R I l Editorial

A scientific look at nursing activities and patient outcomes At first glance, the results of the AORN-WICHE (Western Interstate Commission for Higher Education) study might be considered disap- pointing. The study, which is reported in this Journal, was designed to explore the relation- ship between selected nursing activities in the preoperative, intraoperative, and post- operative periods and the patient’s health status in the immediate and early post- operative period.

In other words, how does what operating room nurses do affect the patient’s well-being or lack of it after surgery? Nurses in 25 hospi- tals collected information about their activities and patient outcomes. The material was then handed over to the computer for a statistical analysis. On the basis of this analysis, the researchers hadto conclude that there was no significant relationship between OR nursing activities and patient outcomes.

That’s what the study showed, but do you believe that? Common sense tells you that it isn’t true. For example, the lack of one sponge count that results in one sponge left in a patient has a strong potential for causing a significant negative outcome.

Even though a research project may not produce a positive desired result or a hoped- for proof of hypothesis, it often uncovers valu- able information and indicates the direction for future study. Perhaps the important thing to look at is why the Study did not show a signifi- cant relationship between nursing activities and patient outcomes.

For one, the researchers found that not enough is known about nursing activities to determine which are significant and related to quality nursing care. Through brainstorming sessions and literature review, the research- ers determined 151 significant nursing ac- tivities, which they subsequently narrowed down to 28, then 10. They carefully defined these activities. This was an accomplishment in itself, but the defined activities didn’t yield the results they had hoped. At the end of the study, they had to conclude that a first priority for any future work was determining what con- stitutes a goal-directed nursing activity, and once you have done that, how do you measure it in terms of quality.

The study identified two factors that did have a strong influence on the patient’s health status after surgery. One was the size of the hospital, and the other was the patient himself. The researchers surmised that nurses might be surprised to find out that the larger the hos- pital the less likely the patient is to be the recipient of some of the components consid- ered part of quality nursing care. The patient is less likely to have a preoperative interview or preoperative teaching and receives less phys- ical and psychological support. Although he probably won’t know it, a sponge count is less likely to be done and the scrub at the surgical site will be performed with more haste. He is more likely to experience some soreness of larynx in the recovery room, and later he is more likely to notice some bruises or stiffness and some coughing.

This appears to support the theory that smal- ler, community hospitals provide better patient care. It also pointed out to the investigators that when you look at the relationship between nursing activity and patient outcome, you have

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to also look at the structure, or the hospital environment itself.

The study also revealed that the patient himself has more impact on his health status outcome than nursing activity. A postoperative cough may well have been present before the patient came to surgery. The researchers point out the need to establish baseline data for the patient preoperatively. But this can require more than simple observation. Operating room nurses have always been concerned with doing everything possible to reduce the possi- bility of a wound infection, and yet it is recog- nized that the most critical factor in post- operative wound infection is the patient’s own ability to resist infection. As the researchers comment, patient influence on outcome “seems like common sense,” but it is usually not considered in evaluating nursing care.

This study is significant in that it is the first attempt to take a scientific look at the broad scope of activities of the OR nurse and relate them to patient outcomes. There are certainly many pressures on nursing to prove that its role is important in terms of quality patient care.

But there is some question in my mind about whether scientific research can be the only approach. Perhaps nursing effectiveness cannot be measureg by the cold, mathematical statistical analysis. Is there a direct, measur- able relationship between nursing activities and patient outcomes?

This study certainly showed the difficulty of isolating nursing activities from the influence of other factors. In addition to the hospital struc- ture and the individual patient, it is also appar- ent that the surgeon, anesthesiologist, and others on the surgical team are going to influ- ence patient outcomes. For example, in wound healing, surgical technique is another factor that might have more impact on outcome than any nursing activity.

One accomplishment of the study is that data-gathering tools for measuring nursing ac- tivities and patient outcomes have been de- veloped. Although they need revision and further refinement, they provide an important basis for further research.

One of the long-term goals of the study was to develop outcome criteria for operating room nurses to use as guidelines in developing methods of evaluating nursing care. Although

operating room nurses have been working on process criteria for evaluating care, they were interested in looking at outcome criteria as well. Outcomes have some distinct advan- tages; for example, they are easier and less expensive to measure. Yet operating room nurses weren’t sure that outcome measures could be developed for OR nursing.

Despite the inherent difficulties in determin- ing patient outcome measures for OR nursing, the AORN Nursing Audit Committee has for- mulated some guidelines for outcome audit, which are published in this issue. The commit- tee cautions that these are only a beginning step in the development of accurate meas- urement tools. They are a starting point for OR nurses who are looking to developing outcome audit for their particular surgical suite. The next step is for nurses to adapt these guidelines to their own setting and find out if these crite- ria can be used to determine the quality of nursing .

Both the report and the guidelines represent progress toward development of outcome criteria for evaluating quality patient care. They are a starting point.

Elinor S Schrader Editor

CE programs for nurses Seven programs to assist nurses in changing their practice or increasing their expertise in specific areas have been announced by the Continuing Education in Nursing Unit at the University of California, San Francisco (UCSF) School of Nursing.

The programs, ranging from one to three years in length, are community health nurse preparation program, family planning nurse program, nurse clinician certificate program, rehabilitation nurse clinician program, occupational health nurse certificate program, school nurse preparation program, and the preparation of nurse leaders in cancer nursing program. Individual courses of study can be arranged to meet personal learning objectives.

For application or more information, contact Maura C Carroll, UCSF Continuing Education in Nursing, San Francisco, Calif 94143.

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