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STAR-2 Network Study

Small Troubles, Adaptive Responses (STAR-2):
Frontline Nurse Engagement in Quality Improvement

                               ISRN Network Principal Investigators

Kathleen R. Stevens, RN, EdD, ANEF, FAAN
University of Texas Health Science Center San Antonio 

Eileen P. Engh, MSN, RN-BC, CPN
Children's National Health System


STAR-2, STAR-2+, STAR-2++

Data collection for the first ISRN Network Study is now complete and data analysis is currently in progress. The STAR-2 research collaborative consists of 33 hospitals investigating operational problems that frontline nurses work around on a daily basis. One of the main objectives of this study is to identify the relationships among practice environment, frontline quality improvement engagement, and outcomes in acute care units. Organizational climate in hospitals, including organizational support for nursing care and engagement in microsystem operations, are potentially modifiable to produce better patient outcomes and workforce satisfaction. However, the causal links between macro- and micro-system features and improvement are poorly understood. By investigating how frontline nurses’ engagement in detecting operational failures is related to organizational learning, work from the STAR-2 Research Collaborative will add to the knowledge of strategies that transform healthcare practices.  

Background and Significance

This study will advance our understanding of relationships among practice environment, frontline quality improvement engagement, and outcomes in acute care clinical units. Results of this study will explain how potentially modifiable attributes of macro- and micro-systems of care interface with frontline nurses’ quality improvement engagement and subsequent system, provider, and care outcomes.

The broad impact on health derives from the fact that most adverse events in healthcare originate from frontline operational failures that are common enough to be taken for granted. Although these process failures include both errors and “problems” (task interruptions due to something or someone not being available when needed), the latter are far more common, yet have drawn far less attention (Tucker, et al, 2008). In fact, such problems occur about once per hour per nurse on hospital units and 95% of problems are managed through workarounds (Tucker, et al, 2008). The implication for practice is that detecting small problems provides practice-based data about operations that could then drive transformation, creating an organizational learning environment that is sensitive and responsive to resolve these latent failures and the small hassles that sap the morale and efficiency of an already overextended nursing workforce.

Specific Aims

The aims of this study are to:

  1. Describe the type and frequency of first-order operational failures detected by frontline nurses on their clinical units.
  2. Examine the association between first-order operational failures that are self-detected by nurses and those that are detected by
  3. Explore the relations among frontline engagement (detection of operational defects and team vitality), work environment (culture of patient safety and excellence in work environment), and quality improvement outcomes (quality improvement activities, quality of care, and job satisfaction).

Research Design and Methods

This investigation is designed as multisite, cross-sectional, multivariate research.  Data will be analyzed using descriptive, multivariate, and path analysis methods.

Variables will be measured using quantitative self-report approaches as follows:


Study Variable

Measurement Approach

Frequency and type of operational failures

STAR Pocket Card
(Ferrer & Stevens, 2010)

Team collaboration

Team Vitality Instrument (Upieneks, et al, 2009)

Hospital staff opinions about patient safety issues, medical error, and event reporting

AHRQ Hospital Survey on Patient Safety Culture (HSOPS) 
(Sorra & Nieva, 2004)

Work environment

Practice Environment Scale of the Nursing Work Index (PES-NWI) (Lake, 2002)

Volume of QI activities

QI Action Scale
(Adapted from Upieneks, et al, 2009)

Quality of care

Nurse Assessment of Quality
(Aiken, Clarke, Sloane, 2002)

Overall job satisfaction

Visual Analog Scale (Schmalenberg & Kramer, 2008)

Detailed analysis is currently in progress.


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