The funny thing about measuring something is that it usually calls attention to the something being measured. This quirk is especially true in health care when regulatory bodies outside of an organization require reporting of that something for payment. In that case, people (in fact, many people) pay a lot of attention to it. So, here is the question and the rub for nursing: How is our work currently being measured in hospitals? You would think that the outcomes we measure would reflect at least most of what nurses do, such as our care and compassion, but current nursing outcome measures are mostly about the absence of nursing—that is, rates of catheter-associated urinary tract infection (CAUTI) and central catheter–associated bloodstream infection (CLABSI), patient falls, and pressure ulcers. Although harm metrics are obviously important, current outcome measures do not fully capture the care that nurses provide, and this needs to change now.

Why now? Because the practice of acute and critical care nursing has never been more difficult. Patients are presenting to hospitals with more complex medical conditions, multiple comorbidities, and challenging social situations. Providing comprehensive care to such patients is high stakes, requiring nursing expertise, critical thinking, and the ability to effectively collaborate with multiple disciplines. Hospital-based nurses are continuously confronted with a complex and relentless array of challenges that not only drain their ability to provide timely, evidence-based, and compassionate care but also compromise their own physical and mental well-being.1  These pressures create a vicious cycle of strain that is exceptionally difficult to break. The need to break this cycle has never been more urgent, as the stakes continue to rise for both nurses and patients. We need to keep talented nurses in hospital-based care. We need to flip the narrative and focus our outcomes measurement on why nurses are consistently valued by the public as the most trusted profession.

To those who are disenchanted with today’s nursing practice environment, we suggest you stay strong, remain vocal, and keep advocating for the changes that are urgently needed in health care. Your voices are being heard, and we remain optimistic about the future of acute and critical care nursing. Part of that optimism stems from the work that is currently underway by members of the American Academy of Nursing’s Expert Panel on Acute and Critical Care. You may think that members of the academy are far-removed academic individuals, but this is not reality. Your colleagues on the panel are leaders in the field who empowered themselves to convene a working group to address the concerns that direct care nurses are voicing about the climate of their work environment. The group felt they had to do something—anything—to support the nearly two-thirds of the nation’s nursing workforce2  who are struggling. The panel specifically aimed to call attention to the essential role of bedside nurses in acute and critical care, the conditions that must be in place for these nurses to excel in what they do, and the outcomes one would expect from their care so that the value of nursing could be adequately measured. The open-source paper titled “Call to Action: Blueprint for Change in Acute and Critical Care Nursing”3  can be found at https://doi.org/10.1016/j.outlook.2024.102271.

The Blueprint calls for a major change in how nursing is considered in acute and critical care hospitals. It sets forth a description of what contemporary acute and critical care nurses do by identifying and describing 9 domains of acute and critical care nursing practice (see Figure).4,5  Why was this important? Aside from reiterating the complexity, scope, and importance of nursing work, this step was foundational to any re-envisioning of nursing’s contributions to patient outcomes—meaning that one must first understand what is being done before considering the effects of what is done. Specifically, the key consideration is the net outcomes of patient care and not simply a count of the processes that are thought to get us there. For example, rather than using process measures that report whether nurses completed pain assessments every 4 hours, use true outcome measures that report whether the patient’s pain was adequately managed during their hospital stay.

The 9 overlapping domains are presented separately but practiced concurrently, depending on the individual needs of each patient and family. Care begins with a focus on nurses creating safe healing environments. Nothing knowingly gets past the voiced bedside nurse that can cause a patient harm (ask any first-year student). Nurses create modern-day hospital environments that are designed to heal the sick and include ensuring mobility and nutrition, limiting environmental noise, providing day and night light variation, and maintaining circadian rhythms. Without this attention, the care environment can be toxic and create a host of additional problems for the patient, such as physical deconditioning, malnutrition, sleep deprivation, and delirium. Safe healing environments engender the patient’s perceptions of feeling safe and well cared for.

From their very first encounter, nurses build caring relationships with patients and their families.6  They come to know patients and their families as individuals who require person-specific care. Nurses learn to be present in the moment, empathetic, and compassionate. They constantly help patients and their families interpret and incrementally master the nuances of the hospital care system and help them understand the significance of the changes that they are experiencing. Nurses teach patients and their families what they need to know to actively participate in their own care and decision-making, as they choose and when they are able. Nurses help patients and their families plan, organize, and be ready to manage their own care, helping them navigate transitions in care across and out of the health care system.

“… we need innovative and powerful ways to measure the profound impact of excellent nursing care, identifying outcomes that truly matter to patients and families.”

Nurses assess and manage patient symptoms. Yes, plans are discussed within the interprofessional team, but the nurse is individually responsible for using their clinical judgment to monitor and adequately manage patient symptoms with the goal of minimizing distress, promoting comfort, and preventing suffering. For example, in the intensive care unit, agitation management in a patient supported on mechanical ventilation requires multimodal interventions, including nurse-led environmental, positional, and ventilator adjustments; bladder and bowel management; enhancement of nonverbal communication if intubated; and psychosocial and family interventions, including use of sedation when all else fails.

Nurses administer physical, therapeutic, preventive, and end-of-life care. Physical care includes personal hygiene (including oral and mouth care), toileting, nutrition, hydration, mobility, rest comfort, sleep quality, and emotional well-being. The provision of this physical care remains highly undervalued. Nurses provide the surveillance, with knowledge of and vigilance for individual patient risks, and are ready to intervene when necessary. Therapeutic and preventive care varies per patient, and the heterogeneity of that care is substantial in the inpatient environment. For example, the nursing care required of a neonate or a geriatric patient with cerebral hypertension, septic shock, or congestive heart failure is nuanced and requires nursing expertise to optimize patient outcomes. Our vigilance and care can abbreviate a patient’s time to physiologic stability (duration of vasopressor administration, mechanical ventilation, and stay in the intensive care unit), can abbreviate time to critical intervention (time to recognize and respond to an evolving clinical situation), and can rescue patients from potential complications (patients at high risk but who never develop a complication). Our caring and compassion allows the provision of end-of-life care that is respectful to each patient and their family.

Nurses collaborate with and coordinate care within the interprofessional team. Each discipline involved in the patient’s care uniquely contributes their perspective, which often requires a coordinated effort from nursing to execute. Nurses advocate for the patient and family, ensuring that their needs and preferences are known and respected within the interprofessional care team. The emotional distress experienced by nurses during the resolution of ethical problems is endemic to inpatient care.

Just because nurses want to provide excellent care does not mean that systems are set up to allow that to happen. The Blueprint provides several core elements and key features of a work environment that fully support nurses.7,8  It is important to note that these elements and features are considered essential, meaning that they are what the group believed was absolutely necessary for patients and their families to receive outstanding nursing care. These assumptions include the following: (1) nurses are adequately prepared to practice in the acute or critical care setting, (2) there are enough nurses with requisite expertise aligned to care for patients, (3) nursing practice is unrestrained by local policies, and (4) systems are in place to help nurses use their expertise when caring for patients. This section of the Blueprint required the team to pause, reflect, and tentatively define what nursing nirvana (ie, a state of perfect happiness or an idyllic workplace) would look like. Specifically, what workplace factors are necessary to improve the health of nurses and retain the best and the brightest in the nursing profession? What would be needed in the care environment to best support optimal patient outcomes and for nurses to end their shift feeling happy and fulfilled and like they made a positive difference in the lives of patients and their families? Although the list is in no way exhaustive, the articulation of the core elements serves as a starting point for health care organizations to assess if they have the conditions that are essential for ensuring that patients and their families receive outstanding nursing care.

Here and now, we reaffirm the immense value of the work that acute and critical care nurses do and clearly define the essential elements of a practice environment that fully supports acute and critical care nurses. Finally, we need innovative and powerful ways to measure the profound impact of excellent nursing care and identify outcomes that truly matter to patients and their families. Know that we are not interested in adding more documentation burden to help make this happen. In fact, given the current and future state of nursing informatics, we believe that nurse informaticians can build clinical information systems that will allow systematic extraction of data that include the outcomes derived from the 9 practice domains. Nurses complete extensive documentation for each patient, and creating an additional workload that consumes valuable time would further limit nurses’ ability to provide patient care.

What we ask from you: We want to hear from you. Specifically, do the 9 domains of practice reflect your current practice? We invite you to take part in a brief survey (https://redcap.nursing.upenn.edu/surveys/index.php?s=XYEE7WP9J4MFK8T4). In the survey we ask if each domain typically falls within your practice as an inpatient nurse, how often you perform the activity, and how important you think the activity is to your patients’ outcomes. Importantly, it will also allow you to comment on what you think might be missing from the 9 domains we have laid out.

In summary, we describe 9 domains of practice and the core elements of hospital environments that support nurses’ capacity to provide optimal care. We propose precision-based outcomes measurement to call attention to the presence—not the absence—of nursing care and ask for partners to help develop and incorporate new measures into hospital accreditation and reimbursement structures. We ask you to engage in conversations about your nursing practice that you believe make a difference to patients and their families and participate in the measurement process. When you validate the 9 domains, others can be held accountable for developing metrics that truly reflect your work, which would allow at least minimal reporting of hospital core metrics that reflect excellence in the nursing care and the value nurses provide to patients and their families. Again, the funny thing about measuring something is that it calls attention to the something (nursing) being measured. As stated in the Blueprint: “We believe the practice of acute and critical care bedside nursing will thrive when the outcomes of their day-to-day practice are made visible to everyone touched by the work of nurses.”

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Footnotes

FINANCIAL DISCLOSURES

None reported.

 

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected].