Discussion: Quality Indicators

NURS 8302 Discussion: Quality Indicators

Discussion: Quality Indicators

As the doctoral of nursing practice (DNP) role continues to flourish. We will be looked upon to be leaders as change agents. There are many areas that will require adjustments and restructuring rather these changes are established in bedside care, informatic or policy and procedures.   Having an advanced knowledge and skill set affords the DNP- prepared the ability to exponentially change the current health care systems, and patient outcomes through quality improvement and nurse-sensitive quality measures.  The Agency of Healthcare and Research and Quality (AHRQ) defines quality indicators as “standardized evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes” (pg.1).  The purpose of trend and tracking health quality indicators can occur for several reasons and their values can be descriptive of warrant or unwarranted variation (Nash et al, 2019). The defining of the two will determine the focus of which type of improvement is required.  Closing the gap between unwarranted variations has strongly relied on implementation research to establish and create effective quality improvement interventions (Shojania, 2004).

Cognizant of  the role that training plays when it comes to improving a nurse’s competencies in EBP and thus empowering them to contribute to the development of EBP, here are certain strategies that can be undertaken from both an organizational level, to the larger professional level. At the organizational level, the organization can organize for opportunities where their nurses can get trained on evidence based practice. On the greater professional levels, professional bodies such as the ANA and the ANCC have developed certification program for nurses. By including components of evidence based practice  in the certification exams, this ensures that nurses will prepare and apprise themselves on EBP and thus, in order to earn the certification, they will have to be competent in EBP. Alternatively, the institutions can include a whole different certification for EBP, where nurses will specifically be trained on EBP, tested on the same and thus, their competency will be proven by their certification. This will ultimately improve their ability to participate in the development and implementation of EBP.

Nurse sensitive indicators are distinct to nursing, and identify structure of care and process that directly affect patient care outcomes (OJIN, 2007). The two nurse quality indicators chosen are in regards to nurse burnout and quality of care.  Research has shown that there is a direct correlation between the nurse burnout and patient care outcomes.  Nurse burnout can be characterized as

Discussion Quality Indicators
Discussion Quality Indicators

a lack of energy that manifest in emotional inability to maintain objectiveness, emotional stability, increased frustration, and a lack of motivation; resulting in mistakes and poor patient care outcomes.  Too often these nurses are met with disciplinary action for poor job performance, but the root cause if the problem is often missed.  Implementation research has contributed to this process in the since that if a set of protocols or algorithms were not followed the nurse’s reprimand was warranted.  The adaptation of the Human Err philosophies has opened the door for change in some setting.  Eltaybani et al. (2021) concluded that staff nurse burnout is a significant determinant of quality care; future research should focus on small but feasible outcomes, as well as address the underlying root causes of the condition prior to staff burnout. Al-Qadi(2021) reflects a contributing factor to nurse burnout is the increased in workplace violence. In this article it attributes that nurse are directly affected by verbal, emotional, physical, violence that is bestowed upon not only by patients and/or family member, but also by supervisor that utilized intimidations tactics.

An organized rational change approach would be beneficial in the efforts to address effective patient and nurse centered outcomes.  This approach brings awareness to the problem or quality gap, identifies the action to address the problem, focuses on implementation of action plan and institutes the change where all appropriate parties are involved.

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: Discussion: Quality Indicators


Al-Qadi, M. M. (2021, January). Workplace violence in nursing: A concept analysis. Journal of occupational health. Retrieved September 10, 2021, from

Eltaybani, S., Yamamoto-Mitani, N., Ninomiya, A., & Igarashi, A. (2021). The association between nurses’ burnout and objective care quality indicators: A cross-sectional survey in long-term care wards. BMC Nursing, 20(1).

Nash, D. B., Joshi, M., Ransom, E. R., & Ransom, S. B. (2019). Variation in Medical Practice and Implication for Quality. In The healthcare quality book: Vision, strategy, and tools (pp. 75–101). essay, Washington, DC.

Polonsky, M. S. (2019). High-reliability organizations. Journal of Healthcare Management, 64(4), 213–221.

The national database of Nursing quality INDICATORS® (NDNQI®). (2007, September). Retrieved September 7, 2021, from

Quality improvement and monitoring at your fingertips. AHRQ. (n.d.). Retrieved September 8, 2021, from

Shojania, K. G. (2004, August). Toward a theoretic basis for quality improvement interventions. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 1: Series Overview and Methodology). Retrieved September 10, 2021, from

Discussion Week 2: Quality Indicators

Nurse-sensitive Indicators of Quality Selected

In 1996 a team of researchers coined the phrase “nursing-sensitive indicators.” to reflect elements of patient care directly affected by the nursing practice, and it has become a bit of a buzzword in health care today (Afaneh et al., 2021). Nursing Sensitive Indicators are said to reflect three aspects of nursing care: structure, process, and outcomes (Afaneh et al., 2021).

Depression assessment and the assessment, management, and follow-up of falls are the two nurse-sensitive indicators of quality that are selected. One NDNQI is depression assessment, as nurses play a vital role in caring for the assessment and management of depression (Montalvo, 2017). Per Petrosyan et al. (2017), depression is a widespread mental health problem for adults. It is associated with decreased quality of life, loss of productivity, increased family stress, utilization, and cost of healthcare, and all-cause mortality. A large percentage of the patients I provide primary care services to have been diagnosed with chronic illnesses such as Headaches, Obesity, Diabetes Mellitus, and Hypertension. According to Petrosyan et al. (2017), it has been well established that depression in combination with a wide range of chronic conditions (i.e., cardiovascular disorders, Diabetes) can harm the outcomes of these chronic illnesses. Bearing this in mind, appropriate assessment, identification, and monitoring of care quality related to depression is critical to improving the health outcomes of patients who are clinically depressed. (Montalvo, 2017).

Another NDNQI is patient falls, as increased patient falls in any healthcare Compared to the average, an organization is usually associated with poor nursing quality or lack of assessment.

Influence of Early Quality Improvement Theories and Philosophies on the Development of the Quality Indicators

The National Database of Nursing Quality Indicators sensitive outcomes measures for quality patient care (Montalvo, 2017). From the days of (NDNQI) has established nursing Florence Nightingale measuring patient outcomes and care given by nurses, improving quality has been at the forefront of nursing research (Montalvo, 2017). Other factors that have contributed to the evolution of quality measurement has been the American Nurses Association (ANA), the use of Quality Assurance (QA) model, and Donabedian’s model (Montalvo, 2017).

Regarding the influence of early quality improvement theories and philosophies in the development of quality indicators as they relate to my chosen NSIs, my thought process is that the Donabedian Model is relevant for both as it provided a comprehensive tool to help measure and assess quality patient care and has also heavily influenced the process for making changes within organizations to help ensure patients receive quality care (Moore et al., 2016). The Donabedian Model also directly bridges the influence of system structures on patient care processes and then serves as a connector as it relates to the direct influence of those patient care process to patient outcomes (Howell & Stevens, 2019). The Donabedian Model is also beneficial because it assists organizations with the identification of adverse patient outcomes as well as processes that need adjustments to ensure quality patient care (Howell & Stevens, 2019).

Nursing Research Articles Selected–How these Indicators May Influence My Practice Setting

The purpose of the first article selected is to explore the health-related quality of life (HRQOL) of youth attending a tertiary obesity treatment center compared to healthy population reference data; compare the congruence between the HRQOL of youth self-reports and caregiver proxy reports, and examine the associations between youth HRQOL and teen and caregiver depression. The sample included 267 youth and caregiver dyads. A cross-sectional descriptive design was used. Analyses included paired t-tests, analyses of variance, correlations, and Chi-square cross-tabulations (Pratt et al., 2018).

The authors of another research article discuss their findings on fall prevention while improving the quality of care to patients (Lisa & Julie, 2016). After many various interventions were implemented to identify those patients who were fall-risks, the authors discuss that it was the direct patient supervision by nurses that was the main factor in fall prevention and reduction (Lisa & Julie, 2016). The authors report that by giving time for nurses to perform their duties in an efficient manner, such as through the use of electronic charting and reducing patient to nurse ratio, quality of care can be improved while reducing patient falls (Lisa & Julie, 2016)


Afaneh, T., Abu-Moghli, F., Ahmad, M. (2021). Nursing-sensitive indicators: a concept analysis. Nurs Manag (Harrow), 28(3), 28-33. DOI: 10.7748/nm.2021.e1982. Lisa, G., & Julie, M. (2016). Making time for nurses to reduce patient falls. Nursing Times, 37, 21

Montalvo, I. (2017). The national database of nursing quality indicators. OJIN: The Online Journal of Issues in Nursing, 12(3).

Pratt, K., Lamson, A., Swanson, M., Lazorick, S., & Collier, D. (2018). The importance of assessing for depression with HRQOL in treatment-seeking obese youth and their caregivers. Quality of Life Research, 21(8), 1367–1377.

Quality of care is measured by the degree in which services rendered achieve desired health outcomes (Quality of Care, 2021).  Nursing has been at the forefront of health care quality and patient safety for many years.  Nurse-sensitive indicators (NSI) are measurable patient related outcomes that are directly affected by nursing care (Burston, Chaboyer, & Gillespie, 2014).  When considering which NSI’s to measure to be effective the DNP-prepared nurse must carefully select NSI’s relative to the clinical context, identify how the NSI data will be reported and used, and consider how the NSI will be embedded into clinical practice (Burston et al., 2014).  Two specific NSI’s are patient falls and pressure ulcer prevention (Montalvo, 2007).

According to Burston, et al. (2014), studies show patient outcomes are affected by both nursing structural and process variables.  Structural variable include nurse-to-patient ratios, nursing hours per patient day, nursing education level, and nursing experience (Burston, et al., 2014).  Process variables include specific nursing interventions provided and process care delivery (Burston, et al., 2014).  Burston, et al., (2014) cautioned that data collection and analyzation approaches can cause inconsistencies.  For example, analysis at the hospital level does not allow for shift-to-shift variations that would be better identified at the unit level (Burston, et al., 2014).  The DNP-prepared nurse must analyze data and consider both structural and process variables to develop process changes at the unit level and organization level to improve quality.

Pressure injuries (PIs) are defined as an insult to the skin and underlying soft tissue usually over a bony prominence that may cause and open wound and cause pain (Hoedl, Eglseer, & Lohrmann, 2019).  Hospital acquired PI prevalence rates in the United States range from 1.4% to as high as 49% (Hoedl, et al., 2019). One quality model utilized to evaluate PI prevention is the Donabedian Model of Healthcare Organizations. It is composed of three quality indicators: structure, process, and outcomes. According to Hoedl, et al. (2019), a systematic mapping review using the Donabedian Model identified 146 quality indicators for PI prevention and care, noting 17.6% were structural-level indicators, 48.6% process-level indicators, and 33.6% were outcome-level indicators.  The researchers utilized the Nursing Quality Measurement 2.0 Survey to further identify specific structure, process, and outcome indicators that could be addressed in the quality improvement project to improve PI injury prevention and care (Hoedl, et al., 2019).  These measures could be utilized by the DNP-prepared nurse to address local quality improvement initiatives for PI prevention and care.

Patient falls are a common cause of patient injury during hospitalizations. Morgan, Flynn, Robertson, New, Forde-Johnston, & McCulloch (2017), discussed a staff-led quality improvement intervention which consisted of engagement and communication activities, teamwork and systems improvement training, support and coaching and iterative Plan-Do-Check-Act cycles in an effort to decrease falls.  Intentional rounding was implemented and evaluated using process (hourly rounding by staff) and outcome (patient falls).  There was 50% reduction in falls noted on the units and researchers concluded that integrating teamwork training and staff-led systems redesign resulted in effective change and improvement (Morgan, et al., 2017).  The DNP-prepared nurse is uniquely aligned as a nurse leader and educator to foster staff-led quality improvement initiatives in the clinical setting.



Burston, S., Chaboyer, W., & Gillespie, B. (2014). Nurse sensitive indicators suitable to reflect nursing care quality: a review and discussion of issues. Journal of Clinical Nursing23(13-14), 1785–1795.

Hoedl, M., Eglseer, D., & Lohrmann, C. (2019). Structure, process, and quality indicators for pressure injury prevention and care in Austrian hospitals: A quality improvement project. Journal of Wound, Ostomy, and Continence Nursing46(6), 479–484.

Montalvo, I. (2007). The National Database of Nursing Quality Indicators. The Online Journal of Issues in Nursing12(3), Article 2.

Morgan, L., Flynn, L., Robertson, E., New, S., Forde-Johnston, C., & McCulloch, P. (2017). Intentional rounding: a staff-led quality improvement intervention in the prevention of patient falls. Journal of Clinical Nursing26(1-2), 115–124.

Quality of care. (2021). World Health Organization. Retrieved September 5, 2021, from