CLINICAL CLIPS

Nursing-Sensitive Indicators: Their Rolein Perianesthesia CareBarbara Godden, MHS, RN, CPAN, CAPA

Background

THE AMERICAN SOCIETY of PeriAnesthesia

Nurses (ASPAN) Clinical Practice network receives

a significant number of questions related to

nursing-sensitive indicators. The clinicians usually

ask whether there are any specific indicators forthe perianesthesia care areas, and if not, how

one should participate in the collection of data in

what appear to be clinical practice concerns not

usually associated with perianesthesia care. Facili-

ties are beginning to look at how to measure these

indicators in the pre- and postanesthesia care

units.

The History of Nursing-SensitiveIndicators

In themid-1990s, health care restructuring was un-

derway with cost-cutting measures, including a re-

duction in the number of registered nurses (RNs)

throughout health care facilities. Much of the

cost cutting stemmed from a decrease in reim-

bursement rates from insurance and managedcare companies. The largest cost to health care

providers is traditionally the labor cost, which is

why registered nurses were replaced with less-

skilled personnel. The American Nurses Associa-

tion (ANA) began studying effects of the health

care restructuring on the quality of nursing care

and patient safety. This study led to research into

the specific elements of professional nursing thataffected patient outcomes.1 Early studies demon-

strated that the number of registered nurses di-

Barbara Godden, MHS, RN, CPAN, CAPA, PACU Clinical

Nurse Coordinator, Sky Ridge Medical Center, Lone Tree, CO

and is the immediate past ASPANDirector for Clinical Practice

2008–2012.

Conflict of interest: None to report.

Address correspondence to Barbara Godden, 9320 Ermine-

dale Drive, Lone Tree, CO 80124; e-mail address: bagodden@

comcast.net.

� 2012 by American Society of PeriAnesthesia Nurses

1089-9472/$36.00

http://dx.doi.org/10.1016/j.jopan.2012.05.007

Journal of PeriAnesthesia Nursing, Vol 27, No 4 (August), 2012: pp 271-273

rectly affected patient outcomes in such areas as

pressure ulcers, pneumonia, and postoperative

infections. Furthermore, they found that these

complications proportionately decreased with an

increased number of professional registered

nurses.1

Creation of Nursing-Sensitive Indicators

Nursing-sensitive indicators were originally classi-

fied into seven categories. These original cate-

gories included the mix of RNs, licensed practicalnurses (LPNs), and unlicensed assistive personnel;

total number of nursing hours per patient day;

pressure ulcers; patient falls; nosocomial infec-

tions; patient satisfaction with pain management,

educational information, nursing care, and overall

care; and nurse satisfaction. The ANA determined

through studies that these factors directly affect

patient safety and patient outcomes.1 Further indi-cators have been added to include nursing turn-

over, pediatric pain assessment and intravenous

infiltration, psychiatric physical and sexual assault,

restraint use, RN education and certification, and

physical environment.2

New indicators are developed and added to the

National Database of Nursing-Sensitive QualityIndicators when it is determined that there may

be another indicator reflective of nursing’s contri-

bution to positive patient outcomes. The new indi-

cators are added through a formal process of

literature review, discussions with experts, pilot

studies, and further collection of data at pilot facil-

ities.2

Accountability and Outcomes

Payors and consumers look at accountability when

it comes to health care. Rising costs of health care

have led both payors and consumers to inquire

aboutwhat benefits and outcomes they can expect

when they enter the health care system.3 Health

care providers are in a race to demonstrate best

practice and outcomes in their facilities, and

271

272 BARBARA GODDEN

much of these data are now publicly reported. The

Magnet Recognition Program is a well-known pro-

gram that has incorporated evidence and clinical

outcomes as part of their requirements for creden-

tialing.3 Success with the Magnet designation in-corporates high patient and nurse satisfaction,

as well as excellent clinical outcomes,3 and the

Magnet designation demonstrates a level of excel-

lence available to the public.

Relevance to Perianesthesia Nursing

Nursing-sensitive indicators and metrics are a way

to measure what nurses, including perianesthesia

nurses, do.4 They demonstrate that professional

nurses make a difference in patient outcomes.

Facilities can measure such indicators as skill mix,

patient satisfaction with pain management, dis-charge information, nursing care, and overall expe-

rience. There are data to support that increased

numbers of registered nurses result in fewer events

related to ‘‘failing to rescue.’’ This data is especially

relevant in an environment such as the post-

anesthesia care unit (PACU), where ‘‘failing to res-

cue’’ would have potentially lethal results.4

Nursing care also involves a qualitative component,

and studies indicate that patient satisfaction highly

correlateswith compassionate aswell as competent

care.4 These type of data are most often collected

with routine patient satisfaction surveys. When sur-

vey results are shared with the clinical staff, nurses

canbecomemore engaged in the process of improv-

ing their own practice through benchmarking andlooking at best practice models.3,5 As a result,

patient outcomes can be enhanced.3

Nurse satisfaction is also measured in many peri-

anesthesia care units. Part of nurse satisfaction is

related to staffing levels, and studies conclude

that increased registered nurse staffing is related

to improved patient outcomes.6 Increased regis-

tered nurse staffing allows nurses more time

for assessments and appropriate and timely

interventions, thereby improving patient out-

comes.6 In addition, other studies indicate that

nurse scheduling plays a role in patient outcomes.7

The prevalence of 12-hour shifts along with addi-

tional responsibilities in a PACU, such as call shifts,

needs to be looked at when collecting data for pa-

tient outcomes. Fatigue is a factor that can affect

performance, including attention to critical infor-

mation as well as decision making in the clinical

arena. Hours worked, along with breaks, rest pe-

riods, and time away from work, are easy areas inwhich to collect data. There are methods and soft-

ware to analyze information collected on work

schedules and patient outcomes and mortality.7 A

supportive work environment with manageable

patient assignments and patient loads may also

contribute to positive patient outcomes.7 The

ASPAN Perianesthesia Nursing Standards and Prac-

tice Recommendations discuss appropriate andsafe staffing for all perianesthesia care areas.8

In perianesthesia nursing, many of the established

nursing-sensitive indicators are indeed relevant.These indicators include the mix of RNs, LPNs,

and unlicensed assistive personnel; total number

of nursing hours per patient day; patient satisfaction

with pain management, educational information,

nursing care, and overall care; and nurse satisfac-

tion. Data in these areas should be collected at the

unit level to make it more relevant. Evidence-based

information can then be used to support interven-tions for any specific improvements in processes

or care.6 Facility quality departments can assist in

collection, aswell as interpretationofdata that is col-

lected. Professional registered nurses do indeed

make adifference inpatient outcomes. Participation

in collection of nursing-sensitive indicator data as-

sists inprovidingevidence ofmaking a critical differ-

ence in the lives of patients.

References

1. American Nurses Association. ANA indicator history. Avail-

able at: http://www.nursingworld.org/MainMenuCategories/

ThePracticeofProfessionalNursing/PatientSafetyQuality/Research

-Measurement/The-National-Database/Nursing-Sensitive-Indicators_1

/ANA-Indicator-History. Accessed April 8, 2012.

2. American Nurses Association. Nursing-sensitive indica-

tors. Available at: http://www.nursingworld.org/MainMenu

Categories/ThePracticeofProfessionalNursing/PatientSafety

Quality/Research-Measurement/The-National-Database/Nursing

-Sensitive-Indicators_1.aspx. Accessed April 8, 2012.

3. Luzinski C. Empirical outcomes: Proof of making a differ-

ence. J Nurs Adm. 2012;42:185-186.

4. Foulkes M. Nursing metrics: Measuring quality in patient

care. Nurs Stand. 2011;25:40-45.

CLINICAL CLIPS 273

5. Haines S, Warren T. Staff and patient involvement in

benchmarking to improve care. Nurs Manag (Harrow).

2011;18:22-25.

6. Hart P, Davis N. Effects of nursing care and staff mix on pa-

tient outcomes within acute care nursing units. J Nurs Care

Qual. 2011;26:161-168.

7. Trinkoff A, Johantgen M, Storr C, Gurses A, Liang Y, Han K.

Nurses’ work schedule characteristics, nurse staffing, and

patient mortality. Nurs Res. 2011;60:1-8.

8. American Society of PeriAnesthesia Nurses. Peri-

anesthesia Nursing Standards and Practice Recommenda-

tions 2010-2012. Cherry Hill, NJ: ASPAN; 2010. pp. 68–71.