Themes included: 1) visualizing performance, 2) communicating everything and everywhere, and 3) engaging ownership. Visualizing performance. Managers perceived dashboards as tools that visually displayed a summary overview of their unit's performance and outcomes. Quality metrics such as infection rates, falls, regulatory reportable measures, pain management, and specialty specific process measurements of nursing interventions and care (such as maternal hypertension, throughput times, ventilator-associated events) were described. Dashboards were used to help managers visualize information for unit-based decision-making, analyzing outliers, and monitoring trends and patterns. The visualization of data was critical to understanding unit performance, identifying opportunities for improvement, and implementing effective solutions, as participants explain here. "I am able to generate what the situation looks like based on data. I generate my information, and then, from there, I'm able to make a decision." (P2) "We have to make sure that we can tell the story through our data and show improvement, so it keeps everyone driven to continue the work." (P9) "I can look for trends...Last year, we were seeing lots of falls, and it was only through pulling a dashboard with lots of information that we were able to...identify and put in a measure to stop [falls]...had we not had all this data...it would be difficult to pinpoint what is the solution you're looking for." (P10) "When we noticed that our compliance was down, that set us forth to finding a process improvement plan." (P8) "I look at what we have control over in our department. What are the things that we can impact ... [then] see what our barriers are and how we can break down each one of those barriers and look at the process pieces and implement them to see if it impacts the outcome." (P6) Managers relied on dashboards to also visualize benchmarks, so they could measure unit performance against goals and standards. Benchmarking facilitated the quick identification of areas needing further improvement and solutions that could have the biggest impact. Managers stated that displaying benchmarks, for example through color-coding (such as red/green), helped them visualize data and gauge unit performance needed for setting and meeting targets for quality metrics. "If it's 100%, it's green. If it's under 100%, there's a color. And then if you're really bad, it's red...So I can look at [dashboard] quickly and say like, 'oh alright, we're really falling out and we've got a lot of red.'" (P5) "We use [dashboards] for benchmarking. We use them for goal setting. We use a dashboard to help figure out if we are hitting goal or are we not?" (P10) Communicating everything and everywhere. Managers described dashboards as tools to increase the visibility of unit data, which facilitated communication about QI work. Sharing positive and negative data guided managers in transparent and open discussions with staff and their own leaders. Communication of data was bidirectional. Nurse managers used dashboards to spread awareness, so staff understood how they influenced patient outcomes, and at the same time, managers presented unit quality and performance indicators to upper management. "Absolutely super transparent. I've learned over time, if you focus on the negative, that doesn't work; if you focus on the positive, it makes people feel good, but you don't get results. I think the only way is just be fully transparent. You share everything...I make sure that every key stakeholder is aware, my leadership team... making sure everyone above me is aware." (P7) Managers shared dashboards through different venues to further increase visibility of unit performance and drive QI conversations. They described bringing dashboards to meetings, including in emails, posting physically as unit displays, and sharing individually with staff. "If I'm seeing outliers or concerns, I'm either talking with a nurse directly or I am putting it into our daily huddle. If I see something that's more global or bigger of a problem, then I feel like everybody could benefit from it. I might put something into the newsletter. I am talking with my educator, letting her know concerns as well, so she can also monitor." (P5) "[The dashboard] is a natural physical item on our unit that displays the outcomes of the unit...so we huddle by that whiteboard, and we call out things or it keeps us on track for those things that are high priority." "I share [dashboards] on the unit. Actually, print it out and then I share with [staff] the processed information... The conference room, the break room, e-mail. It's everywhere." (P2) Engaging ownership. Managers described dashboards as tools to engage staff in owning unit performance so QI work could be shared. By using dashboards, managers led the care team in a supportive and mentoring role. Managers perceived that if direct care staff can understand how their work contributed to achieving unit goals, then managers may gain staff buy-in to increase active involvement in the development and implementation plans. "It's my responsibility to make sure that the direct care staff have an understanding of how their essential job duties and their day-to-day interactions impact our quality metrics...I bring the numbers to an operational level so staff understand the why, so they can support [QI work]." (P3) "They have to see the [dashboard]. They have to be able to ask questions to understand it and then say, how do you think we can fix this? Anybody has any quick whip ideas that we could put into place that won't take up a whole lot of effort and see if it makes a change or not?" (P7) "We form subgroups to involve the frontline staff and then others, whether it's my clinical nurse specialist, different departments, physical therapy...We're all-inclusive. So they'll say, 'Do you think this is possible? What do you think about this?'" (P1) "I definitely try to encourage my team to do the actual implementation or designing of the process improvement because you get more buy-in if you actually have direct members that are going to be implementing the changes involved in the process development... and then [dashboards are] a conversation starter...The staff will bring up concerns of 'why are we headed [in] the wrong direction? What can we do as a team to improve them?'" (P9) To further bolster staff engagement and ownership, managers described using dashboards to celebrate achievements and boost morale. Dashboards were helpful in emphasizing improvement opportunities, but the well-performing areas were equally important in encouraging continued staff involvement in QI work. "I'm trying to use the data to build on strengths rather than make [staff] feel like they're being berated by the data...The staff have made that clear, the communication needs to include the good, not just the bad." (P6) "I am a big proponent of celebrating wins. You can focus on the opportunities, but you shouldn't dwell only on opportunities because it just drags down the culture of the unit...We dwell on the good...on what made those scores productive." (P9) DISCUSSION Nurse managers have an important direct role in leading unit QI. Our findings support the existing nursing literature that dashboards are perceived as useful and important tools for driving unit quality and performance improvement initiatives influencing patient outcomes.7,13 However, our study adds the hospital nurse manager's unique unit-level perspective on how dashboards are used to support their leadership role in influencing QI work. Further, our findings identified what nurse managers find necessary to optimize dashboards for QI. Given nurse managers' unique role of direct responsibilities over unit-level QI initiatives, participants echoed using dashboards to identify patterns and opportunities, so they can implement solutions and evaluate the impact of those solutions on patient outcomes. Nurse managers assess overall unit performance by trending, monitoring, and benchmarking unit performance against similar units and/or best practice standards. Their use of dashboards align with existing interdisciplinary healthcare literature that dashboards aid decision-making, so leaders and clinicians can evaluate and improve performance.11,12,21,22 However, to assist in synthesizing and extracting information critical to making decisions and directing QI efforts at the bedside, our study participants unanimously mentioned the need to "see," "look," or "visualize" the data presented on the dashboards. This finding reinforces that visualization and design play a key role in facilitating QI work.14,23 In particular, participants described that color-coded benchmarking and trendlines assisted in identifying areas of opportunities and success, as well as targets being met. When unit performance data were in the "red" or trending in the opposite direction of the desired target, nurse managers could visually identify the opportunities quickly and implement solutions. Thus, when using dashboards, nurse managers should consider visual displays that facilitate processing of data and information, so they can optimize dashboards to support their leadership responsibilities in QI work. - Research box Purpose To describe how hospital nurse managers use dashboards to support their role in unit-level quality and performance improvement efforts. Ethics The institutional review board determined the study to be exempt. Researchers obtained participant verbal consent prior to data collection. Identifiable information was redacted, and data was stored in password-protected files. Location One health system with 11 hospitals in the Midwestern US. Bed sizes range from 25 to 943. The health system serves a population of approximately 9 million people and is located in a metropolitan city and surrounding suburbs. Time frame January through May 2023 Population Participants were non-Hispanic White (91%, n = 10), female (82%, n = 9), and in the Generation X age group (74%, n = 8). Nine (82%) had more than 15 years of nursing experience; managerial experience varied, with 64% (n = 7) having more than 6 years. All held a bachelor's degree or higher. Unit types included: critical care, medical-surgical, obstetrics, ED, oncology, and rehabilitation. has a detailed breakdown of participant demographics. Data collection Data were collected via 1:1 interviews scheduled for 60 minutes over videoconferencing. Sample size 11 hospital nurse managers participated in the interviews. Dashboards have intrinsic value for nurse managers as a data repository and as an active and passive communication tool. Our participants mentioned using dashboards to encourage staff awareness about unit performance and to tell the unit's QI story. By showing the unit's data, frontline nurses can better understand how their care contributes to patient outcomes.7,13 Further, our findings indicated positive value with sharing dashboards frequently through multiple venues, such as on the unit, at meetings, and in emails. By sharing and communicating often, nurse managers could start conversations about opportunities and successes that drove QI work. Transparency in communicating QI performance to direct care team members and upper management additionally highlighted how dashboards were used to support nurse managers in managing up and down as leaders of their unit. Therefore, dashboards need to serve as purposeful communication tools that complement QI conversations, so nurse managers can confidently share their unit's work. Most important, insights gained from our study emphasize how dashboards can augment nurse managers' roles and responsibilities in supporting and engaging frontline staff in unit QI efforts.24,25 Enhanced visibility and integration of information can foster collaboration among staff, leaders, and departments due to the recognition of how teamwork and improved performance impacts organizational goals.26 In our study, managers described sharing dashboards as support tools to encourage active team participation in QI implementation plans. Sharing dashboard data allowed nurse managers to facilitate discussions on opportunities and seek interdisciplinary staff input on potential solutions. By fostering participation, nurse managers help staff understand the focus of unit QI work, which can increase staff ownership over interventions and ensure initiatives are successful and sustained.25,27 These findings add to the literature by identifying the need for dashboards to be informational, engaging feedback tools so managers can involve staff in developing goals, metrics, and interventions to support QI work. Staff ownership of unit-level QI involved using dashboard data to recognize opportunities and achievements. Managers not only communicated problems but also provided positive feedback, so staff felt empowered to take accountability for driving care outcomes.13 Showing unit performance toward improvement allows nurse managers to build morale and capitalize on staff strengths, so they can create shared team goals, which improves care quality and patient outcomes.25,27,28 This use of dashboards to positively reinforce excellent quality of care provided on the units allows nurse managers to emphasize achievements that are staff-owned. Thus, dashboards not only need to be engaging to staff but also holistic to include the entire unit's story, so managers can address the care team's positive and negative contributions to unit patient outcomes. This study focused on the benefits of the hospital nurse manager's use of dashboard data for improving care at the bedside; however, there exists the potential for too much dashboard data, which can affect nurses and patient outcomes. Literature suggests that too much information can constrain an individual's cognitive capacity, which may overwhelm the individual and impact the adequate and timely processing of information, thereby affecting accurate decision-making.29,30 Further, nurse leaders, including managers, are responsible for reducing cognitive overload among nurses to create a satisfactory and safe working environment.31 Some strategies reported in the literature include filtering or prioritizing key aspects of the information.29,30 Notably, technology and visuals were emphasized as tools that could assist with reducing cognitive load.30,31 Although our study didn't specifically address dashboard overload, our results demonstrated an importance for dashboards to visually support nurse managers' decision-making and communication of information. Thus, nurse managers can consider leveraging or advocating for visuals that simplify or promote cognitive processing of QI information. Future research is therefore needed to explore the consequences of information overload and how nurse managers can mitigate situations when met with multiple dashboards from which to choose and use. Limitations There are several limitations to this study. First, this study occurred within one hospital system, limiting transferability to other settings. Second, there may be a risk of self-selection or volunteer bias because nurse managers chose to participate in the study. Finally, one researcher conducted the interviews and data analysis, but a team of senior qualitative researchers were consulted to ensure study rigor and trustworthiness throughout the study, from design to dissemination. IMPLICATIONS FOR NURSE LEADERS Findings from this study have implications for hospital nurse managers using dashboards for quality and performance improvement. As unit leaders, nurse managers should advocate for dashboards that support their role in directing unit resources and prioritizing QI work. As visual tools that aid in information processing and decision-making, dashboards should include visuals, such as color-coding or trendlines, to enable nurse managers to quickly review their unit's opportunities and successes without requiring additional effort to understand what's displayed. Dashboard visuals should support nurse managers' unit QI efforts, including making decisions, analyzing data, and implementing solutions. As data communication tools, dashboards should be in a format that supports frequent display and sharing of updated unit performance, so managers can enhance QI conversations with staff and senior leaders. Nurse managers need dashboards that can be integrated into their unit's culture and communication structures, so data are continuously available and transparent to everyone. Additionally, dashboards should be engaging and meaningful, so direct care nurses can own QI work and actively influence unit-level work. Nurse managers must therefore leverage dashboards to show how staff can be involved and how their work positively and negatively impacts their unit's outcomes. Thus, given these needs and recommendations, it's crucial for nurse managers to have the right tools, training, and support to effectively use dashboards to work through problems and develop solutions impacting unit patient outcomes. FACILITATING IMPROVEMENT Dashboards are facilitative tools for hospital nurse managers leading unit quality and performance improvement initiatives. This study adds to the literature by sharing one health system's nurse managers' unique perspectives on how they use dashboards to support unit-level QI work. Nurse managers should consider incorporating dashboards into their unit's culture and QI implementation plans, so they can communicate information and engage staff using visuals of their unit's data. As leaders tasked with the responsibilities of overseeing unit-level QI work, nurse managers must be empowered in dashboard utilization, so they can leverage their unique role in improving patient outcomes.