What We Don't Measure

by Teresag_CNS Teresag_CNS

Specializes in ICU, trauma, gerontology, wounds. Has 34 years experience.

Why patient satisfaction and quality of care are not synonymous. Or.....what sick people really care about and why we should pay attention.

What We Don't Measure

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.


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.

Independent wound care expert, educator. I am a PhD-prepared clinical nurse specialist with 30+ years of ICU, teaching, and research experience. Gerontology and acute care are my areas of clinical expertise. Research interest: safety and quality of care in intensive care units. I have a passion for undergraduate teaching.

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3 Comment(s)

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience. 16 Articles; 7,358 Posts

Although we don't have HCAHPS in Canada, we're not exempt from the notion that customer satisfaction is highly important. My patients for the most part are too young to understand if the care I provide them meets standards of any sort, and they wouldn't really care one way or another. My unit's management team have no way to directly measure my performance, as I rarely see them, never mind "do tricks for them". And when I've been in a situation where there has been disagreement between a parent and myself, as an experienced professional nurse, parents' interpretations are usually the ones that are validated. When we're viewed simply as a line item on the budget, what we actually are worth gets lost. Hospitals exist because people require NURSING CARE. If they didn't they'd be at home. So your article is a timely one. Thank you!



2,085 Posts

Great article. All very true. I believe that many people are afraid and/or are very resistant to asking patients if they feel/felt cared for, and I believe many people do not really want to know the answer. How often do we read people suggest that we should ask the patient if they feel/felt cared for? And that nurses should care for the patient's family too? Not very often in my experience. I think it is an excellent idea and that it would be one valuable measurement of the quality of care. It is significant to me that we don't do this already in the surveys. I think part of the truth is that some people, and not just nurses, do not want to really associate nursing/health care with caring, let alone think that caring is most important to the patient, because they know that they don't really care about the patient or whether the patient feels cared for or not, and they have no interest in caring for the patient's family, and even if they had an easy work load they still wouldn't care about the patient or their family. I think it would be very beneficial for patients and their families if they were asked these kinds of questions on surveys, and I note as I'm sure do many others that asking these types of questions on surveys appears to be avoided by design.



2,085 Posts

Patients are primarily seen by the health care industry as customers (sources of revenue) to provide health care services to, not as individuals to care for. Whether a patient feels their nurses/doctors/other health care personnel treat them in a caring manner is largely a peripheral concern from the point of view of the industry (a bonus, if you like), not a primary concern. The primary concern is ascertaining that the patient's bill will be paid and that the patient is eligible to receive health care services. Then the goal is to maximize reimbursement.

Even in primary care settings the physician treating the patient in a caring manner is often not a reality - I see this with my own family members and experience this myself with physicians that treat the patient not as an individual human life with feelings and preferences, but as a demographic with signs and symptoms that are to be treated as cost effectively as possible while ignoring the feeling and wishes of the individual human being if convenient (the feelings and wishes of the individual are very secondary). Lack of caring in health care exists across all health care settings. It is a very sad thing, and as we know, when we ourselves are sick and have to visit doctors or be hospitalized we want to receive care from staff who treat us in a competent and caring way.