Objectives: This quasi-experimental pre-post-study investigated the effect of newly developed Nurse-led Patient Pathways (NPP) designed to improve patients', and health care professionals' as well as institutional outcomes.

Intervention: In the IG patients were cared for under the three newly developed NPP. NPP are characterized by four principles: evidence-based nursing, patient and family centered care, comprehensive discharge planning beyond hospital discharge and nurses' responsibility for patients' processes. The principles support and strengthen patient and family preferences as well as formalize nursing activities, and therefore contribute to process transparency in relation to other health care professionals.

Outcomes: Primary Outcomes were defined as quality of nursing care (nursing care index, NCI), and patient satisfaction (patient satisfaction with nursing care quality, PSNCQ). Secondary outcomes were defined as 1) nursing work environment (nursing work index revised, NWI-R; and nursing workplace quality, NWQ), and 2) institutional-related costs (length of hospital stay, LOS; nursing time and nursing costs). Additionally, nurses' and other health care professionals' experiences of intervention translation will be explored.

In Switzerland, the hospitalization rate of patients with musculoskeletal disorders has increased within the last decade. For example, recent data shows that Switzerland had the highest rate of hip replacement surgery in Europe. Due to the introduction of diagnosis related groups in Switzerland, there is increased pressure to reduce length of hospital stay and increase economic efficiency.

To achieve the required economic efficiency, there is a trend towards standardization of care delivery processes, often in the form of care pathways. The European Pathway Association has defined care pathways as a complex intervention. Pathways should incorporate evidence based care, best practices and patient expectations. As such, care pathways depend on communication and coordination between team members, patients and families, as well as defined roles and sequenced activities.

However, care pathways are often criticized for their organization-driven focus, the lack of a patient centered perspective or missing a holistic approach to care. Therefore, the Balgrist University Hospital and the Zurich University of Applied Sciences developed NPP to enhance patients', and health care professionals' as well as institutional outcomes.

Method: A quasi-experimental prospective study with a pre-post sample design will be conducted. Usual care will be given in the control group (Pre) and compared with a group of patients that were assigned to NPP (Post). The study will be conducted on the two largest orthopedic units at the Balgrist University Hospital, a highly specialized center in musculoskeletal care, located in the Canton of Zurich.

1. A convenience sample will be recruited, consisting of 558 surgical patients hospitalized for total hip arthroplasty, exploration and decompression of the spinal cord, and rotator cuff reconstruction. Demographic, clinical data as well as data to measure quality of nursing care, patient satisfaction, and costs will be obtained,
2. A sample of 38 nurses will be recruited, which are working on the two units. Demographic data and data to measure nursing work environment will be contained,
3. Additionally, a sample of 6 nurses and 5 other health care professionals' (directly involved in patients care) will be recruited to explore experiences of intervention translation within 2 focus group sessions.

The quantitative data analyses will be performed using statistical tests appropriate to the sample size, measurement level, distribution and the independence of variables. For group control appropriate tests for independent groups were used in respect to provision of necessary assumptions. Statistically significance was set on Alpha .05 with undirected hypothesis testing, if necessary correction for multiple testing will be included. Qualitative data analysis will be performed using content analysis.

We hypothesized that the NPP-group (post) will be experienced higher quality of nursing care and increased patient satisfaction, without an increase in health care costs. Secondary outcomes will be enhanced work environment for the nurses.

1. patients

   Inclusion Criteria:

   • surgical patients hospitalized for total hip arthroplasty, exploration and decompression of the spinal cord, and rotator cuff reconstruction,
   • age 18 years or older,
   • German speaking (oral and written),
   • consents to the use of patient data (chart review),
   • give informed consent (patient survey)

   Exclusion Criteria:

   • inclusion criteria will be not met
   • patients that had cognitive deficits such that they were unable to provide informed consent

2. nurses (survey and interview)

   Inclusion Criteria:

   • age 18 years or older,
   • works on one of the two study units
   • give informed consent

   Exclusion Criteria:

   - inclusion criteria will be not met

3. other health care professionals

Inclusion Criteria:

• directly involved in patients care
• give informed consent

Exclusion Criteria:

- inclusion criteria will be not met