Making Value Visible Through Measurement: Creating Actionable Measurement Maps for Nursing Care Processes and Outcomes

In a 2024 call to action for change in acute and critical care nursing, Martha Curley and colleagues emphasized the need to link the value of nursing care to visible, measurable outcomes.1 The call to action asked us to change the nature of how and what we measure that constitutes the value of nursing practice. One key point from the blueprint document was that the value of nursing care for patients, families, care teams, and organizations is often invisible, consisting of critical practices that are difficult to quantify and objectively measure. Examples include nursing priorities such as relationship building, listening, advocating, thinking critically, and taking time to teach and plan with patients and families in preparation for a procedure, another day in the intensive care unit, or a care transition to step-down or home.1 These activities that comprise the everyday practice of nurses are oversimplified when reduced to a checklist,2,3 are often undocumented in an electronic health record,4 and resist conforming to the structure and objectivity of most traditional forms of measurement such as surveys or self-reported questionnaires.5 As a result, nursing care, particularly care that is delivered by expert nurses,6 is often challenging to link to measurable patient outcomes and is particularly absent from current core quality measures or the Centers for Medicare and Medicaid Services pay-for-performance hospital-based measures.7 The call to action1 invites us as advanced practice critical care nurses to link measurable indices of what nurses do across 9 domains of practice with value based on patient-centered outcomes at the local unit, organization, and population levels.The purpose of this column is to describe how to create a measurement map to make nursing care more visible by making the activities that comprise the everyday work of nurses more measurable and more directly linked to critical patient care outcomes. To make the map accurate and actionable, it must contain a data element definition (a specific, operationalized variable), a data source, a measurement level and frequency definition, and an analysis plan for each of the activities and outcomes that are inherent to the nursing value equation. The value equation outlined in the call to action includes 3 arms: (1) what nurses do within each of 9 domains or categories of work (Table 1)1,8; (2) the elements of the work environment necessary to support the activities; and (3) the outcome of interest, which specifies the patient, family, or organizational “deliverables.” This column introduces the steps for creating an actionable measurement map for these 3 arms of the value equation. The subsequent series of columns will present examples of how to apply the measurement map for common outcomes of interest in advanced practice critical care nurses’ clinical inquiry projects, including patient- and family-level outcomes (eg, symptom management or knowledge of self-care), unit-level outcomes (eg, early mobility or intensive care unit length of stay), and system-level outcomes (eg, population control of blood pressure or hospital readmission) as put forth in the call to action.1How can your clinical inquiry team get started in creating an actionable measurement map? One approach espoused by the call to action is to assess what nurses do and attribute value to those activities, commensurate with the extent to which they drive or prevent the associated patient care outcomes. Similar to value-based care or pay-for-performance principles,9,10 this value proposition links the activities nurses do within 9 domains of nursing practice to positive clinical outcomes that patients experience (Table 1).1 Setting the stage or care context for a focus on the value of nursing activities in each of these domains of practice is the important and requisite component of a healthy work environment.11 To effectively link positive patient outcomes to the work that nurses do, a work environment is needed that supports the value of nurses’ work and also facilitates and rewards the work of clinical inquiry to investigate the outcomes associated with clinical practice activities.5–7 For the purpose of this introductory column describing how to create an actionable measurement map, we will focus on the nursing activities and the patient outcomes. Later, we will present an example of how to create a measurement map for evaluating the mediating and moderating effects of a healthy work environment on positive patient outcomes. Preliminary principles are described in an earlier column by Woltz and colleagues12 for nursing practices associated with chlorhexidine gluconate bathing.Creating a measurement map requires the clinical inquiry team to work backward. Step 1 is identifying the outcome of interest, and step 2 is assessing the nursing activities that contribute to or are associated with that outcome using the practice domains in Table 1. The third step is creating the measurement specification grid (Table 2). This step identifies details of the data definitions for key variables of interest, the data sources, the level of measurement for each variable or data element, and the optimal analysis plan to reflect the value (analytic weight) associated with the identified nursing activities. The fourth step is using the measurement specification grid to populate the measurement map (Figure 1).For any given clinical inquiry project, the utility of the results will be dependent on the extent to which these steps to specify each data element were given careful consideration from the start.What is the topic or the primary patient outcome to be measured? In this series on making the value of nursing care visible, the patient outcome of interest is the “dependent variable” or the thing that the clinical inquiry team is trying to improve or quantify to validate value. There are many strategies for identifying and selecting a project topic.9,10 Regardless of the strategy you choose, the goal of this measurement mapping exercise is to make sure the outcome is a single, measurable patient outcome, narrow enough to be operationalized with a concise, objective definition (Table 2).Using the example in Table 2, the outcome of interest is for a specific population of patients, patients with heart failure. The outcome selected is a guideline-based recommendation for care of patients with heart failure: guideline-directed medical therapy (GDMT) prescribed at the time of discharge. In this example, the clinical inquiry project seeks to improve the proportion of patients with heart failure for whom GDMT is prescribed at the time of discharge. Although only the outcome target or goal statement is shown on the measurement specification grid in Table 2, the rationale for variable selection and the specific parameters that comprise indicated drugs and doses for GDMT should be spelled out in detail in the project proposal. To build a measurement map that supports the nursing care value proposition, nursing activities or care processes that occur to ensure that the primary outcome is achieved must also be specified (described below in step 3). Clinical inquiry projects that are well specified in a measurement specification grid before the measurement map is designed can more clearly associate nursing practice with positive patient outcomes and active efforts to close gaps in quality.How is the outcome being addressed by nursing care activities? What are the nursing care activities that contribute value and result in a positive patient outcome? This question brings us to the nursing practice domain. In this series on making the value of nursing care visible, the core domains of nursing practice or nursing care activities that constitute the how of our measurement map will be listed as key process variables in the measurement specification grid. These activities fall within 9 broad practice domains identified by the American Nurses Association8 and summarized into 9 domains in the call to action1 (Table 1). Our challenge in this series is to carefully consider each of these activities and how they can be most efficiently documented or “captured” from an existing data source, ideally an approach that avoids taking nursing time away from care to audit and thus justify the value of that care.The example in Table 2 falls into domain 6 (patient/family teaching) and shows the outcome and 4 process measures. The data element’s operational definition, data source (where the data will come from), level and frequency of measurement, and the analysis approach that will be used to evaluate the measure are each listed in a unique row. The outcome selected, “patients prescribed GDMT at discharge,” is a guideline-based recommendation for care of patients with heart failure that requires a series of nursing activities to enact and achieve.13,14 Nurses must teach using a literacy level and learning modality that matches the patient’s preferences and aptitude. The teaching must be followed by a learning evaluation method such as teach-back or some alternative form of knowledge verification. Then the content must be repeated and reinforced to ensure that learning leads to habit formation and behavioral change once the patient is home.This sequence of nursing activities can be daunting and often requires referral to outpatient follow-up or connection with telehealth resources. At the very least, nurses must take time to ensure that patients have a connection with a primary care clinician for the many questions that will inevitably arise after discharge. Although these activities are embedded in electronic health record documentation fields for patient education and are, for the most part, able to be abstracted, sorted, and programmed in a patient education quality dashboard, this last step (creating a patient education quality dashboard) is rarely prioritized for health system–level quality reporting. Activities that constitute nursing practice need dedicated, concentrated effort to be made visible. Without this effort, the work associated with positive patient outcomes in domain 6 of the call to action will remain hidden from view. A well-specified measurement map can help achieve this goal.The measurement specification grid serves to link, or map, the nursing care activity to an identifiable, discrete, sortable, reportable data source (eg, the specific location of the data in the electronic health record, narrative interview transcripts, case report forms, or other valid, reliable, and retrievable data source). In addition, the measurement specification grid serves to identify the level of measurement for each data element or metric (for research designs, nominal, ordinal, interval, or ratio; for quality improvement designs, attribute or continuous), and it allows the team to prespecify a plan for data analysis using statistics or process control charts.In this upcoming column series on creating actionable measurement maps, we will use case examples across the 9 domains of nursing practice to explore further details on determining the data definition, data source, level of measurement, and analysis plan. For this introduction to the components of the map, we kick off the series by defining and explicating each of the components using an example from domain 6 in the call-to-action blueprint: patient education for GDMT in heart failure.To begin, using the template in Table 2, create a measurement specification grid tailored to your patient population and outcome of interest by inserting your own key variables (outcome and process measures) in the grid. Remember to list nursing activities or care processes that are directly associated with achieving the patient outcome, both those that are visible (easy to see and objectively measure) and those that may be invisible (difficult to see and thus more challenging to objectively measure).Identify, label, and record the primary clinical outcome in the top row of the measurement specification grid (Table 2). The name and label of the primary outcome of interest in the study is typically indicated as a column in a data table or spreadsheet used for data collection (Figure 2). Each participant’s value for the outcome of interest is then represented in that column on a unique row (Figure 2).Next, below the primary clinical outcome in the measurement specification grid, record each of the nursing practice actions or processes linked to the outcome. For each action, ensure that the activity is identified by a unique data definition. For this exercise in creating a measurement specification grid, we will use the terms study variable and data element interchangeably, but they are not always synonymous.A data definition entails describing the meaning and characteristics of each unique data element, or each fundamental, indivisible unit of information in a data set. The definition should identify the context or setting in which the data element exists, the purpose, the possible values for how it is measured, the format for indicating units of measure, and how the data element relates to other data in the dataset. The definition should contain standardized units of measure so that the information can be consistently measured and interpreted across different units, hospitals, clinics, or parts of a larger system. Use of a common data element is most desirable, so that the measurement of the outcome can be replicated and compared at later dates across different studies or different systems.15,16 Key components of the data definition include the name or unique identifier (eg, “admission diagnosis”), the definition or precise description of what the data element represents (eg, the diagnosis assigned to a patient at the time of admission to the acute or critical care facility), the possible responses, categories, or codes for the data element (eg, a list of possible diagnoses for the data element “admission diagnosis”), and the format or type of data field in which the data element is stored in a spreadsheet (eg, number, text, date; Figure 2). The full set of data elements and their respective definitions are in a data dictionary, often in a separate tab in the spreadsheet or the study’s data collection workbook.The data element measure is optimally derived passively from the electronic health record or other integrated technology or device (eg, abstraction of a medication list reflecting GDMT at a time point such as admission or discharge). However, the data source may also be qualitative in nature and derived from recorded interviews or transcribed notes from a focus group. In any case, the source or location of the unique information for each data element is included in the header of each column in the study spreadsheet or data collection form. Each data element is a unique column followed by subsequent columns for process measures in the study’s spreadsheet or data table (Figure 2).The level of measurement refers to precisely how the data element is quantified and recorded. There are 4 statistical levels of measurement: nominal (eg, categories such as yes/no, male/female/nonbinary, or diagnosis), ordinal (eg, Likert scale surveys, ranked preferences), interval (eg, continuous measures like heart rate, blood pressure, laboratory values), or ratio (eg, continuous measures with an absolute zero such as body temperature). In quality improvement or improvement science terminology, these measurement levels are simply referred to as attribute (nominal or ordinal) or continuous (interval or ratio). In either case, the level of measurement dictates the options that can be used for statistical analysis of that measure. For more information on levels of measurement refer to Reynolds and Granger17 or Granger and Tracy.18The final column of the measurement specification grid is the analysis plan. This column is intended to be just that, a plan. The final analysis may change if, for example, the project enrolled fewer than expected participants, or the sample size was not equally varied across or within the respective study groups, or the project was forced to end early, resulting in an imbalance in enrollment across groups. A host of factors may changes the plan for analysis. And yet, this final column in the specification grid serves as a cross-check for the team, encouraging careful thought about whether the measures being collected will result in a valid and accurate answer to the question being posed. In this case, the analysis plan serves 2 roles: as a value-checker by encouraging the team to consider the value proposition for nursing activities and their association to important, patient-centered clinical outcomes and as a means for ensuring that the data elements considered critical to value will be able to be abstracted, collated, and analyzed without resulting in undue nursing burden or time away from the patient.To begin mapping the activity measures that constitute the work and contribute value to important outcomes in your own patient population, use the example grid in Table 2 to define the primary outcome and the nursing activities or processes that contribute to achievement of that outcome. Next, plot the desired outcome and the contributing activities on the measurement map template in the example provided in Figure 1. When transferring outcome and process measures from the measurement specification grid to the measurement map, arrange processes in sequential, temporal order from left to right as they relate to your outcome. Although this example represents one of many nursing practice measures in domain 6, future columns in this series will explore applying this approach to mapping the value of nursing practice across other domains.Creating a measurement map that is actionable requires attention to each of these steps prior to beginning a new clinical inquiry project. Each step forces the team to carefully consider and articulate in an objective, measurable way the activities that nurses do and how those activities are associated with optimal patient outcomes. Stated another way, the value of the work that nurses do is in fact tightly linked to positive patient outcomes across each of the 9 domains of nursing care. By creating a clear, well-specified measurement map for each clinical inquiry project, the activities that nurses do to ensure high quality patient care are measurable and thus more visible. As a result, these activities can more effectively be leveraged to highlight the positive impact of nursing care in quality reporting, value-based care policies, and ultimately, the activities used to define and justify pay-for-performance reimbursement for nursing practice.This approach to articulating (and measuring) the value of nursing as posited in the call to action using positive, preventive outcomes to mark the impact of care activities stands in stark contrast to the current portfolio of quality reports. The counterargument against the barrage of negative outcomes that are often attributed to nursing care (eg, hospital acquired pressure injuries versus nursing care activities carried out to prevent these injuries; central catheter–associated blood stream infections versus nursing care activities carried out to prevent infections; falls versus the nursing care activities carried out to prevent falls) will require robust measurement and diligence in dissemination to justify a new future for nursing quality metrics. By creating and following a measurement map, the team and others can see the magnitude of the relationship between the value of care delivered and the association of that care with quality patient outcomes. Alternatively, the absence of nursing care or gaps in the nursing workforce can also be more visibly linked with gaps in quality outcomes. In a more approach to nursing care activities the value of care more final on the of the measurement are for of your processes and your There are 3 critical time for using to the of your work for patients and the health system. The is before beginning the project, so that the need for your study and the current of the outcome you are trying to change is clearly at the local level (Figure 3). or on the of your data on the outcome of interest for your specific patient population should be using or The to for the type of measure being used will be the topic of a future column in this For our example, the goal is to the measurement of the outcome for a or of 6 to but at 3 is This that the is and at the local The link to nursing activities and the practice domain will be in your or of the project and is not of the measurement time point for the measurable activities is the project. Regardless of study or the processes of care or activities being measured should be each or to the of data with to each of the process measures (Figure the relationship of the outcome to the nursing practice activities must be able to be to the value of nursing to a broad (Figure 2). this last is most the outcome, but the point of with the local and team the way is to of the measurable relationship between nursing practice activities and clinical patient outcomes. this relationship is so central to the measurable value of nursing, your to it both with and will be important for and the future of nursing as a key of value-based care we begin to take action the for in and the steps in this column as for creating an actionable measurement This series will present examples of how to apply the measurement map for outcomes of interest in advanced practice critical care nurses’ clinical inquiry will how measurement can be used as to improve the and articulate the value of activities in nursing practice that are often and by their very nature constitute the by which patient outcomes These may be used to future pay-for-performance and value-based