A challenge of being a nurse researcher studying how nurses, and specifically nurse staffing, during labor and birth influence outcomes is that nursing care is billed as part of the hospital's room and board charge. Patients stay in the hospital when they need nursing care. If a medical condition or procedure does not need associated nursing care, it is done on an outpatient basis. When procedures are done by providers (using this term for clinicians whose care can be billed for) and equipment and supplies are used, a code is generated in the electronic health record (EHR) to link them with a patient charge. One of the purposes of the EHR is to produce billed charges, which can be found when searching various codes in administrative EHR data that clinicians rarely see. Bundling nursing care into hospital charges for room, food, bed, housekeeping, maintenance, and the like is not helpful for researchers studying nursing care relative to patient outcomes.

Outcomes can be studied in other ways, but evidence is lacking on direct links between patient outcomes and nursing care. Some attempts to link care with outcomes have used various markers or proxies for care including nursing documentation in the EHR; however, this method has major limitations as much of nursing documentation is done remotely rather than at the bedside, is rarely done in real-time, and some data such as vital signs are transmitted automatically into the EHR from devices attached to patients without nursing assessment or validation. Documentation may identify the responsible nurse but does not measure bedside nurse attendance and care.

Some quality indicators do not lend themselves to being nurse-sensitive. For example, physicians or nurse midwives, rather than nurses, make the decision about whether a woman has a cesarean birth. Evidence supports nurses promoting vaginal birth, often through a series of countermeasures that are designed to directly or indirectly influence physicians' decisions away from a cesarean (Edmonds & Jones, 2013; James et al., 2003; Simpson & Lyndon, 2017). These include asking for more time to allow labor progression, preparing the woman to speak up for herself, advocating, not being completely transparent about when complete cervical dilation has been reached (to avoid pushing until conditions are favorable), and at times avoiding or delaying communication with the provider. The hospital where women give birth is a major determinant in whether they have a vaginal birth (Grobman et al., 2014). That is primarily because hospitals are where the physicians are who decide a woman should have a cesarean birth. Consensus has not been established on methods to attribute cesarean birth to physicians; for example, is it the person who makes the decision, performs the surgery, or the physician of record? Nurses are not the decision-makers for cesareans; therefore, cesarean birth is not a nurse-sensitive quality indicator. Attributing cesareans (and the associated implications of blame) to labor nurses does not make sense and should not be done. A unit-based cesarean rate that reflects the collective culture of the perinatal team is more appropriate and useful.

Ability to accurately and reliably measure nursing care and link with patient outcomes is a safety issue. The type and dose of nursing care that is required for optimal outcomes must be established as part of the body of evidence to support safe nurse staffing. More work is needed to identify nurse-sensitive measures in maternity, neonatal, and pediatric nursing settings.

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