by by Joanne R. Duffy DNSc., RN, CCRN and
Denise M Korniewicz DNSc., RN, FAAN

Article originally published June, 2000

Introduction

Outcomes measurement is a mandate from accrediting organizations (1) that represents one aspect of evaluating quality. It is an important one, however, since outcomes measurements help form objective evidence about the results of the health care process. Outcomes measurements can provide unique insights into structural components and care processes that may influence quality. At present, there are many outcomes measures used in this manner; however, few of them represent nursing's specific and unique contribution to patient care. Typical outcomes indicators such as mortality, morbidity, and length of stay represent care provided by many healthcare disciplines. Nursing is the only healthcare discipline that cares for patients twenty four hours a day, seven days a week. As such, it seems plausible that nursing influences patient safety. Nursing, therefore, has a social and professional responsibility to provide evidence or data that helps to guide and improve care (2). While it is next to impossible to perfectly choose indicators that solely represent nursing, it is possible to choose indicators that have a theoretical link to nursing services (3).

To address this issue, the American Nurses Association (ANA) instituted the Nursing Care Report Card for Acute Care (4) in which ten specific quality indicators of nursing were developed and defined. According to Moore et. al., (5) "each of the indicators had a strong ideological connection to quality nursing care" (p. 49). These indicators and their operational definitions are listed in Table 1.

Table 1. ANA Nursing Quality Indicators and their Operational Definitions (6)

Nursing Quality Indicators	Operational Definitions
Nosocomial Infection Rate	The rate per 1000 patient acute care days at which patients develop clinically active bacteremia (as defined by CDC) in whom there is no evidence to suggest that infection was present or incubating at admission (using CDC differential criteria)*under development.
Patient Fall Rate	The rate at which patients fall during the course of their hospital stay per 1000 patient days.
Patient Satisfaction with Nursing Care	Patient opinion of care received from nursing staff during the hospital stay as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding key elements of nursing care services.
Patient Satisfaction with Pain Management	Patient opinion of how well nursing staff managed their pain as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding specific aspects of pain management.
Patient Satisfaction with Educational Information	Patient opinion of nursing staff efforts to educate them regarding their condition and care requirements as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding specific aspects of patient education activities.
Patient Satisfaction with Care	Patient opinion of the care received during the hospital stay as determined by scaled responses to a uniform series of questions designed to elicit patient views regarding global aspects of care.
Nursing Job Satisfaction	Job satisfaction expressed by nurses working in hospital settings as determined by scaled responses to a uniform series of questions designed to elicit nursing staff attitudes toward specific aspects of their employment situation.
Maintenance of Skin Integrity	Rate per 1000 patient days at which patients develop pressure ulcers (Grade I or greater) during the course of their hospital stay, but, 72 hours or more following their admission. Mix of RNs, LPNs, Unlicensed Staff Caring for Patients in Acute Care Settings: The ratios (expressed in FTEs) of registered nurses with direct patient care responsibilities to LPNs and unlicensed workers.
Total Nursing Care Hours Provided per Patient Day	Total number of hours worked by nursing staff with direct patient care responsibilities on acute care units per patient day.

A national database has been formed through the ANA whereby acute care organizations can voluntarily report their specific results and compare these to a national benchmark for each indicator. Many acute care organizations throughout the United States are now participating in this database. Such participation, however, presents many challenges for the professional nurse. The purpose of this article is to provide the nurse with beginning knowledge in outcomes measurement to help support the ongoing evaluation of patient safety and quality.