Greetings from your President. As we prepare for the coming holiday season, a traditional time to celebrate giving and caring, it is appropriate that we contemplate the nature of our care. Nurses are instantly recognized as quality caregivers. Even the name of our profession promises we care. Wiedenbach (1964), an early advanced practice nursing leader, articulated the dichotomous nature of caring, describing it as both an art and a science. Artists do not need to defend their art; they simply display it. Scientists, however, need to show the evidence. Historically, nursing has struggled with the challenge of finding that evidence and documenting the outcomes of quality nursing care.
Nursing outcomes as defined by the International Council of Nurses are the “measure or status of a nursing diagnosis at points in time after a nursing intervention, while nurse sensitive outcomes are defined as changes in health status upon which nursing care has had a direct effect” (International Council of Nurses, 2001). Quality of care has been a buzzword since the 1960s. In response to the need to measure quality, Donabedian (1966) proposed a model that divides quality into three measurable parts: structure, process, and outcomes. This model became the foundation for the federal government's continuous quality improvement initiatives. The Institute of Medicine defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge,” which provides direction for all health care practitioners (2001, p. 232).
It is not enough to provide quality care to children and families. Pediatric nurse practitioners (PNPs) and other providers need to quantify that care. Two recent extensive reviews of nursing outcome research (Ingersoll, 2009, Kleinpell, 2009) note that many studies have positively compared the care provided by advanced practice nurses (APNs) to other health care providers. However, fewer studies have attempted to identify the unique contributions or the specific outcomes directly related to care provided by APNs. Now, more than ever, it is imperative to continue to discuss care in terms of outcomes—consumers demand it, regulatory bodies mandate it, and even President Obama expects it!
In February 2009, the American Recovery and Reinvestment Act was signed into law by President Obama in response to the economic crisis. The American Recovery and Reinvestment Act mandates identification of measures to preserve and improve affordable health care. It contains $1.1 billion for comparative effectiveness research (CER) distributed through such government agencies as the Agency for Healthcare Research and Quality, the National Institutes of Health, and the Office of the Secretary of Health and Human Services. CER compares treatments and strategies to improve health, providing information essential for clinicians and patients to decide on the best treatment as well as criteria to improve the health of communities and the performance of the health system. These funds are intended to support research assessing the comparative effectiveness of health care treatments and strategies through efforts that:
1.Conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions.
2.Encourage the development and use of clinical registries, clinical data networks, and other forms of electronic health data that can be used to generate or obtain outcomes data (http://hhs.gov/recovery/overview/index.html). A CER Center has been established as an educational site intended to help stakeholders understand the issues involved in this complex topic (https://www.ecri.org/comparativeeffectiveness/Pages/default.aspx).
Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality, in a statement before the U.S. House of Representatives Committee on Ways and Means, Subcommittee on Health, further reinforced the need to develop better evidence about the benefits and risks of alternative choices. She concluded that CER is imperative to improve the quality, safety, efficiency, and effectiveness of health care for all Americans (http://www.ahrq.gov/news/sp061207.htm).
The National Association of Pediatric Nurse Practitioners (2008) has a clearly articulated research agenda that outlines areas where we can improve the quality of health care for children and families. This agenda is not just for our nurse researchers. It has an impact on all of us because it serves to evaluate our practice and measure the quality of our care. With the emergence of more Doctorate in Nursing Practice programs, clinicians will be better prepared with skills and tools needed to evaluate their own practice. A former mentor of mine, Margaret Hardy, eloquently summarized the relationship of practice to research: “It is from the practice setting that the nurse-scientist should derive ideas and it is for the nurse in the clinical setting that ideas are developed” (1978, p. 37).
As PNPs, we need to document what we do, identify what value we add to health care, develop ways to measure our effectiveness, and share the evidence with the public. We cannot depend on others to justify our contributions to the health care of children and families. A landmark study on the assessment of the safety, quality, and effectiveness of care provided by APNs has been completed recently ((Newhouse et al., 2009). It promises to be the most comprehensive evaluation of APN practice to date providing evidence of our contributions to the health of the United States.
So, in this season of caring and giving, take the time to reflect up on both the art and science of caring. We practice high quality care. We argue forcefully about our worth and value. We need to find the evidence to support our claim that PNPs provide effective, high quality care to children and families.
Happy Holidays!
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