Identifying nurse-sensitive indicators for stand-alone high acuity areas: A systematic review

The development of nursing-sensitive indicators: A critical discussion

Discussion arguments

In a science-based profession, nurses must continuously monitor and evaluate the effectiveness of their care. However, data on what constitutes nursing care in practice and the delivery process is lacking. Insufficient evidence on how nurses contribute to patient care hampers the evaluation of nursing practice.We discuss nursing-sensitive indicators, their origins, current applications, and challenges related to their use in evaluating the quality of nursing care. We analyse nursing-sensitive indicators in the context of criticisms levelled at the profession related to the lack of evidence to support their value in the larger healthcare environment.

Conclusions

We have a disjointed approach to evaluating nursing care. Current systems designed to monitor nursing care, such as metrics and data sets, are not adequate or effective for comprehensively evaluating nursing care, considering the fundamentals and values of the nursing profession.

Nursing Quality Indicators in Emergency Nursing: A Scoping Review

BACKGROUND

Nursing quality indicators (NQIs) are essential for evaluating and managing care, yet few validated NQIs exist for emergency nursing. The dynamic nature of this field demands specific, validated indicators.

PURPOSE

The purpose of this review was to identify NQIs in adult emergency nursing using Donabedian's quality categories (structure, process, outcome) and explore their validation.

METHODS

A scoping review was conducted including articles from 2010 to February 2023, using the Cumulative Index to Nursing and Allied Health Literature and Medline (Ovid) databases.

RESULTS

Among 936 screened articles, 18 were included, identifying 85 NQIs across structure (n = 14), process (n = 45), and outcome (n = 26) in emergency nursing. However, the validation of these NQIs was limited.

CONCLUSIONS

NQIs evaluate emergency nursing quality, primarily in process assessment. Future work should validate the NQIs identified in this review for adult emergency nursing and search for potential new ones.

Emergency nursing nurse sensitive indicators: An integrative review

BACKGROUND

Nurse sensitive indicators (NSIs) capture the outcomes of each nursing function impacted by nursing care. NSIs are critical in clarifying foci for emergency nurses when providing care in the emergency department (ED).

OBJECTIVE

To establish NSIs key to emergency nursing from existing published literature.

METHODS

Ten databases were searched as well as grey literature and Google Scholar in the development of data for this integrative review. Articles underwent a title and abstract review to establish inclusion/exclusion suitability followed by a full text critical appraisal. Data were extracted, synthesized, and analyzed using a structured process.

RESULTS

Twenty-eight emergency nursing NSIs were identified from three included studies, with little consensus across the literature. The NSIs established in the literature reflected a broad range of non-specific technical skills. Overall, the quality of the included articles was low due to factors including study design and high risk of bias.

CONCLUSIONS

The constrained range of NSIs and the limited literature exploring the outcomes of emergency nursing care perhaps reflects a wide ranging and seemingly evolving scope of emergency nurses. Further research is needed to delineate emergency nursing NSI, perhaps underpinned by a clear definition of an emergency nurse in terms of capability statements, core skills and defining attributes.

Exploring nurse-sensitive patient outcomes in Dutch district nursing care: A survey study

There is a lack of evidence to guide district nurses in using nurse-sensitive patient outcomes as it is unclear how these outcomes are currently used in daily district nursing practice. Therefore, we aimed to explore (1) which nurse-sensitive patient outcomes are measured and how these outcomes are measured, (2) how district nurses use the outcomes to learn from and improve current practice and (3) the barriers and facilitators to using outcomes in current district nursing practice. An exploratory cross-sectional survey study was conducted. The survey was distributed online among nurses working for various district nursing care organisations across the Netherlands. The responses from 132 nurses were analysed, demonstrating that different instruments or questionnaires are available and used in district nursing care as outcome measures. The nurse-sensitive patient outcomes most often measured with validated instruments are pain using the Numeric Rating Scale or Visual Analogue Scale, delirium using the Delirium Observation Scale, weight loss using the Short Nutritional Assessment Questionnaire and caregiver burden using the Caregiver Strain Index or a Dutch equivalent. Falls and client satisfaction with delivered care are most often measured using unvalidated outcome measures. The other nurse-sensitive outcomes are measured in different ways. Outcomes are measured, reported and fed back to the nursing team multiple times and in various ways to learn from and improve current practice. In general, nurses have a positive attitude towards using nurse-sensitive outcomes in practice, but there is a lack of facilitation to support them. Because insight into how nurses can and should be supported is still lacking, exploring their needs in further research is desirable. Additionally, due to the high variation in the utilisation of outcomes in current practice, it is recommended to create more uniformity by developing (inter)national guidelines on using nurse-sensitive patient outcomes in district nursing care.

Validation of the McIntyre Audit Tool to measure haemodialysis nurse sensitive indicators

BACKGROUND

Nurse sensitive indicators measure the quality of nursing care. Although there are some haemodialysis nurse sensitive indicators, there are currently no validated audit tools available to measure the indicators.

OBJECTIVES

To test the validity of the McIntyre Audit Tool.

DESIGN

This study used a descriptive observation design conducted over two phases to assess face and content validity.

PARTICIPANTS

An expert panel of haemodialysis nurses (n = 13).

METHODS

Face validity (phase 1) involved 13 nurses in two focus groups who reviewed the audit tool with qualitative data generated analysed to identify common themes. Phase 2 used a modified version of the audit tool to test for content validity for each item and then scale level content validity was calculated by combining all item scores.

MEASUREMENTS

Ten nurses rated 26 indicators in the audit tool using a 4-point Likert scale to assess each item for clarity, relevance, appropriateness, and ambiguity.

RESULTS

All 26-haemodialysis nurse sensitive indicators achieved item content validity indices ranging from 0.825 to 1.00 with a scale content validity index average of 0.910. However, based on feedback from phase 2, 6 outcome indicators were removed from the audit tool to reduce staff burden and assist with ease of use. The final audit tool had an excellent average scale content validity index of 0.924.

CONCLUSIONS

The McIntyre Audit Tool to measure 20 haemodialysis nurse sensitive indicators has been validated. It now requires feasibility and reliability testing before auditing the quality of haemodialysis nursing care.

Nursing care factors influencing patients' outcomes in the intensive care unit: Findings from a rapid review

Aims

To examine the nursing care factors investigated regarding their influence on outcomes of critically ill patients.

Background

A large number of studies have considered patients' outcomes as sensitive to nursing practice in intensive care unit environments. However, no summary of nursing factors influencing these outcomes has been provided.

Design

Rapid review, following the seven‐stage process outlined by Tricco and colleagues.

Data Sources

Articles published up to March 2020 were identified in MEDLINE (via PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus databases.

Review Methods

Eligibility of studies was first assessed at the title and abstracts level. Study inclusion was then established by two researchers by analysing the full texts.

Results

A total of 93 studies were included, with a total of 21 nursing care factors documented. At the structural level, nursing factors have been investigated at the organizational and at the personnel level. At the process level, nurse‐led programmes, independent nursing interventions and nurse behaviours have been investigated to date.

Conclusion

The set of nursing factors that emerged can be used in future research to improve poorly developed areas and to accumulate further evidence through additional studies, both at managerial and practice levels.

What is already known about this topic?

Thirty‐five nursing‐sensitive outcomes capable of being used to measure the quality of care in the intensive care unit have been identified to date.

Several nursing care factors in structural and process dimensions have been documented as having an influence on the outcomes of critically ill patients.

What this paper adds:

Many interventions have been assessed in relation to nursing outcomes, more often at the process than at structural levels.

Specifically, a total of 21 nursing factors have been studied to date in the context of intensive care units, divided into structure (organizational and personnel) and process (nurse‐led programmes, independent nursing interventions and behaviours) dimensions.

The implications of this paper

The set of nursing factors that emerged can be considered as a basis for further research, especially regarding poorly developed areas.

Emergent nursing care factors can be used as a blueprint to design and develop educational programmes both at under‐ and postgraduate levels.

At the managerial levels, both structure and process dimensions of nursing care are capable of affecting outcomes and could be used to inform decision‐making.

Setting minimum standards of practice in times of crisis

The COVID‐19 global pandemic is certainly taking a toll on all countries of the world. Health care systems are seriously challenged, and shortages both in staff and in equipment are evident even in high‐income countries. Nonetheless, one cannot avoid wondering: Were these problems new or did they just exacerbate because of the terrible pandemic? Were there ways to have avoided the trauma faced by nurses (International Council of Nurses, ICN, 2021) after the overexposure to the health care crisis? Such a grim realization has specific implications for nursing. Naturally, one cannot change the world. Similarly, nurses cannot affect all aspects of health care systems that need serious reform. But nurses can affect nursing‐sensitive outcomes. Most importantly, nursing‐sensitive outcomes can be used to establish criteria for safe nursing practice. Health care institutions must enable health care professionals to function within the scope of their professional ethical codes. After all, systems operate thanks to the professionals comprising them. Similarly, professionals need to be facilitated by systems to function with integrity.

Nursing-sensitive indicators for nursing care: A systematic review (1997-2017)

AIM

To provide a systematic review of the literature from 1997 to 2017 on nursing-sensitive indicators.

DESIGN

A qualitative design with a deductive approach was used.

DATA SOURCES

Original and Grey Literature references from Cochrane Library, Medline/PubMed, Embase, and CINAHL, Google Scholar Original and Grey Literature.

REVIEW METHODS

Quality assessment was performed using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

A total of 3,633 articles were identified, and thirty-nine studies met the inclusion criteria. The quantitative assessment of investigated relationships in these studies suggests that nursing staffing, mortality, and nosocomial infections were the most frequently reported nursing-sensitive indicators.

CONCLUSION

This review provides a comprehensive list of nursing-sensitive indicators, their frequency of use, and the associations between these indicators and various outcome variables. Stakeholders of nursing research may use the findings to streamline the indicator development efforts and standardization of nursing-sensitive indicators.

IMPACT

This review provides evidence-based results that health organizations can benefit from nursing care quality.

Compassion fatigue in critical care nurses and its impact on nurse-sensitive indicators in Saudi Arabian hospitals

AIM

To examine the previously untested relationship between the level of compassion fatigue (CF) in critical care nurses and the rates of three nurse-sensitive indicators in four critical care units in hospitals in Saudi Arabia.

BACKGROUND

CF can manifest in nurses who provide direct, intimate care to patients with different levels of illness including nurses working in specialty areas such as critical care where they care for patients experiencing challenging illnesses. Pressure injuries, patient falls, and medication errors are key nurse-sensitive indicators that identify critical care nurses as the primary causal agent. These indicators also correlate with burnout and poor multidisciplinary team communication, both factors that govern CF.

METHODS

A multisite survey was conducted to collate and examine the number of reported pressure injuries, falls, and medication errors over 3 months at four hospitals in two Saudi Arabian cities during 2018 to determine the relationship between the occurrence of these nurse-sensitive indicators and the level of CF in critical care (intensive care unit [ICU]) nurses. A survey of 516 critical care nurses was undertaken; analysis was performed using the Professional Quality of Life Scale, version 5 (ProQol-5), and results were further analysed using Pearson's correlations and three-way analysis of variance.

RESULTS

The results of the regression analysis indicated resilience as a predictor explained 66% of the compassion satisfaction (CS) variance (B = 0.318, R² = 0.436, F_{(2, 12.495)} = 123.013, p < 0.001) and 26% of the burnout (BO) variance (B = 0.152, R² = 0.067, F_{(2, 11.500)} = 3.279, p < 0.001). In addition, the level of resilience as a predictor explained 15.4% of the secondary traumatic stress (STS) variance (B = 0.063, R² = 0.024, F_{(2, 7.758)} = 2.785, p = 0.006). Conversely, coping strategies did not predict CS, BO, or STS (p > 0.05) at a statistically significant level. The concurrent measure of CF, BO, and STS found that almost 20% of the critical care nurse participants reported having very low CS, indicating increased potential for the development of CF. In addition, male nurses reported experiencing higher levels of stress and BO than female nurses. This study also found that neither the number of patients being treated nor the number of beds in the care setting affected the rate of the nominated nurse-sensitive indicators. The results for rates of pressure injuries did vary among the hospitals, with the worst performing hospital reporting pressure injury rates of one in every 40 patients and the better performing hospital reporting no cases of pressure injuries after treating more than 100 patients. Patient falls and medication errors were rare occurrences and did not vary between hospitals.

SIGNIFICANCE

This study indicates that there is a possible issue contributing to the differential level of care between hospitals. The mode and length of time nurses spend on handover may also reflect communication issues that increase both the rate of nurse-sensitive indicators and the level of CF reported by nurses. Therefore, the implications of this study, in terms of improving nursing practice, occurs in handover to ensure that information on aspects of nonpatient critical care are fully covered, such as time of patient turning to avoid pressure injuries.

What nursing sensitive outcomes have been studied to-date among patients cared for in intensive care units? Findings from a scoping review

BACKGROUND

Although many studies have considered mortality and adverse effects as outcomes sensitive to nursing practice, it seems that other outcomes of nursing care in intensive care units have been explored less commonly.

OBJECTIVES

To describe the state-of-science in research in the field of nursing sensitive outcomes in intensive care units and to synthesize outcomes that have been documented to date as being influenced by nursing care.

DESIGN

A scoping review study based on the framework proposed by Arksey and O'Malley, further refined by the Levac and Joanna Briggs Institute was performed in 2019.

DATA SOURCES

The Medline, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and Google Scholar electronic databases were searched. In addition, the reference list of included articles was screened.

REVIEW METHODS

Two researchers independently identified publications on the basis of the following criteria: (a) articles that reported nursing sensitive outcomes on critically-ill adult patients admitted to the intensive care unit, (b) as primary and secondary studies, (c) written in English, and (d) without any time frame limitation.

RESULTS

Of the 4,231 records, 112 fully met the inclusion criteria and were included. Publications were mainly authored in the US and Canada (n = 44, 39.2%), and the majority (n = 62, 55.3%) had an observational design. A total of 233 nursing sensitive outcomes emerged, categorized in 35 outcomes, with, on average, two per study included. The most often measured outcomes were pressure ulcers (20 studies) and ventilator-associated pneumonias (19 studies); the less studied outcomes were quality of life, secretion clearance, patient-ventilator dysynchrony, and post-extubation dysphagia. When categorizing outcomes, the ones concerning safety (n = 77, 33.1%) were represented the most, followed by those concerning the clinical (n = 72, 30.9%), functional (n = 70, 30.0%), and perceptual (n = 14, 6.0%) domains. The interdependent outcomes linked to multi-professional interventions (e.g., ventilator-associated pneumonias) were the most frequently studied nursing sensitive outcomes (n = 20, 57.1%), while independent outcomes resulting from autonomous interventions performed by nurses were less often studied (n = 8, 22.9%).

CONCLUSIONS

From a clinical point of view, a large heterogeneity of outcomes influenced by nursing care emerged. However, identified outcomes have been studied with different approaches and metrics, so that future efforts will need to establish homogeneous conceptual and operative definitions. Moreover, increasing efforts in establishing perceptual outcomes, or those close to the fundamentals of nursing care, are suggested in order to better depict the contribution of critical care nurses in the field.

A quantitative systematic review of the association between nurse skill mix and nursing-sensitive patient outcomes in the acute care setting

AIMS

To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.

DESIGN

A quantitative systematic review included studies published in English between January 2000 - September 2018.

DATA SOURCES

Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria.

REVIEW METHODS

The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association.

RESULTS

Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.

CONCLUSION

Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.

IMPACT

Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.