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Why measuring the quality of nursing really does matter

Elaine Maxwell
Elaine Maxwell
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A recent comment posted on the Health Foundation website in response to Peter Griffith’s piece on measuring the quality of nursing asked: ‘Do we really want to measuring quality in nursing or the overall quality of care provided to the patient? I believe that patient centred care is much more important than focusing solely on the provision of care by nurses.’

This made me start to think about the relationship between nursing and patient, or person, centred care. It seems to me that that there is a false distinction here as there is no single endpoint for healthcare. Person-centred care that produces poor outcomes is of no benefit to the patient, just as a full tank of fuel but no brake pads is not safe for a car driver, so it's important to measure both.

Healthcare is made up of complex interactions – in order to improve person-centred care we need to understand the quality of the component parts. For example, as a car driver I want to be sure that the car starts, travels smoothly and gets me to my destination. If I don’t understand the importance of and monitor the fuel level, the oil and the brake pads, I can’t ensure that they are all in good condition and I can’t be sure I won’t break down. And if I do break down, I won’t know why I’ve broken down or what to do to get going again. If I only measure the fuel, I’ll be stuck if the oil runs out. When looking at the components, fuel is no more important than oil or brake pads; they are equal but different.

Whilst nursing is only one element of healthcare, patients in hospital spend more time with nurses than any other professional group. The reports into care at at Mid Staffordshire Foundation NHS Trust have repeatedly demonstrated that patients and their families see nurses as an essential component of delivering person-centred care.

The nursing profession agrees. Virginia Henderson defined the purpose of nursing in 1960 as ‘to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.’

The problem is that many people don’t know what nurses contribute to either clinical outcomes or to person-centred care. Florence Nightingale wrote in 1859 that the elements of nursing are all but unknown – I would suggest that, nearly 150 years later, they are still unknown to large numbers of people.

Improvement science tells us we cannot improve a thing unless we can measure it to see if a change is an improvement. So yes, I would say it is important for person-centred care (and all other aspects of good, safe healthcare) that we can measure the quality of nursing in addition to other quality measures, just as it is important for car drivers to monitor oil along with fuel levels and brake pads.

Elaine is an Assistant Director at the Health Foundation, www.twitter.com/maxwele2

Tags: quality, person-centred care, nursing, francis report




 
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Comments
Sandra Pearson 01 February 2013
I think the means used determine the ends. As such I think it's vital to assess the quality of nursing which is aimed at delivering patient-centred care. I think this helps us understand the whole process better.
Linda Jane McLean 01 February 2013
I note that there is no definition of patient centered (or person centered) care - unless you are going along with Virginia Henderson? I certainly cannot fault this definition of Nursing, and it ensures that the patient is at the very centre of everything. I trained under those rules: I was taught to treat every patient as my mother/father/sister brother. - and what a difference it made! And when I moved it into the Community, it was those rules I aimed to meet. Encouraging the patient to be in a position of responsibility is as rewarding as it is challenging.

Florence Nightingale took on a mammoth task in providing a template for Nursing and for hospital design, Both of these models, so carefully developed, we have decided to casually discard in a modern world. We choose to complain that our modern systems are not working!

With person-centered care, all present standards are turned upside down.. The patient comes to the appointment when it suits the patient - or has elective surgery in the near or distant future - as it suits the patient. ( As they do in France).

We still talk the talk, but have not yet learned to walk the walk.
Our British friends, now resident in France,reported an increase in trust in the Medical Profession when they really felt that their opinion and lives mattered. They would not consider moving back to the NHS. In fact, now that they have autonomy, they did not know how they had tolerated the system for so long.

The most important difference to them?
If they phoned the GP surgery in France, it was the GP you spoke to. A doctor who knew you and your history, and how urgently you should be seen. A convenient time was arranged mutually.
NOBODY came between the patient and the Doctor. No receptionist asking what was wrong and telling them when they WOULD be seen..
They found this direct contact invaluable:it saved time and surgery costs, enhanced their experience and generated trust.. Secretaries typed up notes, but they were never visible.

So, I ask: If you tried to introduce that here, what group would stand against it?
And is there an awareness that such a small thing can alter the quality of relationships so dramatically?



Elizabeth Robb 03 February 2013
It is vital that we measure the quality of nursing in relation to patient health. Every report we read shows the importance of this fundamental relationship with patients as they are the professionals who spend the majority of time with them.
Current measures focus mainly on the absence of harm but good nursing is about far more than that and it is high time we recognised and valued it.
It would be excellent to see the Health Foundation investing in this area of work.
Ross Scrivener 04 February 2013
If we know the outcome we want (Virginia Henderson has articulated it eloquently) we need to attend to those “inputs” that contribute to the outcome. This will include the nursing contribution in addition to other factors that impact on that outcome.

A clinical human factors approach helps here because it identifies what those factors invariably are no matter what the setting. For example we know that workload is important. A HF approach shows this can impact at unit level (nurse-patient ratios), job level (degree of difficulty involved), patient level (acuity) and situation level (working environment constraints and enablers).

We know you can’t build the best car in the world by taking the best bits from other designs. System performance derives from how these elements interoperate. Clinical human factors helps us appreciate the system and directs us to look at measures that will provide the best feedback. For example if we know that teamworking is vital for patient safety efforts then we should look at metrics about interdisciplinary training.

Setting a clear goal and linking it to a measurement that can drive progress toward that goal sounds pretty basic. The difficulty is understanding the “system” and co-ordinating the actions that will achieve the goal.
Michael Palmer 06 February 2013
I would be very interested to hear which metrics you propose to measure how well - or otherwise - a nurse assists individuals with activities that contribute to health or its recovery. I believe that there are several issues with this proposition:

1. What happens when there is disagreement between the professional and the individual as to the best course of action?

2. Who defines the activities that are beneficial to health or its recovery?

3. How does one measure outcomes, when, as you state, there is "no single endpoint for healthcare"?
Elaine Maxwell Asistant Director The Health Foundation 06 February 2013
Dear Michael
All good points and I think they serve to illustrate the need for a
wide debate on not only what nurses do but how they do it. Some metrics exist, others need to be developed.
With specific regard to your questions:
1) inherent in the definition is that the nurse assists individuals and therefore the choice is ALWAYS the patient's (unless lacks mental capacity)
2) nurse can offer and patient can decline
3) there are multiple types of outcomes, they are equal but different
I
am happy to continue the conversation if you want to email me elaine.maxwell@health.org.uk
Davina Allen 07 February 2013
Elaine, I think you captured one of the major challenges we face in measuring the quality of nursing when you repeat Florence Nightingale’s observations about its unknown elements. Too much ink has been split over the years trying to formulate what nursing should be, rather than researching empirically what nurses actually do. Situated between the patient and the context of care, the shape of nursing practice is inextricably linked to the changing shape of healthcare systems. Estimates suggest that more than 70% of nursing time is spent on non-direct clinical care. This is commonly seen as ‘dirty work’ in the sociological sense of this term; that is, professionally impure work which is out of alignment with the profession’s sense of its true metier. But we actually know relatively little about it. Last year I spent 6 months shadowing nurses in a range of clinically-facing roles in order to get a better understanding of this element of the nursing function, the skills and knowledge that underpin it and the circumstances that give rise to it. My research reveals that nurses fulfil a vital role in joining up the different elements of the system but this is largely taken for granted and, rather like electricity, is only visible in its absence. Yet this work is hugely consequential for the overall safety, quality and efficiency of patient care and all too readily denigrated as non-nursing duties, particularly at a time when basic nursing care is under critical scrutiny. I plan to disseminate these findings soon, and I very much hope that it will enable the profession to better understand the value of this work and reflect on its implications for professional development and the organisation of nursing practice at the front-line. And, if in the wake of the Francis Report we are to see more careful scrutiny of staffing levels, I sincerely hope that this invisible element of nursing is taken into account.
Alison Crombie 14 February 2013
The article has resonance with my thinking. Although I sometimes struggle with the terminology, outcomes measures and outcomes, mainly quantitative in nature and as such these measures often miss the context, more tick box than truly getting to the essence. I was interested in Davina's research as clearly ethnography can get to the heart of what it is nurses do and their vital input. I look forward to seeing her findings. A great debate.

Heather McClelland 11 March 2013
Thank you Elaine for your insightful 'challenge' to the measure of nursing. Henderson's definition of nursing was a central tennant to my training and still is exactly how I envisage our contribution to health. As much as I empathise with the thoughts of many who feel measurement misses the whole picture, there are many elements of our care and practice that lend well to measurement. We have worked in emergency care to come up with measures generated by patients and by staff that we feel provides a picture of quality care. It may not be a fine art reproduction of what nursing is but equally is is not Salvadore Dali! The measures are easy to complete, involve all the staff, and quickly build a representation of our impact. Whilst there is much discussion about what nursing is, or is not, the very act of deciding on and implementing our measurement has raised the debate. Staff can objectively look at their own and others care and documentation and make a level of judgement. We have committed to reviewing these measures, and the way measurement is done regularly. My instinct is that we continue to miss some of the vital elements, or art of nursing, which is much less tangible in these measures, such as compassion, and the multi-faceted approach to co-ordination of care, but it is a start. I would much rather be in a position to inform the debate on measurement rather than have measurement forced upon us which has so often been the way. Thanks again Elaine, I love the car analogy.
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