All nurses aren’t the same. Is it time to stop measuring them like they are?

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Nurse writing on clipboard next to patient in bed

The way nurses are evaluated could be heading for a change.  

“Think about it, in our healthcare system nursing care is counted like sheets or meals,” said University of Michigan School of Nursing Associate Professor OIga Yakusheva, Ph.D. “I think it undervalues nurses. I’m trying to break through the stereotype that ‘a nurse is a nurse is a nurse.’”

Currently, most health care professions, such as physicians, are evaluated individually. However, nurses are usually assessed by unit-level staffing measures. Nursing care is billed to insurance companies on a per-day basis as part of the room rate.Olga Yakusheva

Yakusheva readily acknowledges that nursing care is complex and has intrinsic team-based characteristics. However, she believes current evaluation methods are symbolic of outdated views of nurses as physician helpers, not as well-educated co-leaders of modern patient-care teams who have the ability to make notable impacts on patient outcomes. “If all nurses provided care in the same way, we would not have found differences between individual nurses--but we did.”

“If nurses want to be viewed as equal partners with other health care professionals, we have to be able to have accountability – and credit – for individual nurse’s performance,” said Yakusheva. “Health systems have spent a tremendous amount of effort on quality and safety initiatives, like education and evidence-based practice, but there is a ceiling effect where it’s hard to make high-quality care better. But low-value care still exists and can be improved; it’s the low performers that now need to be pulled up. We can standardize care as much as possible but as long as there is clinician level variability, some patients will receive excellent care and some will be inadvertently exposed to below-average care.”

Yakusheva and a team of researchers examined the productivity of nurses preparing patients for discharge and relationships to a readmission or emergency room visit within 30 days. They found “individual nurse effects explain almost 10 percent of patient-level variability in readiness for hospital discharge… and patients of higher productivity nurses were less likely to return to the hospital.” The study is published in Medical Care.

The data set included more than 500 nurses caring for almost 30,000 patients in 31 medical-surgical units across the United States. The researchers made adjustments for patient characteristics such as age, severity of illness, diagnoses, and complications, and hospitalization characteristics such as the length of hospital stay and previous hospitalizations. In addition, each nurse’s productivity was measured over an 8-month period and tested in two independent patient samples to confirm the results.

Yakusheva is prepared for resistance to the new approach, including from nurses themselves.  

“There could be a lot of reasons why a nurse may have lower results,” Yakusheva explained. “Maybe there is something about the environment that is not working for the nurse. There may be high levels of stress and burnout. People respond differently to those types of factors. We need to learn from high performers, and also identify how we can help lower-performing nurses to improve.”

Yakusheva compares the strategy to grading college students.

“When we see a student who is scoring lower than others, it is our duty as educators to reach out, try to find out why and then do what we can to help,” she said. “Health systems have a similar responsibility to their staff. It should not be only the nurses themselves.”

She hopes that nurses will also look deeply into their own practice for individual opportunities to embrace high performance and improve low performance.   

“Nurses are the most trusted profession. With that comes personal responsibility. In the end, patients and their families are the ultimate beneficiaries here.”