Patient-Centered Quality in Practice: A Nurse Navigator Brings Shared Decision Making to Knee Replacement Consultations
[Student Name]
University of Phoenix
NSG/468: Influencing Quality within Healthcare
Week 5 Assignment
[Instructor Name]
[Date]
The clinic, patients and figures are a composite written for a model paper.
Quality in health care is often measured by what happens to the body: infections, falls, readmissions. A broader standard has stood for more than two decades: patient-centered care, meaning care that respects and responds to individual patient preferences, needs and values, is one of six aims for a quality health system, alongside safety, effectiveness, timeliness, efficiency and equity (Institute of Medicine, 2001). On a composite orthopedic clinic, a nurse navigator interviewed 40 patients in the week before their scheduled total knee replacement and found that fewer than half could name the typical recovery time, and about a third expected the surgery to relieve symptoms that it rarely changes, such as hip or back pain. A patient who consents to surgery without understanding what it will and will not do has received technically correct care that fails the quality standard at its first step. This paper proposes a nurse-led shared decision making program for knee replacement consultations and explains how it would be measured as a quality improvement.
Shared Decision Making as a Quality Standard
Barry and Edgman-Levitan (2012) call shared decision making the pinnacle of patient-centered care: the clinician brings evidence about options, benefits and harms, the patient brings knowledge of his or her own values and goals and the two reach a decision together. For preference-sensitive decisions, where more than one reasonable option exists and the right choice depends on what the patient values, they argue that a decision made without the patient's informed preferences is a form of medical error.
Knee replacement is a preference-sensitive decision. For a patient with knee osteoarthritis, the options include continued conservative management, such as exercise therapy, weight management and medication, or surgery, which relieves pain for most patients but carries surgical risks, a long recovery and a minority of patients who remain dissatisfied. Which option is better depends on how much the patient's pain limits the activities that matter to him or her and how the patient weighs recovery time and risk.
The Evidence for Decision Aids
Decision aids are tools, printed, video or online, that present options with their benefits and harms in plain language and help patients clarify what matters to them. Stacey et al. (2017), in a Cochrane review of more than 100 randomized trials, found that people exposed to decision aids had greater knowledge of their options, more accurate expectations of benefits and harms, felt clearer about their values and participated more in decisions, without evidence of harm. Arterburn et al. (2012) studied the introduction of decision aids for hip and knee osteoarthritis at a large health system and found that the introduction was associated with substantially lower rates of joint replacement surgery and lower costs, suggesting that some patients who understood the options chose not to have surgery.
That second finding needs careful framing in a quality paper. The goal of shared decision making is not fewer surgeries; it is surgeries that informed patients choose. A program that aimed to reduce surgery would simply swap one bias for another.
The Proposed Program
The program follows the three-talk model of Elwyn et al. (2012), which describes shared decision making as team talk (making clear that a choice exists and that the patient's view matters), option talk (describing options with their benefits and harms) and decision talk (helping the patient arrive at a preference and a decision). Each stage has a clear owner.
Team talk begins when the clinic books a new patient with knee osteoarthritis. The nurse navigator calls to explain that the first visit will include a discussion of all reasonable options and sends a decision aid chosen from a vetted source, with a request that the patient review it before the visit.
Option talk happens at the visit. The surgeon or physician assistant reviews the examination and imaging, then walks through the options using the same decision aid, so the patient hears consistent information. The navigator attends for new patients during the pilot and takes responsibility for checking understanding with the teach-back method.
Decision talk is where the navigator's role is largest. Many patients do not decide during the visit. The navigator calls within a week, asks what matters most to the patient, such as walking a grandchild to school, returning to work or avoiding a long recovery, and helps the patient connect those priorities to the options. If the patient chooses surgery, the navigator documents the patient's goals in the record so the surgical team and physical therapists can refer to them after the operation.
Measuring Decision Quality
A quality program needs measures. The program will use three. The first is a short knowledge test of five questions drawn from the decision aid, given before surgery; the target is that at least 80% of patients answer four or more correctly. The second is a measure of whether the decision matched the patient's stated priorities, recorded by the navigator and reviewed monthly. The third is a decisional conflict scale completed before surgery, which asks patients how certain and informed they feel. Two balancing measures watch for unintended effects: the percentage of new patients who choose surgery, which is tracked but has no target, and clinic visit length, which could grow enough to strain the schedule.
Patient outcomes after surgery matter too. The clinic already collects function scores at baseline and one year. Adding the patient's documented goals makes it possible to ask a new question at one year: did the surgery deliver what this patient hoped for?
Anticipating Objections
Two objections are likely, and the proposal should answer them before the pilot begins. Surgeons may worry that the program will talk appropriate patients out of an effective operation. The answer is in the design: the decision aid presents surgery's benefits as fully as its harms, the navigator does not recommend an option and the balancing measure tracks surgery rates without a target, so a fall in surgery would be reviewed, not celebrated. Administrators may worry about cost, since the navigator's time and longer first visits are real expenses. The pilot will count navigator hours per patient and compare them with the cost of cancellations on the day of surgery, which the clinic already tracks and which often reflect patients who agreed to surgery without being ready for it. If informed patients cancel less often, part of the program pays for itself.
The Nurse's Leadership in Quality
This program depends on a nurse, not because nurses alone should hold these conversations, but because a nurse navigator is positioned to lead the whole process: before the visit, during it and after. Leading it means more than holding calls. It means persuading surgeons that a longer first visit is worth the time, selecting decision aids with the team, training schedulers, collecting and presenting data and adjusting the program when the data show a problem. Those are the leadership skills the course has built, applied to a dimension of quality that is easy to overlook because no alarm sounds when a patient decides without understanding.
Conclusion
Patient-centered care is one of the aims by which health care quality is judged, and for a preference-sensitive decision such as knee replacement it depends on patients understanding their options and choosing in line with their values. A composite clinic found that many patients booked for surgery lacked that understanding. A nurse-led program built on the three-talk model and supported by the evidence for decision aids offers a way to close that gap, and measuring knowledge, value match and decisional conflict turns a principle into a quality result the clinic can track.
References
Arterburn, D., Wellman, R., Westbrook, E., Rutter, C., Ross, T., McCulloch, D., Handley, M., & Jung, C. (2012). Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. Health Affairs, 31(9), 2094-2104. https://doi.org/10.1377/hlthaff.2011.0686
Barry, M. J., & Edgman-Levitan, S. (2012). Shared decision making: The pinnacle of patient-centered care. New England Journal of Medicine, 366(9), 780-781. https://doi.org/10.1056/NEJMp1109283
Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rollnick, S., Edwards, A., & Barry, M. (2012). Shared decision making: A model for clinical practice. Journal of General Internal Medicine, 27(10), 1361-1367. https://doi.org/10.1007/s11606-012-2077-6
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://doi.org/10.17226/10027
Stacey, D., Legare, F., Lewis, K., Barry, M. J., Bennett, C. L., Eden, K. B., Holmes-Rovner, M., Llewellyn-Thomas, H., Lyddiatt, A., Thomson, R., & Trevena, L. (2017). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 2017(4), Article CD001431. https://doi.org/10.1002/14651858.CD001431.pub5
How this NSG 468 Week 5 example is structured
The NSG/468 library guide pairs Week 5 with readings on shared decision making, the link between nurse certification and outcomes, and leadership in quality through systems thinking. The paper treats patient-centeredness as a measurable dimension of quality, not a courtesy, which is why it defines the gap with data and closes with measures. The program itself is built from a named decision making model so each step has a reason, and the nurse's leadership role is made explicit because the course ends on influencing quality, not only describing it. Students search this week as NSG 468 Week 5, NSG468 Wk 5 or NSG/468 Wk 5; all three are the same assignment.
NSG/468 Week 5 questions, answered
What does NSG/468 Week 5 usually ask for?
The course library guide pairs Week 5 with readings on shared decision making, nurse certification and outcomes, and leadership for quality and safety. Many sections ask for a final paper or presentation on how nurses influence quality in their organization, often including a proposal. Your instructions decide the exact format.
Is shared decision making really a quality topic?
Yes. The Institute of Medicine named patient-centered care as one of six aims for health care quality, and decision quality, meaning an informed choice that matches the patient's values, can be measured like any other outcome. The sample shows how to measure it.
Do I need to propose a real decision aid?
Name the type of aid and where it comes from, such as a library of vetted aids, rather than inventing one. The sample describes the aid's content and the process around it; the evidence for decision aids comes from the Cochrane review cited in the paper.
Write yours, or have the desk draft it
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