Efforts to define the quality of nursing practice began with Florence Nightingale, as she worked to improve hospital conditions and measure patient outcomes. More recently, research linking hospital nurse staffing issues and adverse patient outcomes has caught the attention of those both inside and outside of health care. Numerous studies were done on the correlation between the two during the ’90s and the early 2000s, an era when news about the nursing shortage was bleak and nurses were reporting under-staffed units, burnout, and job dissatisfaction. When it was reported that under-staffing was associated with increased mortality, the media and the public became interested in the conclusions of these studies. The resulting attention has helped to pave the way for measuring other indicators that relate to the quality of care.
It was in 1996 that a team of researches coined the phrase “nursing-sensitive indicators” to reflect elements of patient care that are directly affected by nursing practice – and it’s become a bit of a buzzword in health care today. These indicators are said to reflect three aspects of nursing care: structure, process, and outcomes.
- Structural indicators include the supply of nursing staff, the skill level of nursing staff, and the education and certification levels of nursing staff.
- Process indicators measure methods of patient assessment and nursing interventions. Nursing job satisfaction is also considered a process indicator.
- Outcome indicators reflect patient outcomes that are determined to be nursing-sensitive because they depend on the quantity or quality of nursing care. These include things like pressure ulcers and falls. Other types of patient outcomes are related to other elements of medical care and are not considered to be nursing-sensitive – these include things like hospital readmission rates and cardiac failure.
Taking it a step further…
In 1999, the American Nurses Association (ANA) identified 10 critical nursing sensitive indicators for acute care settings. In 2002 the ANA added 10 others that are applicable to community-based, non-acute care settings. Since then, the lists have been refined and expanded many times, with new indicators being added annually. The ten original indicators that apply to hospital-based nursing are:
- Patient satisfaction with pain management
- Patient satisfaction with nursing care
- Patient satisfaction with overall care
- Patient satisfaction with medical information provided
- Pressure ulcers
- Patient falls
- Nurse job satisfaction
- Rates of nosocomial infections
- Total hours of nursing care per patient, per day
- Staffing mix (ratios of RNs, LPNs, and unlicensed staff)
By identifying this first group of indicators, the ANA became a pioneer, of sorts, in evidence based practice. The next step was a literature search to identify other indicators that were potentially nurse-sensitive. Those were then reviewed and either validated as being truly nurse-sensitive, or discarded.
In 1998, the ANA established the National Database of Nursing Quality Indicators™ (NDNQI®), in order to continue to build on data gained from earlier studies. There was already an established link between nurse staffing and patient outcomes, but more data and reporting was needed to evaluate other indicators of nursing quality at the unit level. The NDNQI became the very first database to gather such unit-level information. It now supplies hospitals with performance reports that allow administrators to compare their data with national averages, percentile rankings, and other important information.
Nursing sensitive quality indicators are an important part of the equation when it comes to establishing evidence-based practice guidelines. But measuring these indicators is not simply good science – it’s an ethical imperative. Nursing’s foundational principles and guidelines state that, as a profession, nursing has a responsibility to measure, evaluate, and improve the quality of nursing practice.
Next week, more on the databases that are measuring and improving nursing practice!
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