CLINICAL CLIPS

Nursing-Sensitive Indicators: Their Role

in Perianesthesia Care
Barbara 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 for
the 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. Facilities are beginning to look at how to measure these
indicators in the pre- and postanesthesia care
units.

The History of Nursing-Sensitive

Indicators
In the mid-1990s, health care restructuring was underway with cost-cutting measures, including a reduction in the number of registered nurses (RNs)
throughout health care facilities. Much of the
cost cutting stemmed from a decrease in reimbursement rates from insurance and managed
care companies. The largest cost to health care
providers is traditionally the labor cost, which is
why registered nurses were replaced with lessskilled personnel. The American Nurses Association (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 that
affected patient outcomes.1 Early studies demonstrated 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 ASPAN Director for Clinical Practice
20082012.
Conflict of interest: None to report.
Address correspondence to Barbara Godden, 9320 Erminedale 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 classified into seven categories. These original categories included the mix of RNs, licensed practical
nurses (LPNs), and unlicensed assistive personnel;
total number of nursing hours per patient day;
pressure ulcers; patient falls; nosocomial infections; 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 indicators have been added to include nursing turnover, 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 Quality
Indicators when it is determined that there may
be another indicator reflective of nursings contribution to positive patient outcomes. The new indicators are added through a formal process of
literature review, discussions with experts, pilot
studies, and further collection of data at pilot facilities.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
about what 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

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BARBARA GODDEN

272

much of these data are now publicly reported. The

Magnet Recognition Program is a well-known program that has incorporated evidence and clinical
outcomes as part of their requirements for credentialing.3 Success with the Magnet designation incorporates high patient and nurse satisfaction,
as well as excellent clinical outcomes,3 and the
Magnet designation demonstrates a level of excellence 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, discharge information, nursing care, and overall experience. 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 postanesthesia care unit (PACU), where failing to rescue would have potentially lethal results.4
Nursing care also involves a qualitative component,
and studies indicate that patient satisfaction highly
correlates with compassionate as well as competent
care.4 These type of data are most often collected
with routine patient satisfaction surveys. When survey results are shared with the clinical staff, nurses
can become more engaged in the process of improving their own practice through benchmarking and
looking at best practice models.3,5 As a result,
patient outcomes can be enhanced.3
Nurse satisfaction is also measured in many perianesthesia 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 outcomes.6 In addition, other studies indicate that
nurse scheduling plays a role in patient outcomes.7
The prevalence of 12-hour shifts along with additional responsibilities in a PACU, such as call shifts,
needs to be looked at when collecting data for patient outcomes. Fatigue is a factor that can affect
performance, including attention to critical information as well as decision making in the clinical
arena. Hours worked, along with breaks, rest periods, and time away from work, are easy areas in
which to collect data. There are methods and software 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 Practice Recommendations discuss appropriate and
safe 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 satisfaction. 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 interventions for any specific improvements in processes
or care.6 Facility quality departments can assist in
collection, as well as interpretation of data that is collected. Professional registered nurses do indeed
make a difference in patient outcomes. Participation
in collection of nursing-sensitive indicator data assists in providing evidence of making a critical difference in the lives of patients.

References
1. American Nurses Association. ANA indicator history. Available 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 indicators. 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 difference. J Nurs Adm. 2012;42:185-186.
4. Foulkes M. Nursing metrics: Measuring quality in patient
care. Nurs Stand. 2011;25:40-45.

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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 patient outcomes within acute care nursing units. J Nurs Care
Qual. 2011;26:161-168.

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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. Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ: ASPAN; 2010. pp. 6871.