What We Don't Measure

Teresag_CNS

Nineteen-eighty-two was the year I began nursing, associate's degree proudly in hand, in a community hospital's coronary care unit. My excitement about practicing in critical care was tempered by the fear of inadequacy familiar to many new nurses.

Early in my career, a man had a huge myocardial infarction in the coronary care unit, right before my eyes. He was sweating, in pain, panicked, and dyspneic. This was before the thrombolytic era, so the treatment was to use our standing orders for nitroglycerin, valium and morphine. He lived through the night, and the following morning he gratefully told the day shift RN, "The night nurse held my hand." He didn't know I gave him nitroglycerin to dilate his vessels, improving coronary blood flow and reducing preload. He wasn't aware that morphine is both an analgesic and a mild vasodilator. Nor was he aware that the valium tablet was to reduce myocardial oxygen demand, not just to temper his well-justified anxiety.

"The night nurse held my hand." This statement reflected the priorities of a man in a changing, unknown and threatening situation, when safety and comfort predominate. No standardized tool measures hand-holding or other intangibles such as projecting an aura of confidence. Giving backrubs, reducing noise, and changing sweaty linens figure only obliquely into patient satisfaction measurements. Yet, when you are the man having the MI, they stand out.

Patient satisfaction scores are not synonymous with quality scores for this reason: patients' priorities are not clinical, they are personal. Naturally patients want the best care, but they are not equipped to judge whether the nurse gave medications correctly or made the correct judgment about an abnormal lab test.

Nurses spend at least 30% of our time documenting. Electronic health records (EHR) may have increased this. They are designed for documentation from a regulatory, reimbursement, and quality management perspective, not a nursing practice perspective. These administrative purposes matter, of course, but they are not why the patient thinks we're there. The patient believes we are there for them.

What we value, we measure. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey tool asks a handful of questions regarding nurses and physicians: if they treated the patient with courtesy and respect, if they listened, and if explanations were clear. Pain management is included, too. HCAHPS is important administratively because patient satisfaction scores influence group purchasing power, reducing costs for high-scoring hospitals.

The problem is that courtesy, respect, listening and pain relief are nursing fundamentals, not indicators of excellence. What if we also measured nurses' skill in modifying the environment to enhance rest? What if we measured the many aspects of comfort, such as pillow-fluffing, linen changes, backrubs, and the nurse's ability to convey information with confidence and reassurance? Why not ask if we included the patient's family in our care? What if we simply asked patients if they honestly felt cared for? Excluding this information from our data-gathering efforts sends the message that these things are not valued, which may well hurt our efforts to improve patient satisfaction, and ultimately the financial well-being of our healthcare institutions.

Would scores for respect and pain management rise if we captured skills like maintenance of a therapeutic healing environment and holistic family care? Possibly. Patients may not know that the backrub is a pain and anxiety management strategy, or that it promotes restorative sleep, but they do know whether they felt cared for and comforted. Measuring comfort interventions may bolster comfort and satisfaction by emphasizing their importance to clinicians, who might otherwise give them low priority in their busy schedules.

However, to measure, we must document, and no nurse has more time for documentation. If we add non-pharmacological nursing measures to our EHRs, then something would have to go. Fortunately, nurse scientists have given us ample candidates for removal from nursing routines. Examples include 2-hour turning for pressure ulcer prevention (Bergstrom, Horn, Rapp, Stern, Barrett & Watkiss, 2013) and auscultation of bowel sounds prior to feeding post-operatively (Noblett, 2010). Enumerating the many candidates for elimination is beyond this article, but every registered nurse should know and have the right to practice up-to-date nursing that will improve outcomes and eliminate pointless practices.

As a profession, we must reduce nursing time spent in practices that do little to improve patient outcomes. As we do this, we should reconsider the effective fundamental nursing practices that seem to have lost their place among our routines. Valuing (and measuring) them will benefit our patients, our employers, and our profession.

References

Bergstrom, N., Horn SD, Rapp MP, Stern A, Barrett R,& Watkiss. (2013). Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. Journal of the American Geriatric Society, 61, 705-13.

Noblett, H. (2010). Bowel Management After Surgery. ADVANCE for Nurse Practitioners, (18), 2, 45.

What We Don't Measure

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