I mourn for the demise of nursing care. I really miss giving back massages, changing linens merely for comfort, and sitting down to talk with people. I especially miss the value placed on caring as critical to quality health care.

Since my career began, gradually, it seems quality has been reconfigured to suit the criterion of measurability over any other. Perhaps this is a natural consequence of the health care industry's attempt to be more transparent.  The ability to track standardized processes of care (not necessarily outcomes) is now the primary purpose of the health record, and recording such details as how best to position the person with dementia, rib fractures and chronic back pain is devalued, and even discouraged. There is little room these days for individualized care, one of the places where the nursing profession has always excelled.  And, in my opinion, one of the most important aspects of quality care.

Case in point: Because of suboptimal documentation, the hospital where I work was threatened with revocation of its Joint Commission certification - which meant if our quality did not improve, Medicare reimbursement would be revoked, and Medicare constitutes the major source of payment for any hospital. This could have shut our doors. 

Pain management is one criterion for which our hospital was cited. Certainly a worthy goal. The Joint Commission requires that pain be quantified (preferably on 0-10 scale), treated, and re-assessed after treatment, and these elements must be documented such that they can be audited.  Management repeatedly stressed that nurses document these elements (note: not that nurses do these things). Indeed, the chief nurse executive informed us that one of the benefits of our brand new computerized health record is that chart audits can quickly tell which nurses are not documenting correctly and disciplinary action can be taken. (Yes, wrong in so many ways; I won't start.)

There is no evidence, of course, that good documentation = good  care.  Partly because there is nowhere to chart I gave my 70-year-old Cantonese-speaking patient more narcotic than was ordered, but her pain was still a 7 out of 10. Nowhere to chart that her snoring respirations caused me enough concern that I was reluctant to increase her dose of narcotic further, in spite of the pain she reported. Nowhere to chart that the non-verbal pain scale did not concur with what she said when her son was there to translate. Nor is there a check box to say that I discussed the situation with the physician, who concurred with my plan.

The gap between what is measured and what is quality nursing care is huge. Quality nursing care means letting her family remain at her bedside, judging cautiously how much narcotic to give and when, covering her with warm blankets when she was cold, believing her son's translated Cantonese descriptions instead of the mandated pain scale, wiping her forehead with a cool cloth when she vomited, speaking softly to her. But none of these actions fit in the check boxes, so none of them count.

"The Joint" doesn't know that these are  nursing quality indicators. They don't know that the time I spend checking boxes is time stolen from backrubs and consoling words. "The Joint" didn't even begin talking to nurses until 2003, when their first nurse advisory group was convened. The American Hospital Association (AHA) and the American Medical Association (AMA) have long been integral to the Joint Commission, but the American Nurses Association (ANA) was shut out for years, despite attempts to make contact. No matter than the AMA and the AHA have very different priorities from the ANA. No matter that nurses are the largest group of health care professionals. No matter that skilled nursing care is the reason people are hospitalized.  (If people did not need nursing care, they would go home and visit their physicians as outpatients.  Convenience would be a really bad reason to keep people in the hospital.)

But, happily, now there is hope: in 2008, one of 13 Joint Commission officers is a nurse. In 2002, "The Joint" released a white paper on the nursing shortage with recommendations for improving the supply of nurses. Some of the white paper covered what was known: the nurse shortage is unprecedented, people are aging, bedside nurses and faculty are needed, nurses are crucial and cost-effective health care providers.  Other parts of the paper are more action-oriented, pointing out the need for fiscal incentives to enhance nurse retention, ongoing nurse education and  enhancements in educational and health-care settings. 

So perhaps "The Joint" is starting to get it.  I hope that one day they will notice how the individuality of each person informs my caring much more profoundly than a Joint Commission mandate ever could.  I will continue wiping foreheads and applying warm blankets. I will continue to combine my knowledge of, for example, the duration of intravenous benzodiazepines and the physiologic consequences of portal hypertension with my knowledge of the patient's individual preferences and needs. And perhaps in the future there will be more time for changing linens and explaining treatments and a time when caring is also considered quality health care.