National nursing workforce data from the American Association of Colleges of Nursing and NSI Nursing Solutions, Inc. show that half of all nurses’ work in acute care; however, according to current nurse-sensitive outcomes fail to fully capture the immense impact nurses can have in acute and critical care settings. Nurses provide most of the care to patients in the acute care environment, yet our contributions are mainly measured in terms of harm—rates of pressure injury, falls, and hospital-acquired infection. Similarly, the economic value of nursing within healthcare systems is measured in terms of staffing cost rather than revenue generated from high-quality nursing care.

Competing demands limit the ability of nurses to demonstrate our true effect on patient outcomes. According to Grosso and colleagues, nurses spend one-third of our shift in administrative or supportive activities (changing linens, answering phones, tracking down supplies) that don’t require our clinical expertise and limit time for value-added nursing care. Think about the last shift you worked. How much of your time was spent on tasks that don’t require a nursing license and could have been delegated to a different team member? Imagine a shift where you’re relieved of those administrative activities and can focus solely on providing high-quality nursing care.

When we reflect on our clinical practice, the memories that stand out are the times we were able to fully utilize our nursing expertise and truly impact patient outcomes. For instance, empowering a patient and their caregiver to manage complex medical needs after discharge or advocating for a patient’s religious beliefs within and across their plan of care. Hlebichuk and colleagues describe how top of license nursing practice positively impacts patients and the nurses who care for them, improving professional role perceptions and job satisfaction. This is the value of nursing.

For nurses to practice at top of license they need to be unburdened of administrative activities. To support the delegation of non-nursing activities, the nursing profession must advocate for nurse-sensitive outcomes that capture the unique value nurses bring to acute care environments. According to Hlebichuk and colleagues, these outcomes must capture workforce efficiency, patient care and clinical outcomes, and nurse perceptions of their clinical practice. Currently, these aspects of nursing practice aren’t captured or measured in acute care environments.  

Current measures include patient experience scores (Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS]) and harm-focused nurse-sensitive indicators (National Database of Nursing Quality Indicators [NDNQI], American Nurses Credentialing Center [ANCC] Magnet Recognition Program, etc.). Take a moment to reflect on your last shift. Did any of your patients develop a pressure injury or a hospital-acquired infection? Did they fall? These are important patient outcomes, certainly, but do they fully measure the nursing care you provided? Did you ensure your patient’s pain was adequately controlled so they could participate in physical therapy? Did you advocate for your patient during interprofessional rounds? Did you identify the early warning signs of patient deterioration and escalate care? Current nurse-sensitive outcomes capture a very small portion of true nursing work.

To address this measurement and value problem, members of the Acute and Critical Care Expert Panel of the American Academy of Nursing recently identified the following nine domains of acute and critical care nursing practice—the core elements of what nurses do:

1. Create safe, healing environments.
2. Build caring relationships with patients and families.
3. Assess and manage patient symptoms.
4. Administer physical, therapeutic, preventive, and end-of-life care.
5. Provide surveillance, vigilant of patient risks, and remain ready to intervene.
6. Teach patients and families what they need to know to actively participate in their care and decision-making and manage their care after hospital discharge.
7. Collaborate with and coordinate care within the interprofessional team.
8. Advocate for the patient and family, ensuring that their needs and preferences are known and respected within the interprofessional care team.
9. Navigate patient transitions in care across and out of the healthcare system.

Compared to current nurse-sensitive outcomes, is the variety of nursing care you provide in your role better identified within these domains? If you’re a nurse actively working in the inpatient environment in any role or setting, we invite you to take part in a brief survey to share your perspective. Are these domains relevant to your nursing practice? How frequently do you provide care within each domain? How important is each domain to patient and family outcomes? Importantly, have we missed any part of your nursing practice?

We’ll use your survey responses to validate the nine domains of nursing practice and support the development of nurse-sensitive outcomes focused on the core elements of what nurses do. These new nurse-sensitive outcomes will demonstrate what we can deliver to patients and families in acute and critical care when we’re unburdened from administrative tasks and are free to practice at the top of our license. This work complements the AANC Economic Value of Nursing initiative, enhancing the visibility of nursing’s value within the healthcare system through identification and measurement of truly nurse-sensitive outcomes. We know nurses bring unique expertise to the bedside. It’s time we start measuring it!

Jeanne Hlebichuk, PhD, MSN, RN, NE-BC, is a Nurse Scientist at Advocate Health, Milwaukee, WI and Laura Beth Kalvas, PhD, RN is a Nurse Scientist at Nationwide Children’s Hospital in Columbus, OH.

References

American Association of Colleges of Nursing. Nursing workforce fact sheet. 2024. www.aacnnursing.org/news-data/fact-sheets/nursing-workforce-fact-sheet

Curley MAQ, Zalon ML, Seckel MA, et al. Call to action: Blueprint for change in acute and critical care nursing. Nurs Outlook. 2024;72(6):102271. doi:10.1016/j.outlook.2024.102271  

Grosso S, Tonet S, Bernard I, et al. Non-nursing tasks as experienced by nurses: A descriptive qualitative study. Int Nurs Rev. 2019;66(2):259-68. doi:10.1111/inr.12496

Grosso S, Longhini J, Tonet S, et al. Prevalence and reasons for non-nursing tasks as perceived by nurses: Findings from a large cross-sectional study. J Nurs Manag. 2021;29(8):2658-73. doi:10.1111/jonm.13451

Hlebichuk J, Lancaster RJ, Vizgirda V, Quinlan S. Top-of-license practice for registered nurses: A scoping review. Nurs Outlook. 2025;73(3):102397. doi:10.1016/j.outlook.2025.102397

McEvoy NL, Kalvas LB, Walsh K, Curley MAQ. The identification and characterization of nurse-sensitive outcomes in acute and critical care settings: A systematic review. Nurs Outlook. 2025;73(2):102379. doi:10.1016/j.outlook.2025.102379

NSI Nursing Solutions, Inc. 2025 NSI National Health Care Retention & RN Staffing Report. March 2025. nsinursingsolutions.com/documents/library/nsi_national_health_care_retention_report.pdf

Yakusheva O, Lee KA, Weiss M. The nursing human capital value model. Int J Nurs Stud. 2024;160:104890. doi:10.1016/j.ijnurstu.2024.104890

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