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Research project: State of the art metrics for nursing - Dormant - Dormant

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This report was commissioned from England's National Nursing Research Unit by the department of health to support the nursing contribution to Lord Darzi's next stage review of the NHS. It considers possible outcome indicators for nursing, the criteria for good metrics and the evidence base for currently proposed / implemented indicators. It concludes by making a number of recommendations including identifying 'best bets' for future development of metrics based on nurse sensitive outcome indicators and a call for the RCN and others to facilitate a nursing quality coalition.

The Next Stage Review committed to quality measurement that reflects the compassion, safety and effectiveness of nursing care. As such measurement provides both a challenge and an opportunity for the profession, this report reviews ‘state of the art' nursing quality measurement.

Many possible indicators and existing indicator sets measure nursing's contributions. Among the most widely used indicators are safety measures such as failure to rescue (death among patients with treatable complications), falls, healthcare associated infection and pressure ulcers. Neither effectiveness (positive contributions to well-being) nor compassion (elements of patient experience) are strongly represented in the existing measures.

We did not set out to focus specifically on acute general inpatient nursing care, but examples from this setting dominate both indicators and evidence reviewed because there has been more development in these areas. Many themes apply equally to other areas even if specific indicators differ, and the lessons learned in acute care can assist in developing indicators for all specialties and care settings.
To be useful, indicators must be measurable with available data at reasonable cost. There must be evidence that the quality or quantity of nursing substantially contributes to changes measured by the indicator. The indicator must be recognised as important (by the public, managers and nurses) and nursing's contribution must be recognised (by nurses and others).

Nurses must have responsibility for actions leading to outcomes in terms of legitimate authority, self-perception and sphere of practice. Measures should be chosen to minimise the risk of gaming, where improving performance on specific indicators detracts from overall improvement. Measures focussing on the performance of care (process) rather than outcome are most vulnerable to gaming.
Not all existing indicators meet these requirements, and considerable work will be needed to develop practical, valid and useful indicators. Strong evidence supports an association between nurse staffing levels and mortality, but mortality is determined by many causes and is not likely to be a useful quality measure for nursing.

This report identifies ‘best bets' for indicator development, including measures of safety, effectiveness and compassion. Health care providers should form a quality coalition, facilitated by stakeholders including the Royal College of Nursing and The NHS Confederation, to share best practices and to move toward standard measurement of important nursing indicators. A programme of indicator development must include development of technical specifications for indicators, research to validate them and, crucially, patient involvement in identifying metrics for compassion. State of the art metrics: A rapid appraisal 

Project team

Peter Griffiths

Project Funder

Department of Health Policy Research Programme



Associated research themes

 Workforce: re-configurations and enabling and measuring workforce effectiveness

Related research groups

Health Work and Systems
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