Metrics feature - Measuring up

Ciara White and Martina Giltenane look at how using metrics can enhance the delivery of nursing and midwifery care in Ireland

Nursing and midwifery metrics offer ways of measuring the quality of nursing and midwifery care, by utilising process performance quality indicators, which provide a framework for how fundamental nursing care can be measured.1 Thus, quality care metrics aim to illuminate the efficiency and effectiveness of nursing and midwifery care in specific clinical practice areas.1 The drive in health services globally to demonstrate effectiveness and efficiency through performance management processes has never been greater. 2, 3 Quality in healthcare involves reaching and exceeding a standardised level of care through the provision of a safe and effective service. Quality and safe patient care is an integral component of healthcare delivery and is mandatory in many countries where there are obligations to comply with standards for healthcare. 4

Healthcare facilities in Ireland are being confronted by an unprecedented economic downturn coupled with escalating healthcare costs. Concurrently, hospitals are facing growing scrutiny over the quality of care and patient safety issues which are highlighted in the media, both eroding public confidence and increasing public demand for transparency in cost, quality and safety data.5

In March 2014, the Health Services Personnel Census data revealed that 34,664 WTE nurses and midwives were employed in the HSE and HSE funded (voluntary) healthcare organisations nationally, which represents more than one-third of all healthcare service employees in Ireland. Yet nursing and midwifery’s contribution to patient care often remains virtually indiscernible to policy-makers and healthcare managers and many analysts consider it undervalued and understudied. 6

As the largest professional group in the HSE – comprising the largest pay bill – and as the only staff group caring for patients 24 hours a day, seven days a week, nurses and midwives need to clearly demonstrate the quality of care they provide.

Benefits of quality care metrics Metrics
measure nurse and midwifery care processes and patient experiences, enabling nursing and midwifery staff to frequently review real time data and improve clinical practice appropriately.7 Measuring nursing and midwifery standards and acting on the results are a key leadership function of nurses and midwives at every level.8

Nursing and midwifery quality care metrics provide valuable information to managers in understanding how well their individual wards or units are managing the delivery of safe, quality patient care. When implemented as a component of an organisational team-based improvement initiative, metrics promote staff engagement with, and accountability for the quality of their services. Metrics also provide assurance to directors of nursing and midwifery, that care is provided in line with current best practice evidence and that it is congruent with national and organisational policies.9 The potential benefits of collecting nursing and midwifery quality care metrics are summarised in the Table.

Table: Summary of benefits of
implementing metrics
M Measurement of compliance with standards
E Engagement of staff
T Timely information
R Results = openness and transparency
I Improvements for service users
C Culture change
S Shared learning

The different metrics collected and reported on by a healthcare organisation provide a range of scores and reports known as a ‘clinical dashboard’, which can be used to compare and consider the overall healthcare quality and performance of different wards or areas within one hospital. Reports use a traffic light system where scores are either, green, amber or red, so that overall performance can be summarised at a glance. Clinical dashboards can also be used in the delivery of service improvement projects as they enable leaders to integrate disparate data into a holistic picture of the organisation’s strengths and weaknesses to help establish priorities for performance improvement.1,10

Evolution of metrics
The concept of ‘metrics’ has come from the business sector where the term is used to describe a set of measurements to quantify results or outcomes in order to identify how successful a business is in meeting its targets. However, nursing and midwifery metrics aim to measure the process as opposed to targets.11 For the past 20 years, the American Nurses Association has been formally compiling a database of nursing quality indicators, the National Database of Nursing Quality Indicators (NDNQI), using nursing audit data gathered from 1,700 hospitals in the US.12

More recently, within the NHS, chief nursing officer Mandie Sunderland introduced nursing metrics in 2009 in the Heart of England Foundation Trust (HEFT ), aimed at increasing patient safety and promoting quality care following an increase in complaints, falls, pressure ulcers and medication management issues. Following implementation across the HEFT, results indicated significant improvements across quality of nursing care provision in all areas. 8

Ms Sunderland first presented her work on metrics to the Irish Association of Directors of Nursing and Midwifery (IADNAM) in 2010 and has returned to Ireland on several occasions since, to support metrics development in various regions.

Future plans
Nursing and Midwifery Planning and Development Units (NMPDU) in Dublin North, North East and North West regions have been progressing on the collection of metrics for almost two years in acute hospital settings, older person services, mental health services, intellectual disability services, maternity services and children’s services. Nursing and midwifery quality care metrics implementation is now being supported at a national level by Dr Michael Shannon, Office of Nursing and Midwifery Services Director (ONMSD), in order to assist services to provide assurance of the quality and standards of nursing and midwifery care provided. Anne Gallen, director NMPD North West, will lead on this work on behalf of the ONMSD.

This national initiative will be co-ordinated through seven work-streams. Each work-stream has been allocated a project lead and co-lead. These leads are project officers working within the eight NMPDs nationally and will be supported by the NMPD Directors. Each work-stream lead will establish a national working group of key clinical professional representatives involving inter-professional contribution to review and achieve national standardisation of metric indicators.

Nurses and midwives have a significant impact on the quality and safety of patient care. Nursing and midwifery quality care metrics offer an opportunity to maintain high nursing and midwifery standards, providing tangible measures of nursing and midwifery’ contribution to patient care.13 Metrics can make a significant contribution to gaining greater insight into quality of care and can be a catalyst to encourage staff engagement by facilitating discussions about quality at all levels.

An emphasis on the quality of nursing and midwifery care and keeping quality high on the agenda of managers, is vital for continued improvement. At a time when cases of poor quality care and lack of compassion have become the focus of media attention, now more than ever, nurses and midwives and their leaders need to advance the ways in which they use measurement to best effect. 14

There is ongoing professional concern that nursing and midwifery’s contribution to quality health care is under-recognised, leaving nursing and midwifery services vulnerable to cost-reducing efforts.13 Measuring the quality of care is central to providing a nursing and midwifery service that is more transparent, accountable and focused on quality improvement. By making the contribution of nursing and midwifery explicit through quality care metrics at the patient, organisational and national level, it is hoped that the nursing and midwifery component of quality care can be supported and invested in, rather than overshadowed in the drive to meet other performance targets.

Further information can be obtained from the respective NMPD project officers:

Ciara White and Martina Giltenane are nursing and midwifery metrics project officers at NMPDU Dublin South, Kildare & Wicklow and Dublin North respectively

For more on metrics - please see page 43 for this month’s quality and safety column by Maureen Flynn


  1. Foulkes, M. (2011) Nursing metrics: measuring quality in patient care, Nursing Standard, 25, 42, 40-45
  2. McCance, T, Telford, L, Wilson, J, MacLeod, O & Dowd, A. (2011) Identifying key performance indicators for nursing and midwifery care using consensus approach, Journal of Clinical Nursing, 21, 1, 1145-1154
  3. Office of the Nursing and Midwifery Services Director- ONMSD (2013) Developing and Implementing Nursing and Midwifery Metrics in HSE Dublin North East, ONMSD, 4, 1, 9
  4. Health Information and Quality Authority, (2013) Guidance on Developing Key Performance Indicators and Minimum Data Sets to Monitor Healthcare Quality, Dublin 7: Georges Court, Georges Lane, [Online], Available from: [Accessed 23rd May 2014]
  5. Brown D, Donaldson N, Burnes Bolton L, Aydin C. (2010) Nursing-Sensitive benchmarks for hospitals to gauge high-reliability performance. Journal for Healthcare Quality, 32, 6, 9-17
  6. Dubois CA, D’Amour D, Pomey MP, Girard F, Brault I. (2013) Conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review. BMC Nursing, 12, 7, doi:10.1186/1472-6955-12-7
  7. Royal College of Nursing (2011) Nursing dashboards - Measuring Quality.
  8. Sunderland M. (2009) Metrics enable the profession to take control of nursing quality. Nursing Times, 19th November 2009.
  9. Cusack, E, Dempsey Ryan, D, Kavanagh, C & Pitman, S. (2014) An Evaluation of the Development & Implementation of a Nursing & Midwifery Metrics System in HSE Dublin North Healthcare Services, Swords Co. Dublin: Nursing & Midwifery Planning & Development
  10. Donaldson N, Brown D, Aydin C, Bolton L, Rutledge D. (2005) Leveraging nurse-related dashboard benchmarks to expedite performance improvement and document excellence. Journal of Nursing Administration, 35, 163-172
  11. Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report, London: The Stationery Office
  12. American Nurses Association (2011) The National Database of Nursing Quality Indicators (NDNQI)
  13. Griffiths P, Jones S, Maben J, Murrells T. (2008) State of the art Metrics for Nursing: A Rapid Appraisal. Kings College London, London
  14. Maben J, Morrow E, Ball J, Robert G, Griffiths P. (2012) High Quality Care Metrics for Nursing. Kings College London, London
Metrics feature - Measuring up


All rights reserved by INMO. Please don't use without permission