The Value of Nursing

Acute and critical care nurses are at the bedside 24 hours a day, 7 days a week, to provide care that cannot be delivered in any other setting. They provide the first line of surveillance and vigilance to detect subtle changes in a patient’s condition. For example, calling a rapid response team for a 39-year-old with evolving sepsis before the cardiac monitor has even started to alarm. Facilitating a conversation with the family of a 96-year-old with a broken hip and pneumonia to determine the extent of care that would align with the patient’s advance care directive. Supporting the resilience of a new mother and family with the birth of a baby with a genetic anomaly. Providing education to a 56-year-old man with a left ventricular assist device and his spouse who are expected to manage this new, complex, life-sustaining device and medications, potentially for months or years, as he awaits a call for a heart transplant. Or skillfully administering a complicated chemotherapy regimen to an 11-year-old with cancer, working diligently to minimize distressing side effects while simultaneously having a conversation with the child and her parents about the likelihood of chemotherapy success and the reality of her future.

These are just a few examples of what acute and critical nurses do on a daily basis, using evidence to provide quality care while simultaneously tailoring each of their interactions and interventions to the unique needs of that patient, that family. Nurses do all this while functioning in increasingly stressful environments, environments that are not consistently supportive or healthy and are becoming increasingly violent, abusive, and morally distressing. Despite these challenges, nurses find glimpses of joy in those moments when they provide exquisite care, comfort, and knowledge—experiencing a connection with patients and families. Society in general and patients in particular have come to expect this level of commitment by the nursing profession in providing care. But how do those commitments and expectations translate into identifying the value of nursing care provided in today’s health care system—sometimes at great personal cost to nurses?  

The idea that there is a gap in articulating and measuring the value of nursing is not new. It has been acknowledged for decades that nurses are the glue that hold health care systems together, and yet their work is frequently "invisible." In 2000, Disch¹ highlighted the 1983 observation of Lewis Thomas: “My discovery, as a patient first on the medical services and later in surgery, is that the institution is held together, glued together, enabled to function as an organism, by the nurses and nobody else.”^2(p67) Disch notes in her writing that what is “valued, preserved and receives resources is that which is visible.”^1(p189) Although the essential functions of nurses were heralded during the COVID-19 pandemic, we as a society and as a health care system have yet to fully acknowledge or quantify the true value of nurses. Rather, the value of nursing care has been measured with a focus on a few distinct negative metrics that have been attributed, not always appropriately, to nursing. Authors of a recent article have shined a light on this ongoing travesty, providing a clarion call to action for the value of nurses to be made visible to patients and families, bedside nurses themselves, health care leaders and organizations, and policy makers.³ The authors propose 9 domains of care routinely provided by acute and critical care nurses as a first step in a comprehensive articulation of this work. In addition, they also propose key elements that must be in place to ensure a quality work environment, excellent nursing practice, and ultimately positive patient outcomes: adequate preparation to practice in the acute and critical care setting; appropriate nurse staffing; unrestrained practice to promote full use of clinical expertise; and systems to support nurses and their practice, including professional governance structures that engage the expertise of bedside nurses, technology that eases the work of nurses rather than adding to their burden, and access to advanced practice nurses such as clinical nurse specialists to provide at-the-elbow support and expertise for complex patient situations.³

It is imperative that nurses and our allies take action to delineate the value of acute and critical care nursing and identify metrics to measure the positive outcomes of our vital work. If you are an acute or critical care nurse and interested in engaging in this call to action movement, I would encourage you to read the article by Curley et al³ and then provide your voice to articulate the breadth and depth of your practice by responding to the 9 domains of acute and critical care practice survey. 

Mary Fran Tracy, PhD, RN, APRN, CCNS, FCNS, FAAN