Nurse Performance Metrics: A Scoping Review : JONA: The Journal of Nursing Administration

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Nurse Performance Metrics

A Scoping Review

DePesa, Christopher D. RN, MS; Jurgens, Corrine Y. PhD, RN, ANP, FAHA, FHFSA, FAAN; Lee, Christopher S. PhD, RN, FAHA, FAAN, FHFSA; O'Reilly-Jacob, Monica PhD, RN, FNP-BC

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JONA: The Journal of Nursing Administration 53(2):p 110-115, February 2023. | DOI: 10.1097/NNA.0000000000001251

Abstract

The measurement of nurse performance has been a subject of inquiry for decades among nurse scientists.1-4 However, researchers have primarily focused on assessing the impact of nurses collectively, at the unit, department, or hospital level.5-7 Measuring nurses in the aggregate limits the ability of nurse leaders to understand the effect of individual nurse attributes on patient outcomes.8 Recently, new metrics that capture the impact of an individual nurse on patient outcomes have been developed.9 The purpose of this scoping review is to identify and characterize what is known about measures of individual nurse performance.

Background

In 2004, the National Quality Forum (NQF) published a consensus report that created a framework in which nursing performance could be measured. Fifteen nursing-sensitive quality indictors to establish performance measures that could report the influence of nurses on patient care were proposed.10 The report recommended that future research focus on the relationship between patient outcomes, nurses, and their interactions.10 Nursing outcomes research, including studies published both before and after the NQF report, conceptualized nursing care as a collective variable and a component within the Donabedian model of outcome measurement.2,4,6

The Donabedian model asserts that high-quality clinical care is delivered when the appropriate personnel are given the appropriate resources.11 Nurses, when considered within this framework, are collectively part of the process and structure that influences patient outcomes.5 There is evidence from nursing outcomes research that there is a relationship between the quality of nursing care and patient mortality and adverse events.6,12 More specifically, research on nurse staffing suggests that higher nurse staffing levels are associated with decreased patient mortality.4 There also is a relationship between unit-level nurse characteristics (eg, level of education or experience) and patient-related adverse events.3,13 Collectively, the work of nurses has been examined, but the effect of an individual nurse is not well described.

There is a growing call to reexamine how nurse performance is evaluated and compensated.14,15 Recently developed methods that can calculate the value-added care of nurses allows managers to assess how nurses spend their time, including both with and without direct patient interaction.16 Value-added care has created the opportunity to more comprehensively design a workflow that maximizes activities which improve patient outcomes while minimizing activities that do not add value.17 These calculations of individual nurse value to both an organization and to patient care could inform a payment structure that appropriately compensates individual nurses based on the quality of their work.9 The development of these metrics also has both clinical and administrative implications for nurse leaders looking to tailor quality improvement efforts to the performance of an individual nurse to improve patient outcomes.18 There is an opportunity for nurse researchers to identify and develop metrics that capture the value of individual nurses that could benefit patients, hospital operations, and the nurses themselves.

Objectives

The purposes of this scoping review were: 1) to identify instances in the literature where measuring the influence of individual nurse performance was described and 2) to characterize those metrics in their applications and proposed uses.

Methods

Rationale for Scoping Review Methodology

Although there exists a robust body of research on aggregated nurse performance measures (at the unit or hospital level), there remains an opportunity to establish performance measures at the individual nurse level. A scoping review methodology, as described by the Joanna Briggs Institute, was selected to map the current state of the literature on individual nurse performance metrics.19 This methodological approach allowed the research team to be systematic in interrogating the literature while also affording researchers the flexibility to describe both the state of the science as well as the individual resulting items.19

Identification of Search Terms

The research team sought to identify documented examples of metrics used to measure the contribution of an individual nurse on a collective outcome. Because the focus of this review primarily concerns nurses, the team began by developing the appropriate search terms in the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Once a combination of terms was identified to deliver an appropriate number of search results, that sequence then was used with the other databases (SDC 1, https://links.lww.com/JONA/A985).

Search Strategy

The research team performed the searches in May 2022, and each search included the keywords nurse and performance and metrics. We used the following databases: CINAHL, PubMed, Scopus, and Web of Science. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) guideline to present the results of this scoping review.20 Researchers compiled each database search and deleted duplicate results. If an article was included for analysis, researchers screened its reference list to identify related material that may have been missed because of limitations associated with electronic database indexing.21

Eligibility Criteria

The research team limited this review to any type of English-language material published in an indexed journal, including research articles, opinion pieces, and conference presentations materials between January 2004 and May 2022, as the NQF introduced nurse-sensitive measures in 2004. Eligibility criteria required that materials address performance metrics at the level of individual nurse.

Data Abstraction

As described in Figure 1, the initial search yielded 1,350 sources, and after removing duplicates, the research team identified 879 items to be screened. The 879 items were screened, and 770 items that were deemed unrelated to the aim of the review were removed. The team then reviewed 108 manuscripts for whether the item's description of nurse performance could include metrics at the individual nurse level. Ninety-eight items were further excluded, with reasons documented in Figure 1, leaving 10 articles for analysis. After reviewing the reference lists of these final 10 items, the team included 2 additional articles that met the inclusion criteria, leaving 12 articles for inclusion.

F1
Figure 1:
Selection of sources of evidence.

The research team reviewed the selected items in depth, with a focus on the metrics described and their uses, both demonstrated and proposed. Given the nature of the aim of this review, the team considered any critical appraisal of the methodological quality irrelevant and excluded it.19 SDC 2, https://links.lww.com/JONA/A986 describes the information abstracted from each included publication, including: a) type of nurse being measured; b) clinical setting; c) whether the metric was proposed or described by the article; d) the name of the metric described; e) a description of the metric; and f) any proposed uses.

Results

The research team identified 12 articles that described individual nurse performance metrics published within the last 19 years across journals in the nursing, medical, and economic disciplines. The team classified 5 of them as empirical reports, 3 as quality improvement papers, and 4 as commentaries. In reviewing the 12 articles, we identified 3 themes: 1) individual nurse performance metrics as an emerging body of research; 2) variability among the metrics described; and 3) implications for evaluating nurse performance.

An Emerging Body of Research

The 1st theme addresses the relative recency of creating and using performance metrics that capture individual-level behavior. Articles described this line of inquiry as emerging or new,22-25 a result of a lack of previously available measures,26-28 and/or as a novel or innovative approach to performance evaluation.29 Of the 12 articles, 4 cite proposed metrics that have yet to be demonstrated in either a research or clinical setting and lack a specific description of how they were derived.22-24,30 This is further reflected in the variety of materials captured in the scoping methodology, including 4 articles that were neither reflections of research efforts or quality improvement projects.22,23,25,26 Furthermore, the search criteria ranged from 2004 to 2022, and in those 19 years, 11 of the 12 included articles were published within the most recent decade (SDC 3, https://links.lww.com/JONA/A987). The single exception, a research study examining the performance of a group of cardiac nurses when removing an arterial femoral sheath, did not have the primary aim of measuring individual nurse performance.31 Rather, the researchers analyzed performance at the individual level only to ensure that variability in mean group scores was not impacted by extreme individual scores.31

Nurse Metric Variability

Researchers identified wide variation in both the type of performance measured and in the nurse work environments.25-29,31-33 The types of nurse performance ranged from discrete, technical tasks, such as compliance with a protocol for arterial sheath removal31 or blood culture collection,33 to more global measures, such as value calculations that incorporated multiple patient outcomes29 and calculations that demonstrated individual variation in performance among nurses.25 The development of the metrics relied on a range of data, including survey data from coworkers and patients,26,27,32 retrospective review of the electronic medical record,25,29,33 and direct observation.31

The included papers also reflected a diverse range of clinical settings, including the emergency department,30,33 cardiac catheterization laboratory,31 inpatient mental health unit,27 and medical-surgical floors.29 Three of the articles focused on advanced practice nurses, such as nurse practitioners in the intensive care unit,26 certified nurse anesthetists in the perioperative department,32 and nurse midwives.28 In these varied clinical environments, the performance metrics reflected the skills and priorities of those specific settings. For example, in the mental health setting, individual nurses were measured on the basis of therapeutic engagement,27 a quality that is not a priority for nurses in the cardiac catheterization laboratory where performance can be evaluated on the basis of technical skills.31

Performance Implications

The 3rd theme describes how these data could improve nurse performance and, subsequently, patient care quality. Half of the included articles suggested direct education designed to adjust the performance of the individual nurse.27,28,30,31,33 Researchers again noted variability in how that education would be structured depending on the clinical setting, and the varied suggestions included delivering specific time-based metrics to nurses to improve length-of-stay in the emergency department,30 as well as reviewing how senior nurses spend their clinical and nonclinical time to improve organizational efficiency.28 Two articles focused on advanced-practice nurses and made specific recommendations to include the individual performance metrics as part of the clinician's ongoing professional practice evaluation (OPPE), mirroring the physician model for OPPE.26,32

Three articles proposed using the metrics to create new models of staffing and to reconsider compensation for the work of nurses.22,23,29 These proposals focused on better matching individual nurses to the acuity of their patients as well as staffing based on individual nurse performance rather than the traditional method of nurse ratios.23 The application of these suggested metrics calls for a reexamination of the current status quo in hospital staffing and consideration of a new framework for understanding nurse work and its effect on patient outcomes.29

Discussion

This scoping review is the 1st to document the emerging field of individual nurse performance metrics. The search criteria yielded 12 appropriate studies for inclusion, with most published since 2013 (SDC 2, https://links.lww.com/JONA/A986). The articles represent a variety of metrics used for specific clinical settings and initiatives. This growing body of research represents an opportunity for targeted education to improve clinical outcomes, as well as reevaluation of the traditional staffing approaches and reimbursement strategies currently used in hospitals. New, innovative data that capture the impact that an individual nurse on patient outcomes provide the framework for nurse leaders to improve their organizations by reconsidering how nursing care is measured.

There already exists a call for the development of individual nurse performance metrics, and this review demonstrates that efforts are already underway to derive them.9 Identifying individual variability and seeking a better understanding of why that variability exists, nurse leaders can create improved organization efficiency, workforce productivity, and improved quality of care.25 The nursing literature contains numerous studies in multiple clinical settings that demonstrate the work of nurses and its impact on patient outcomes.1,3,34 However, these studies measure nurses in aggregate, overlooking the individual qualities and characteristics each unique provider brings to patient care that could represent the next stage in quality improvement efforts.35 The traditional approach of following the Donabedian model, with nurses included as a group as part of the structure and process, has not identified a way for nurse researchers to move the field forward. The paucity of literature in this area, as revealed by this review, suggests that the conceptual development of individual nurse performance metrics may need to look beyond nursing science and into economic theory.

Human Capital Theory

Human capital is an economic variable that refers to an individual's acquired skill, inclusive of that person's education and experience.36 The theory of human capital assumes that, as one acquires more experience, their productivity increases, as does their added value toward an organization.37 By acknowledging that individual variation exists among nurses, nurse researchers can develop and refine metrics that capture that value to improve both individual and organizational productivity and efficiency.29 Rather than adding new staff to meet previously considered ratios or staffing guidelines, hospitals and departments can focus on investing in their existing nurses, delivering targeted education based on individual performance metrics and creating the conditions to accumulate experience to enhance their human capital.38 By considering an approach outside of the field of nursing science, nurse leaders have an opportunity to improve patient care delivery while also creating an environment that will retain nursing staff and possibly save costs.

Unintended Consequences

As with any innovation, using individual nurse performance metrics may undermine potential benefits. Two articles made specific mention of the potential of performance metrics to either exacerbate underlying inefficiencies within the healthcare system or to be misused by those motivated by financial targets without a fundamental understanding of the value of nurses.22,24 These authors noted the proliferation of electronic medical record–generated data and the likelihood of performance metrics becoming ubiquitous in nursing, including those that capture individual-level effects.22,24 The future in application of individual nurse performance metrics requires focus to avoid exploiting these data to serve primarily financial purposes rather than clinical ones.24 One author compared the advent of individual-level nurse performance metrics with “Pandora's box,” but noted that if nursing were central to development and application, the patients would benefit most.22

Limitations

There are several limitations to this scoping review. First, although researchers made efforts to create a comprehensive search strategy, it is possible that the search terms did not capture eligible articles. Given the nascent nature of this body of research, there could be terms that describe this phenomenon that were not identified. The authors of this particular review were interested in whether individual nurse performance metrics were described and not whether they were featured as a part of a research study, and some articles may have been missed because of the lack of description of the metrics in the abstracts.19 In addition, the review was performed during a specific date range, from 2004 to 2022, when it was thought that the development of these metrics would most likely appear in the literature. Because of the limited timeframe, any efforts to derive these metrics prior to then were not included. The team made an additional attempt to capture these efforts by reviewing the reference lists for applicable materials, but it is still possible that valid articles were excluded.

Conclusion

The purpose of this scoping review was to identify and characterize the study and application of individual nurse performance metrics. Twelve relevant articles were included, and 3 themes were identified: 1) this body of research is emerging; 2) there is variability in how metrics are derived and interpreted; and 3) these metrics can be used to improve nurse performance. The findings of this study demonstrate the need for further efforts for nurse researchers to work with nurse leaders and staff nurses to create metrics that capture the impact of individual nurses on patient outcomes.

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