FLORENCE NIGHTINGALE FOUNDATION
Measuring the impact of nurses and nursing: the core values
58
healthcare values. However, it is difficult to argue for evidence-based practice and the value of nursing if we are not creating the evidence on which to base our practice. Patients feel that relational aspects of nursing are very important: the approach of the nurse is the most important factor in securing a good experience for patients, enabling them to be ‘treated as a human being not a case’ with compassion, respect, empathy and by staff who are ‘interested in YOU’ (Maben and Griffiths, 2008: 7). We work in a health service where numbers matter and the measurable is influential. The lack of evidence on important aspects of nursing care has contributed to a largely reductionist debate about staffing levels and numbers of nurses needed on a shift in acute care. The focus is on maintaining the minimum nurse staffing needed to prevent harm, rather than what nurse staffing is needed to deliver excellence and individualised patient-centred care that encompasses our nursing values. Current staffing in acute care (and likely other settings) leaves many tasks undone (Ball et al, 2013), with the tasks essential for safety prioritised and ‘relationship’ aspects of nursing neglected. ‘Comfort/talk to patients’ was felt to have been left undone by 53% of nurses in acute care across Europe (UK: 66%) on their last shift because of insufficient time, with educating patients reported as not done by 41% (UK: 52%) (Ball et al, 2013; Ausserhofer et al, 2014). These are surely key elements of the nursing role? But without evidence of a measurable difference made to patients, it is difficult to argue our case in a metrics-obsessed resource-constrained health service. Lack of time to perform what nurses have been trained to do and indeed what they came into nursing for and want to do, leaves many feeling frustrated, stressed and burnt out. They feel they cannot reliably deliver care of the standard to which they aspire (Heinen et al, 2013). Nurses are being counted as a homogenous commodity to be provided in a numbers game that hospitals are obliged to report on, with little debate on quality rather than quantity; we are reduced to the minimum acceptable for safety rather than enough for excellence in care. Unless we can capture nursing’s unique contribution to positive aspects of care, such as compassion and dignity, we will be in a weak position to argue for the importance of enabling nurses to deliver care as they wish to.
This is not an optional extra, but absolutely central to our role as nurses. With initiatives to embed compassion in practice and the spotlight continuing to focus on dignity and care, we have an opportunity to develop academic and clinical partnerships focused on demonstrating the value of nursing. Recommendations are easy, but it is much harder to produce high-quality evidence on what actually works in practice. Academics and practitioners should work together to develop the evidence for the value of holistic nursing care to patients. We know patients value nurses, but we need to provide better evidence to BJN support our case. Ausserhofer D, Zander B, Busse R et al (2014) Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry crosssectional RN4CAST study. BMJ Qual Saf 23(2): 126-35 Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P (2013) “Care left undone” during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf 13. doi:10.1136/bmjqs-2012-001767 Deaton C, Baillie L, Lowes L, Norton C, Tod A, Robb E (2014) Education and compassion: complementary not contradictory. Br J Nurs 23(22): 1213 Griffiths P, Jones S, Maben J, Murrells T (2008) State of the art metrics for nursing: a rapid appraisal. National Nursing Research Unit, King’s College London. http://tinyurl.com/ beu3twk (accessed 15 December 2014) Heinen MM, van Achterberg T, Schwendimann R et al (2013) Nurses’ intention to leave their profession: A cross sectional observational study in 10 European countries. Int J Nurs Stud 50(2): 174-84. doi: 10.1016/j.ijnurstu.2012.09.019. Maben J, Griffiths P (2008) Nurses in society: starting the debate. National Nursing Research Unit, King’s College London, London. http://tinyurl.com/njq668e (accessed 15 December 2014) McCance T, Telford L, Wilson J, MacLeod O, Dowd A (2011) Identifying key performance indicators for nursing and midwifery using a consesus approach. J Clin Nurs 21(7-8): 1145-54
Christine Norton, Lesley Baillie, Angela Tod, Christi Deaton, Lesley Lowes, Debbie Carrick-Sen Florence Nightingale Foundation Professors of Clinical Nursing Research
Elizabeth Robb
Chief Executive, Florence Nightingale Foundation
© 2015 MA Healthcare Ltd
I
n the last issue of BJN (Deaton et al, 2014) we discussed the need for knowledge and evidence in nursing. However, there is a problem with definitions and outcome measures that demonstrate the value of the nursing contribution to patient care. While work has started to define ‘nurse-sensitive indicators’ (Griffiths et al, 2008) these focus on measuring what we can quantify: patient numbers, waits and length of stay, falls, pressure ulcers and infections. These are obviously very important, but our inability to articulate the value of nursing in relational aspects of care means that we are often focusing on preventing harms rather than doing good. When nurses are asked what is important to them, they vote overwhelmingly for personcentred care rather than more easily measured metrics (McCance et al, 2011). There has been little research trying to capture the value of nursing in terms of our core values and nursing’s unique contribution to patient care. Indeed, it is not clear that we even agree what constitute our core nursing values: are they the 6 Cs (Care, Compassion, Competence, Communication, Courage and Commitment); kindness, respect and dignity as in the new draft Nursing and Midwifery Council (NMC) code; or the NHS Constitution multidisciplinary values (respect, dignity, compassion, getting the basics right every time, improving lives and patient involvement)? It is a pity that these high-level values are not aligned. Many values are poorly defined and we are lacking a consensus on how to improve or measure them. Although academics have conducted concept analyses on some, practical operational definitions and agreement on what behaviours demonstrate the values are few. Indeed, they are maybe easier to identify if they are absent than present. For instance, dignity has been much talked about, with numerous recommendations, but attempts to measure it, or interventions with measurable outcomes, are lacking. We simply do not have evidence on what works (and just as importantly what does not work).There is a similar lack of evidence on interventions related to most of our other values. Does it matter that we cannot measure many of the core elements and values in nursing practice? Most are likely to be difficult to measure directly, but can be observed from behaviours.They are multi-factorial and require multidisciplinary behaviours. Additionally, nursing should not be the sole custodian of
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
Measuring the impact of nurses and nursing: the core values
58
healthcare values. However, it is difficult to argue for evidence-based practice and the value of nursing if we are not creating the evidence on which to base our practice. Patients feel that relational aspects of nursing are very important: the approach of the nurse is the most important factor in securing a good experience for patients, enabling them to be ‘treated as a human being not a case’ with compassion, respect, empathy and by staff who are ‘interested in YOU’ (Maben and Griffiths, 2008: 7). We work in a health service where numbers matter and the measurable is influential. The lack of evidence on important aspects of nursing care has contributed to a largely reductionist debate about staffing levels and numbers of nurses needed on a shift in acute care. The focus is on maintaining the minimum nurse staffing needed to prevent harm, rather than what nurse staffing is needed to deliver excellence and individualised patient-centred care that encompasses our nursing values. Current staffing in acute care (and likely other settings) leaves many tasks undone (Ball et al, 2013), with the tasks essential for safety prioritised and ‘relationship’ aspects of nursing neglected. ‘Comfort/talk to patients’ was felt to have been left undone by 53% of nurses in acute care across Europe (UK: 66%) on their last shift because of insufficient time, with educating patients reported as not done by 41% (UK: 52%) (Ball et al, 2013; Ausserhofer et al, 2014). These are surely key elements of the nursing role? But without evidence of a measurable difference made to patients, it is difficult to argue our case in a metrics-obsessed resource-constrained health service. Lack of time to perform what nurses have been trained to do and indeed what they came into nursing for and want to do, leaves many feeling frustrated, stressed and burnt out. They feel they cannot reliably deliver care of the standard to which they aspire (Heinen et al, 2013). Nurses are being counted as a homogenous commodity to be provided in a numbers game that hospitals are obliged to report on, with little debate on quality rather than quantity; we are reduced to the minimum acceptable for safety rather than enough for excellence in care. Unless we can capture nursing’s unique contribution to positive aspects of care, such as compassion and dignity, we will be in a weak position to argue for the importance of enabling nurses to deliver care as they wish to.
This is not an optional extra, but absolutely central to our role as nurses. With initiatives to embed compassion in practice and the spotlight continuing to focus on dignity and care, we have an opportunity to develop academic and clinical partnerships focused on demonstrating the value of nursing. Recommendations are easy, but it is much harder to produce high-quality evidence on what actually works in practice. Academics and practitioners should work together to develop the evidence for the value of holistic nursing care to patients. We know patients value nurses, but we need to provide better evidence to BJN support our case. Ausserhofer D, Zander B, Busse R et al (2014) Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry crosssectional RN4CAST study. BMJ Qual Saf 23(2): 126-35 Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P (2013) “Care left undone” during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf 13. doi:10.1136/bmjqs-2012-001767 Deaton C, Baillie L, Lowes L, Norton C, Tod A, Robb E (2014) Education and compassion: complementary not contradictory. Br J Nurs 23(22): 1213 Griffiths P, Jones S, Maben J, Murrells T (2008) State of the art metrics for nursing: a rapid appraisal. National Nursing Research Unit, King’s College London. http://tinyurl.com/ beu3twk (accessed 15 December 2014) Heinen MM, van Achterberg T, Schwendimann R et al (2013) Nurses’ intention to leave their profession: A cross sectional observational study in 10 European countries. Int J Nurs Stud 50(2): 174-84. doi: 10.1016/j.ijnurstu.2012.09.019. Maben J, Griffiths P (2008) Nurses in society: starting the debate. National Nursing Research Unit, King’s College London, London. http://tinyurl.com/njq668e (accessed 15 December 2014) McCance T, Telford L, Wilson J, MacLeod O, Dowd A (2011) Identifying key performance indicators for nursing and midwifery using a consesus approach. J Clin Nurs 21(7-8): 1145-54
Christine Norton, Lesley Baillie, Angela Tod, Christi Deaton, Lesley Lowes, Debbie Carrick-Sen Florence Nightingale Foundation Professors of Clinical Nursing Research
Elizabeth Robb
Chief Executive, Florence Nightingale Foundation
© 2015 MA Healthcare Ltd
I
n the last issue of BJN (Deaton et al, 2014) we discussed the need for knowledge and evidence in nursing. However, there is a problem with definitions and outcome measures that demonstrate the value of the nursing contribution to patient care. While work has started to define ‘nurse-sensitive indicators’ (Griffiths et al, 2008) these focus on measuring what we can quantify: patient numbers, waits and length of stay, falls, pressure ulcers and infections. These are obviously very important, but our inability to articulate the value of nursing in relational aspects of care means that we are often focusing on preventing harms rather than doing good. When nurses are asked what is important to them, they vote overwhelmingly for personcentred care rather than more easily measured metrics (McCance et al, 2011). There has been little research trying to capture the value of nursing in terms of our core values and nursing’s unique contribution to patient care. Indeed, it is not clear that we even agree what constitute our core nursing values: are they the 6 Cs (Care, Compassion, Competence, Communication, Courage and Commitment); kindness, respect and dignity as in the new draft Nursing and Midwifery Council (NMC) code; or the NHS Constitution multidisciplinary values (respect, dignity, compassion, getting the basics right every time, improving lives and patient involvement)? It is a pity that these high-level values are not aligned. Many values are poorly defined and we are lacking a consensus on how to improve or measure them. Although academics have conducted concept analyses on some, practical operational definitions and agreement on what behaviours demonstrate the values are few. Indeed, they are maybe easier to identify if they are absent than present. For instance, dignity has been much talked about, with numerous recommendations, but attempts to measure it, or interventions with measurable outcomes, are lacking. We simply do not have evidence on what works (and just as importantly what does not work).There is a similar lack of evidence on interventions related to most of our other values. Does it matter that we cannot measure many of the core elements and values in nursing practice? Most are likely to be difficult to measure directly, but can be observed from behaviours.They are multi-factorial and require multidisciplinary behaviours. Additionally, nursing should not be the sole custodian of
British Journal of Nursing, 2015, Vol 24, No 1
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved.
