Bedpans to outcomes: Why can’t we quantify nursing care?


“So, will you go get me a bedpan?”

The bar was fancy, so I let it slide. This was not the first time my response to an occupational query was followed with a statement about bedside toileting; people just don’t know what to do when an educated, confident woman says she’s a nurse.

I smiled tersely, as I have trained myself to. In past years, I’d offer varying responses: anger, heated debate. Instead of launching my usual acerbic attack on this man’s inference that all nurses do is bring bedpans to patients, I posed him a simple question:

“Tell me, what, exactly, you think a nurse does during a typical shift?”

Thanks to Hollywood, most people equate nursing to following doctor’s orders, making patients comfortable, and giving medications and bedpans. The word “assessment,” which is the bulk of a nurses’ responsibility, falls foreign. This man, as charming as he was, had no idea that as a nurse, my work is deeply rooted in my ability to collect, recognize, and act on complex sets of information: The science of nursing care.

This disconnect between stereotype and understanding, is, I believe, largely our own professional fault, and until nurses deliberately explain their complex work of care, our professional battles for workplace and workforce improvement and, in direct connection, the quality of care we provide, will continue to remain buried in the graveyard of bad bedpan jokes and unsolved professional problems.

In 2014, New York Times health journalist Jane Gross reviewed a collection of nurse stories, edited by long-time medical writer, Lee Gutkind. In it, she tells of how Gutkind had no idea what nurses did until he spent time at the bedsides of hospitalized relatives. His interactions with the doctors, who he knew by name, paled in comparison to how often he saw and spoke to the nurses. In reflection of their nursing work, he was deeply disturbed by his inability to name them, deeming them semi-invisible players in the care his family was receiving.  He knew they were working irreplaceably, but he had no idea what defined the work that kept them so busy, or, more importantly, who they were as individual professionals.

Perhaps this lack of nurse-led visibility has to do with our inability to quantify the complex nature of our primary skill: the science of care. Physicians, with the central function to diagnose, might have an easy advantage. Diagnostics are largely quantifiable — the skill can be easily translated and replicable in research, data, and even conversation.

In contrast, care, which is the primary nursing skill, equally complex and patient-specific, remains difficult to quantify. Although it has been studied for decades, nursing care’s complexities can often slip between quantifiable parameters, and thus, out of public dialogue.

Recently, a friend of mine told me of a patient care experience she facilitated as a nurse in a fast-paced cardiovascular surgical ICU, where her nursing work is largely based on numbers — vital signs, lab values, documentable assessment pieces.

One patient, deemed ready for transfer to the less acute observation floor, gave her pause. His heart rate was a touch too high, and his blood pressure equally too low, albeit both in the normal range. His blood counts had dropped some over the past day, but not abnormally, considering his recent surgery. He looked — on paper, and in person — OK to transfer.

But there was a nagging alarm in my friend’s gut, and she told the surgeon, who trusted her intuition and immediately took the patient back to the OR, trumping another surgeon’s schedule. He found three liters of blood in the patient’s chest. The timing of the lab draws had masked a slow bleed from one of his stitches, and if undetected, the patient would have decompensated quickly, making intervention impossible. Instead, because of his nurse’s hunch, he was saved.

I asked my friend what made her act on this feeling she had. Why did she trump logic for intuition? What if she had been wrong and the patient was re-opened for nothing? She couldn’t say. She couldn’t quantify the care that she gave, even though she knew that her patient needed further intervention, without knowing how to describe why.

Nurse researcher Patricia Benner, in her seminal book, From Novice to Expert, describes my friend’s care as expert-level, the pinnacle of nursing experience, while acknowledging it’s near-impossibility to quantify, “… a deep understanding of the total situation; the chess master, for instance, when asked why he or she made a particularly masterful move, will just say: ‘Because it felt right.’”

It is this inability to explain our most complex, expert-level work that trips us up in the public eye, but it is also this complexity that demands reform of healthcare systems and nursing requirements of care. A nurse with ten patients cannot learn to think beyond the face-value assessments that she whizzes through. A nurse with fifteen ER patients can’t listen for the subtle signs of danger when the bells of half of them are ringing for emesis basins or pain medicine. A nurse without a strong foundation of education can’t determine when to think past tasks and into the realm of deep intuition.

In their book, From Silence to Voice, journalists Bernice Buresh and Suzanne Gordon speak of the importance, and absence, of nursing voice in the media, the key to undoing nursing’s invisibility and changing our professional tide: “Just as people recognize that it takes someone with education and expertise to do brain surgery, they would know that it takes someone with education and expertise to care for a patient who has just had brain surgery.”

So, the next time you think of telling a nurse a bedpan joke instead of asking about the details of nursing care, think again. And nurses: Stop passively fielding these nursing jokes. Respond with a detailed description of just how important and elaborate your care actually is. Just make the person asking buys you another drink; it might take awhile.

Amanda Anderson is a nurse with a background in intensive care who currently works in health care administration.

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