Performance measurement, an increasingly pervasive trend in health care, is credited with significant improvements in the quality of care . . . . Even so, this is little comfort when a nurse faces a situation where an action necessary for meeting a performance measure isn’t what she or he believes is best for a particular patient. For example, falls are often tallied as a performance measure, but frail patients need to be walked; raising the head of the bed to prevent pneumonia is often counted in performance evaluation but may result in less turning of the patient, which may mean more sacral ulcers—which may or may not be tallied as a separate performance measure.

That’s from an article in this month’s AJN by nurse ethicist Doug Olsen. It’s called “When Being Good Means Looking Bad,” and is about potential unintended effects of some well-intentioned performance measures that don’t easily allow for consideration of clinical context. Olsen writes that the nurse may, in certain situations, find herself or himself faced with three highly imperfect options to choose between:

  • Conform care to get the best score on the performance measurement, although that may mean less than the best care for the patient.
  • Use deception, in the form of a work-around or an outright lie, to give the appearance of meeting the measure—while actually doing what one thinks is best. 
  • Give the best care, document accurately—and accept the consequences.

Olsen explains the ethical principles in play, weighs the options, and then offers nurses some succinct advice for finding a way forward. Please have a look and let us know if you’ve ever experienced such a conundrum.—Jacob Molyneux, senior editor

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