From the Editor

Nursing’s Primary Commitment Embedded in the Quintuple Aim

nursing, DNP-prepared nurses, patient outcomes, health equity, evidence-based practice
CJON 2024, 28(3), 236-237. DOI: 10.1188/24.CJON.236-237

Anecdotally, from personal experience as a growing editor and in talking with experienced editors, rejecting evidence-based project manuscripts that do not include patient outcomes is routine. Phrased differently, it is typical for editors to see hopeful publications that exclude patient outcomes, only to reject them because they miss the mark.

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    Anecdotally, from personal experience as a growing editor and in talking with experienced editors, rejecting evidence-based project manuscripts that do not include patient outcomes is routine. Phrased differently, it is typical for editors to see hopeful publications that exclude patient outcomes, only to reject them because they miss the mark. In 2022, the American Association of Colleges of Nursing published The State of Doctor of Nursing Practice Education summary, which included results of an independent survey of DNP-prepared nurses, employers, faculty members, and students, as well as a consensus that DNP work is intended to improve quality and patient outcomes and effect practice changes. Although most nurses holding a DNP degree—and their employers—agreed they are focused on patient and system outcomes (American Association of Colleges of Nursing, 2022), a 2023 study of 214 DNP project manuscripts identified broad variation across scholarly published projects, including across outcome measurement, both before and after the American Association of Colleges of Nursing published the DNP Project Roadmap, which built on a 2015 white paper providing guidance for DNP curricula and projects (Milner et al., 2023). DNP-prepared nurses are only one nursing group focused on improving patient and system outcomes.

    As with all things in health care, change is inevitable. New science emerges, and professions and industries shift. In 2007, the Institute for Healthcare Improvement launched the Triple Aim framework focused on simultaneously improving care experience and health of populations, and reducing healthcare per capita costs (Berwick et al., 2008). Since then, the Institute for Healthcare Improvement has moved through the Quadruple Aim, adding a focus to improve clinician experience, and to the call for the Quintuple Aim, paralleling foci on also achieving health equity (Nundy et al., 2022). This is quite similar to the Institute of Medicine’s (2001) seminal six aims, or domains, of healthcare systems, also known as STEEEP: safe, timely, effective, efficient, equitable, and patient-centered. In both frameworks, the ultimate goal is better care.

    According to the American Nurses Association (ANA, 2021), “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity” (p. 1). The Code of Ethics for Nurses indicates in Provision 2 that “[t]he nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population” (ANA, 2015, p. 5). Numerous nurse theorists have developed views all stemming from the relationships nurses have with various individuals and populations because nursing is inherently about others beyond the nurse (ANA, 2015, 2021). The ultimate goal is better care for others.

    Evidence-based practice (EBP) is “a life-long problem-solving approach to the delivery of health care that integrates the best evidence from well-designed studies (i.e., external evidence) and integrates it with a patient’s preferences and values and a clinician’s expertise, which includes internal evidence gathered from patient data” (Melnyk et al., 2014, p. 5). The outcomes are the internal evidence. Through strong design, analysis, and dissemination efforts, the internal evidence transforms into external evidence. It is the outcomes that help others know the effects of interventions. Per Provision 7 of the Code of Ethics for Nurses, nurses, “in all roles and settings, [advance] the profession through research and scholarly inquiry” (ANA, 2015, p. 27), and identifying the proper outcome(s) is a primary nursing competency. Nursing competency strengthens on a continuum from focusing on individual outcomes to system and/or population outcomes as nurses gain advanced knowledge and training (ANA, 2021). Nurses continually grow in EBP to improve care one person at a time or through systems affecting large groups of people (White et al., 2019). The ultimate goal is better care for many people.

    The Clinical Journal of Oncology Nursing publishes “clinically relevant, evidence-based content for oncology nurses in diverse roles and practice settings to use when caring for those affected by cancer” (Oncology Nursing Society [ONS], 2024, para. 2). The Clinical Journal of Oncology Nursing disseminates evidence—in the form of original EBP manuscripts and department articles, comprehensive clinical literature reviews, case studies, and oncology-related health policy analyses—“to promote the mission of ONS, which is to advance excellence in oncology nursing and quality cancer care” (ONS, 2024, para. 1). The ultimate goal is better cancer care.

    Nurses are duty bound to improve patient care through various methods (ANA, 2015). However, nurses can become inward-focused to improve nursing (e.g., clinician satisfaction or process measures) without considering the primary commitment to “an individual, family, group, community, or population” (ANA, 2015, p. 5). Quality and EBP interventions solely focused on measurement of the clinician may garner insight into some system outcomes. System outcomes are important because people make up systems, and interconnected systems amplify patient outcomes, contributing to equities or inequities. However, if nurses separate the Quintuple Aim or STEEEP domains, excluding a focus on patient care, how do others know the intervention is worth replicating? What good is EBP without focusing on nursing’s primary commitment?

    Nurses study nurses and assess nursing processes and program measures for the ultimate goal of better care. We study nurses because nurses change work and care outcomes. It cannot be the only focus, though. We keep multiple aims to achieve our primary commitment. If EBP efforts focus solely on clinician satisfaction and exclude the remainder of the Quintuple Aim’s work and care outcomes—quality, patient experience, cost, and equity—we risk violating our ethical obligation, changing our profession without upholding our primary commitment. As our profession expects all nurses in all roles and settings to propel work and care forward through scholarly inquiry and practice (ANA, 2015), oncology nurses everywhere need to ensure EBP work includes patient and/or system outcomes.

    Move beyond looking at clinician-centric measures of an intervention. What does the intervention do to the systems affecting work and care? Does the intervention change patient care? If so, in what way(s)? How will we know? (That is, what will we measure?) Ultimately, what does that mean for patients, whether they are individuals, families, groups, communities, or populations? Demonstrate the nursing impact by showing the patient and system outcomes, and indicate the patient and/or system impact by presenting the nursing outcomes. Mapping EBP measures to STEEEP domains or the Quintuple Aim helps us clearly see what we are focusing on and what we may be missing in our care vision. When we omit patient outcomes, we risk hyperfocusing on nursing, moving our eyes off the patient. That is the antithesis of nursing. We know and aim better, all in pursuit of better care.

    About the Author

    Joni L. Watson, DNP, MBA, RN, OCN®, is the chief vision officer of the Creating Collective, LLC, with a consulting associate faculty appointment in the School of Nursing at Duke University in Durham, NC. Watson can be reached at CJONEditor@ons.org.

    References

    American Association of Colleges of Nursing. (2022). The state of doctor of nursing practice education in 2022. https://bit.ly/44mXVUE

    American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.

    American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.).

    Berwick, D.M., Nolan, T.W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759–769. https://doi.org/10.1377/hlthaff.27.3.759

    Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.

    Melnyk, B.M., Gallagher-Ford, L., Long, L.E., & Fineout-Overholt, E. (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and cost. Worldviews on Evidence-Based Nursing, 11(1), 5–15.

    Milner, K.A., Hays, D., Farus-Brown, S., Zonsius, M.C., & Fineout-Overholt, E. (2023). National evaluation of DNP projects based on 2015 AACN white paper and 2019 DNP Project Roadmap. Journal of Professional Nursing, 48, 60–65. https://doi.org/10.1016/j.profnurs.2023.05.002

    Nundy, S., Cooper, L.A., & Mate, K.S. (2022). The Quintuple Aim for health care improvement: A new imperative to advance health equity. JAMA, 327(6), 521–522.

    Oncology Nursing Society. (2024). About CJON. https://www.ons.org/cjon/about

    White, K.M., Dudley-Brown, S., & Terhaar, M.F. (2019). Translation of evidence into nursing and health care (3rd ed.). Springer Publishing Company.