Hospitals today are collecting more and more clinical data to determine whether they're improving care. But improvements are often confined to what's being measured, and this may have unintended and even tragic consequences. Consider the following three examples.
First, the 5 Million Lives Campaign of the Institute for Healthcare Improvement (IHI) focuses on preventing several problems that involve nursing care, such as ventilator-associated pneumonia (VAP). I've heard nurses boast of achieving periods of "zero VAP" after their units adopted the IHI's recommendations, which include performing oral care and elevating the head of the bed to 30[degrees] or higher. But two ICU nurses in Massachusetts told me that their unit's rate of pressure ulcers increased after they adopted the recommended head-of-the-bed elevation. I've since asked nurses across the country whether they're seeing the same thing, and I have yet to be told no. These are only anecdotes, and IHI vice president Pat Rutherford told me that some hospitals have reduced both VAP and pressure ulcer rates to zero, a campaign aim. Still, these accounts raise a nagging question: are nurses monitoring the unintended consequences of targeted improvements in care?
Second, last year a nurse noted on a listserv that her hospital is participating in the IHI's campaign to reduce the number of falls. On her unit, she wrote, patients at high risk for falling may be kept in bed because there aren't enough staff to walk with them. Of course, this unnecessary bed rest increases the risk of functional decline and complications such as pulmonary embolism. But no one is tracking the incidence of pulmonary embolism or assessing functional decline. (For more on assessing functional decline in older adults, see pages 52 and 64.)
Finally, in the October-December 2006 issue of the Journal of Nursing Care Quality, Beatrice Kalisch published findings of focus groups she held with 107 RNs, 15 LPNs, and 51 nurses' aides working in two hospitals. She found that the nursing care not being given to patients included discharge planning, teaching, ambulating, turning, and feeding, among other tasks that can have real consequences if not done. I learned many years ago during my brother's hospitalization for brain surgery that feeding a patient may not be a priority unless a tube feeding is "ordered." But who's counting? A missed tube feeding can be considered an error that is counted, but missed meals are seldom counted.
Are we keeping data on whether patients are fed or taught about self care? And why did we need the IHI to tell us to give oral care to patients on ventilators? Why aren't nurses responsible for determining what nursing care is best for patients? I know that nurses are ready for this responsibility. I've heard many enthusiastic reports of nurses developing evidence-based practices, whether by reviewing the literature or conducting their own studies when the literature is inconclusive. Regardless of your setting, consider the following.
Discuss with your colleagues the care you're not giving but ought to be. Analyze why, set priorities, examine the effect of the missed care, and explore options for ensuring that it's delivered. One nurse told me that her hospital has trained volunteers to help with ambulation and feeding.
Write to AJN with your creative solutions for ensuring that essential nursing care is provided and the evidence that they work ([email protected]). We'll publish the best in a future issue.
Ask about possible unintended outcomes when adopting a "best practice" and monitor those, as well.
Pay attention to policy implications. To date, the presidential candidates have focused almost exclusively on funding the current system rather than changing the kind and quality of the care given (see Policy and Politics, page 34). Talk with political candidates and policymakers about where nursing care figures into health care reform. Because if nurses don't talk about nursing, who will?