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Wanted: Nursing-Sensitive Indicators in Nephrology Settings
by ANNA President Sandra Bodin
I
first read about ‘Nursing-Sensitive Indicators’ while searching for
evidence based data on the difference registered nurses (RNs) make in
the quality outcomes and safety of nephrology patients. I certainly
believe that care delivered by RNs leads to improved outcomes and
safety for nephrology patients, but I want to have the evidence to
verify it to others. ANA’s Nursing-Sensitive Quality Indicators
Nursing-sensitive
quality indicators are defined as those that “capture care or its
outcomes most affected by nursing care” (American Nurses Association
[ANA], 1999, p. 4). The ANA (2002) has identified 10 nursing-sensitive
quality indicators for acute care settings and 10 for community-based,
non-acute care settings.
Acute care settings. The nursing-sensitive quality indicators for acute care settings have been identified as:
- patient satisfaction with pain management, nursing care, overall care, and educational information,
- pressure ulcers,
- patient falls,
- nurse satisfaction,
- nosocomial infection rate,
- direct care staffing mix, and
- total nursing care hours per patient per day (ANA, 1999).
Community-based settings. Nursing-sensitive quality indicators for community-based settings include:
- pain management,
- staff mix,
- consistency of communication,
- client satisfaction,
- prevention of tobacco use,
- cardiovascular risk reduction,
- caregiver activity,
- activities of daily living, and
- psychosocial interaction (ANA, 2002).
National awareness.
Many groups and organizations are becoming interested in this issue.
Awareness of nursing-sensitive indicators is stimulating government
agencies and accrediting organizations to collect data on them. The
National Quality Forum (NQF) is a private, not-for-profit membership
organization created to develop and implement a national strategy for
healthcare quality. The NQF recognizes that nurses, as the principal
caregivers in any healthcare system, directly and profoundly affect the
lives of patients and are critical to the quality of care patients
receive. NQF is leading an effort to understand more fully the extent
to which nurses contribute to improved patient safety and healthcare
outcomes and has developed a Nursing-Sensitive Care Performance
Measures Set of 15 indicators. (NQF, 2004). The Joint Commission is
advancing these measures by funding a performance measurement project
and has recruited volunteer hospitals that are interested in testing
the NQF developed Nursing-Sensitive Care Performance Measures (Joint
Commission, 2007).
Nephrology Nursing-Sensitive Indicators
IDespite
the fact that patients with kidney disease receive much of their care
in both acute and ambulatory settings, there still have been no
specific studies on nephrology nursing and the difference RNs make for
patients with kidney disease. While there has been little or no
attention to nursing-sensitive quality indicators in dialysis
facilities, there is growing evidence that adverse outcomes in patients
on dialysis may be sensitive to RN staffing and care.
To illustrate, in one study of patients on dialysis, at least 50% of
the patients reported problems with pain management (Davison, 2003).
The etiology of pain in these patients is arthritis, neuropathy,
peripheral vascular disease, calciphylaxis and dialysis related
discomfort. A study of patients on dialysis that includes routine
nursing assessment of pain could lead to further research and the
identification of nursing-sensitive outcomes in pain management. Other
studies have shown that falls with injury in the dialysis population
are occurring with increased frequency. (Cook & Jassat, 2005;
Desmet, Beguin, Swine, Jadoul, & Universite Catholique de Louvain
Collaborative Group, 2005). Injuries from falls can be debilitating and
frequently result in a long and difficult recovery period. We need a
definitive study of nursing-sensitive indicators in the prevention of
falls in patients on dialysis. Can you imagine what a difference having
this data could mean if it leads to evidence-based nurse staffing and
improved patient safety?
Fortunately, researchers are beginning to look at these concepts in
relation to patients with kidney disease. ANNA has provided funding in
the form of a research grant for a comprehensive research study
entitled, “The Work Environment and Nurse-Reported Outcomes in Dialysis
Centers” conducted by principal investigators Charlotte Thomas-Hawkins
and Linda Flynn, both faculty members at Rutgers University School of
Nursing. I am enthusiastically anticipating the publication of this
first study of nursing-sensitive quality indicators in a future issue
of Nephrology Nursing Journal. I am hopeful that this research will
stimulate additional nursing-sensitive quality indicator studies in
nephrology settings. A similar study is already underway at UCLA. The
UCLA/VA Center for Outcomes Research and Education is in the process of
analyzing survey results from their Best Practices in Dialysis Study.
The principle investigator, Brennan Spiegel, MD, MSHS, wrote that
preliminary results were amazing in that responses to one topic — the
importance of nursing care — were remarkably consistent. As with the
ANNA-funded study, results from UCLA will be available later this year.
Conclusion
It is important that nephrology nurses are able to speak about
nursing-sensitive quality indicators specific to nephrology settings.
We can say repeatedly that we believe the quality of care that
nephrology patients receive is dependent on nursing care; however,
having confirmed data on the achieved outcomes due to nephrology nurses
is the evidence we need to validate it.
Sandra Bodin, MA, RN, CNN
ANNA President
Member, Gitchee Gumee Chapter
References
American
Nurses Association. (1999). Nursing-sensitive quality indicators for
acute care settings and ANA’s safety and quality initiative. Washington
DC: Author. Retrieved June 24, 2007 from
http://www.nursingworld.org/readroom/fssafe99.htm
American Nurses Association. (2002). Nursing-sensitive indicators for
community-based non-acute care settings and ANA’s safety and quality
initiative. Washington, DC: Author. Retrieved June 24, 2007 from
http://www.nursingworld.org/readroom/ nurssens.htm
Cook, W.L. & Jassat, S.V. (2005). Prevalence of falls among seniors
maintained on hemodialysis. International Urology and Nephrology, 37,
649-652.
Davison, S.N. (2003) Pain in hemodialysis patients: Prevalence, cause,
severity and management. American Journal of Kidney Diseases, 42,
1239-1247.
Desmet, C., Beguin, C., Swine, C., Jadoul, M., & Universite
Catholique de Louvain Collaborative Group. (2005) Falls in hemodialysis
patients: Prospective study of incidence, risk factors and
complications. American Journal of Kidney Diseases, 45, 148-153.
National Quality Forum. (2004) National voluntary consensus standards
for nursing-sensitive care: An initial performance measure set.
Washington, DC: Author. Retrieved June 24, 2007 from
http://www.qualityforum.org/projects/completed/nursing/index.asp
The Joint Commission. (2007). Joint Commission testing and national
implementation of the fifteen National Quality Forum (NQF) endorsed
nursing-sensitive care (NSC) performance measures. Oakbrook Terrace,
IL: Author. Retrieved June 24, 2007 from
http://www.jointcommission.org/PerformanceMeas
urement/CallsforParticipation/cop_nscm.htm
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