JOGNN
AW H O N N P O S I T I O N S T A T E M E N T
Nursing Care Quality Measurement
An official position statement of the Association of Women’s Health, Obstetric and Neonatal Nurses
Approved by the AWHONN Board of Directors November, 2013.
AWHONN 2000 L St. N.W., Suite 740 Washington, DC 20036 (800) 673-8499
Position he actions of nurses have significant effects on patient outcomes. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) asserts that measuring the quality of care that registered nurses provide to women throughout their lives, before, during, and after birth and to newborns is fundamental to the wellbeing of women and newborns. The nurse’s expert knowledge confers the authority to shape the care environment and to influence decisions of patients. Therefore, measuring the quality of nursing care is a necessary component of any effort to improve the overall quality of health care provided to women and newborns.
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lationships incorporate doing (physical work), being with (interaction), and knowing (relationship). Two predominant caring relationships comprise the greater part of nurses’ work. Independent relationships include patient/family–nurse interactions that the nurse initiates autonomously and for which he/she is solely held accountable (nursing discipline-specific). Placing a healthy newborn skin-to-skin with a healthy mother immediately following birth is an example of an independent relationship. Collaborative relationships include activities and responsibilities that nurses share with the healthcare team (multidisciplinary). Titrating the oxytocin infusion according to protocol for a woman in labor is an example of a collaborative relationship.
Background Because nurses represent the largest group of health professionals in the United States, effective quality measurement must account for their actions. Currently, the contribution and significance of nursing practice to overall patient outcomes is not well recognized or well documented, especially in the areas of women’s health and perinatal nursing. The development of quality measures is a dynamic, multi-step endeavor. Quality measures must be patient-centered; the needs of the patient and evidence-based clinical practice must determine a measure’s specifications and exclusions. Research outlined in AWHONN’s evidencebased clinical practice guidelines (EBGs), practice standards, and scholarly journals provides clinical practice recommendations for the development of nursing care quality (NCQ) measures. The Quality Caring Model is the theoretical framework that guides AWHONN’s work in developing NCQ measures. This model demonstrates the value of nursing practice within the evidencebased practice milieu of modern health care (Duffy & Hoskins, 2003). Duffy and Hoskins described the core or essence of the work nurses do as caring relationships, specifically human interactions grounded in clinical caring processes. Caring re-
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Because nurses work independently and collaboratively, “their contributions to patient outcomes are simultaneously unique and shared” (Duffy & Hoskins, 2003, p. 83). The role of the nurse is to maintain appropriate balance between these complementary professional relationships while keeping patient needs as a central focus. In so doing, the nurse becomes “the link between the patient, the health care team and the unseen possibilities known as outcomes” (Duffy & Hoskins, 2003, p. 83). The professional nurse’s caring relationships foster positive outcomes in patients and families, in members of the health care team, and in the system. According to the Institute of Medicine, there is a healthcare quality chasm in the United States (2001). Measuring the quality of nursing care is an essential part of measuring the quality of the health care provided to patients because the caring relationships embedded in nursing practice are key, independent factors affecting outcomes. The presence and perspective of nurses in the course of surveillance, assessment, and intervention and the ability of nurses to mobilize the healthcare team enable them to identify, track, and reduce errors and to improve the quality of patient care (National Council of State Boards of Nursing, 2010).
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
AW H O N N P O S I T I O N S T A T E M E N T
Historically, the profession of nursing in the United States has faced a difficult dichotomy: nurses accepted the duty to care but did not fully recognize their right to establish and define the work of nursing. The consequences of this dichotomy continue even today, albeit to a lesser degree. Some nurses are challenged to see themselves as independent professionals; some are uninformed about the parameters of their independent practice. Rather than remaining in the background, hard to discern, or invisible, the work of nurses must be brought to the foreground so that nursing practices may be assessed and measured with clarity and accountability. AWHONN’s development of NCQ measures (AWHONN, 2013) will help nurses to identify the impact of evidence-based independent nursing practice on the quality of care that their patients receive from the healthcare team. Independent nursing practice is primary to quality care; collaborative nursing practice maintains quality care; and a balance between independent and collaborative nursing practice ensures quality care.
The Impact of NCQ Measures on Nurses Measures of independent nursing practice will teach nurses about the boundaries of their discipline-specific clinical work so that they can incorporate appropriate evidence-based practice into patient care promptly, without undue deliberation or hesitation. In addition, increased awareness of their independent clinical work will assist nurses to establish the appropriate balance between their autonomous and collaborative practices within each patient encounter. Measures of independent nursing practice will promote awareness about the value and significance of high quality nursing care for women and newborns. Currently, many staff nurses and managers do not see quality improvement as relevant or integral to their work. When measures are developed to demonstrate the positive outcomes of nursing practice, nurses are more likely to commit to quality improvement endeavors and to gain satisfaction from quality improvement efforts. Measures of independent nursing practice will increase nurses’ consciousness of accountability and motivation to identify,
JOGNN 2014; Vol. 43, Issue 1
acknowledge, and more fully accept a professional identity.
Recommendations A quality measure is not change, rather it is a framework for change, a path to better patient outcomes, and a means to make what is essential and possible a reality. For this reason, AWHONN affirms the goal of quality measurement: every woman and every infant will receive the highest quality, evidence-based care. We cannot know what is possible to achieve unless we endeavor to achieve perfection. For example, only a few years ago it seemed impossible for one year to pass without a central line infection on a neonatal intensive care unit (NICU). Yet now hospitals report no such infections for several years. There are no benchmarks for the AWHONN NCQ measures under development; it takes many years for benchmarks to be established. But even after benchmarks are established, AWHONN will continue to encourage all nurses to strive beyond benchmarks and make steady progress toward the goal that every woman and every infant has equal access to the highest quality, evidencebased care. Currently, the contribution and significance of nursing practice to overall patient outcomes is not well recognized or well documented. Other organizations that are working on women’s health and perinatal NCQ measures are encouraged to contact and collaborate with AWHONN. To ease the burden of data collection, AWHONN recommends that the electronic medical record charting programs be modified to incorporate and standardize the key components of nursing care. NCQ measures are necessary components of local and national efforts to monitor and improve the quality of nursing care for women and newborns in the United States. Measuring nursing care will ultimately lead to better patient outcomes.
REFERENCES Association of Women’s Health, Obstetric and Neonatal Nurses. (2013). Women’s health and perinatal nursing care quality draft measures specifications. Washington, DC: Author. Duffy, J.R. & Hoskins, L.M. (2003). The quality caring model: Blending dual paradigms. Advances in Nursing Science, 26(1), 77–88. Institute of Medicine Committee on Quality of Health Care in America. (2001). Crossing the quality chasm. Washington, DC: National Academies Press. National Council of State Boards of Nursing. (2010). Nursing pathways for patient safety. St. Louis, MO: Mosby.
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AW H O N N P O S I T I O N S T A T E M E N T
Nursing Care Quality Measurement
An official position statement of the Association of Women’s Health, Obstetric and Neonatal Nurses
Approved by the AWHONN Board of Directors November, 2013.
AWHONN 2000 L St. N.W., Suite 740 Washington, DC 20036 (800) 673-8499
Position he actions of nurses have significant effects on patient outcomes. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) asserts that measuring the quality of care that registered nurses provide to women throughout their lives, before, during, and after birth and to newborns is fundamental to the wellbeing of women and newborns. The nurse’s expert knowledge confers the authority to shape the care environment and to influence decisions of patients. Therefore, measuring the quality of nursing care is a necessary component of any effort to improve the overall quality of health care provided to women and newborns.
T
lationships incorporate doing (physical work), being with (interaction), and knowing (relationship). Two predominant caring relationships comprise the greater part of nurses’ work. Independent relationships include patient/family–nurse interactions that the nurse initiates autonomously and for which he/she is solely held accountable (nursing discipline-specific). Placing a healthy newborn skin-to-skin with a healthy mother immediately following birth is an example of an independent relationship. Collaborative relationships include activities and responsibilities that nurses share with the healthcare team (multidisciplinary). Titrating the oxytocin infusion according to protocol for a woman in labor is an example of a collaborative relationship.
Background Because nurses represent the largest group of health professionals in the United States, effective quality measurement must account for their actions. Currently, the contribution and significance of nursing practice to overall patient outcomes is not well recognized or well documented, especially in the areas of women’s health and perinatal nursing. The development of quality measures is a dynamic, multi-step endeavor. Quality measures must be patient-centered; the needs of the patient and evidence-based clinical practice must determine a measure’s specifications and exclusions. Research outlined in AWHONN’s evidencebased clinical practice guidelines (EBGs), practice standards, and scholarly journals provides clinical practice recommendations for the development of nursing care quality (NCQ) measures. The Quality Caring Model is the theoretical framework that guides AWHONN’s work in developing NCQ measures. This model demonstrates the value of nursing practice within the evidencebased practice milieu of modern health care (Duffy & Hoskins, 2003). Duffy and Hoskins described the core or essence of the work nurses do as caring relationships, specifically human interactions grounded in clinical caring processes. Caring re-
132
Because nurses work independently and collaboratively, “their contributions to patient outcomes are simultaneously unique and shared” (Duffy & Hoskins, 2003, p. 83). The role of the nurse is to maintain appropriate balance between these complementary professional relationships while keeping patient needs as a central focus. In so doing, the nurse becomes “the link between the patient, the health care team and the unseen possibilities known as outcomes” (Duffy & Hoskins, 2003, p. 83). The professional nurse’s caring relationships foster positive outcomes in patients and families, in members of the health care team, and in the system. According to the Institute of Medicine, there is a healthcare quality chasm in the United States (2001). Measuring the quality of nursing care is an essential part of measuring the quality of the health care provided to patients because the caring relationships embedded in nursing practice are key, independent factors affecting outcomes. The presence and perspective of nurses in the course of surveillance, assessment, and intervention and the ability of nurses to mobilize the healthcare team enable them to identify, track, and reduce errors and to improve the quality of patient care (National Council of State Boards of Nursing, 2010).
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
AW H O N N P O S I T I O N S T A T E M E N T
Historically, the profession of nursing in the United States has faced a difficult dichotomy: nurses accepted the duty to care but did not fully recognize their right to establish and define the work of nursing. The consequences of this dichotomy continue even today, albeit to a lesser degree. Some nurses are challenged to see themselves as independent professionals; some are uninformed about the parameters of their independent practice. Rather than remaining in the background, hard to discern, or invisible, the work of nurses must be brought to the foreground so that nursing practices may be assessed and measured with clarity and accountability. AWHONN’s development of NCQ measures (AWHONN, 2013) will help nurses to identify the impact of evidence-based independent nursing practice on the quality of care that their patients receive from the healthcare team. Independent nursing practice is primary to quality care; collaborative nursing practice maintains quality care; and a balance between independent and collaborative nursing practice ensures quality care.
The Impact of NCQ Measures on Nurses Measures of independent nursing practice will teach nurses about the boundaries of their discipline-specific clinical work so that they can incorporate appropriate evidence-based practice into patient care promptly, without undue deliberation or hesitation. In addition, increased awareness of their independent clinical work will assist nurses to establish the appropriate balance between their autonomous and collaborative practices within each patient encounter. Measures of independent nursing practice will promote awareness about the value and significance of high quality nursing care for women and newborns. Currently, many staff nurses and managers do not see quality improvement as relevant or integral to their work. When measures are developed to demonstrate the positive outcomes of nursing practice, nurses are more likely to commit to quality improvement endeavors and to gain satisfaction from quality improvement efforts. Measures of independent nursing practice will increase nurses’ consciousness of accountability and motivation to identify,
JOGNN 2014; Vol. 43, Issue 1
acknowledge, and more fully accept a professional identity.
Recommendations A quality measure is not change, rather it is a framework for change, a path to better patient outcomes, and a means to make what is essential and possible a reality. For this reason, AWHONN affirms the goal of quality measurement: every woman and every infant will receive the highest quality, evidence-based care. We cannot know what is possible to achieve unless we endeavor to achieve perfection. For example, only a few years ago it seemed impossible for one year to pass without a central line infection on a neonatal intensive care unit (NICU). Yet now hospitals report no such infections for several years. There are no benchmarks for the AWHONN NCQ measures under development; it takes many years for benchmarks to be established. But even after benchmarks are established, AWHONN will continue to encourage all nurses to strive beyond benchmarks and make steady progress toward the goal that every woman and every infant has equal access to the highest quality, evidencebased care. Currently, the contribution and significance of nursing practice to overall patient outcomes is not well recognized or well documented. Other organizations that are working on women’s health and perinatal NCQ measures are encouraged to contact and collaborate with AWHONN. To ease the burden of data collection, AWHONN recommends that the electronic medical record charting programs be modified to incorporate and standardize the key components of nursing care. NCQ measures are necessary components of local and national efforts to monitor and improve the quality of nursing care for women and newborns in the United States. Measuring nursing care will ultimately lead to better patient outcomes.
REFERENCES Association of Women’s Health, Obstetric and Neonatal Nurses. (2013). Women’s health and perinatal nursing care quality draft measures specifications. Washington, DC: Author. Duffy, J.R. & Hoskins, L.M. (2003). The quality caring model: Blending dual paradigms. Advances in Nursing Science, 26(1), 77–88. Institute of Medicine Committee on Quality of Health Care in America. (2001). Crossing the quality chasm. Washington, DC: National Academies Press. National Council of State Boards of Nursing. (2010). Nursing pathways for patient safety. St. Louis, MO: Mosby.
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