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)
References
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). http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/
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. https://doi-org.ezp.waldenulibrary.org/10.1007/s11136-011-0042-1
Sample Answer 2 for NURS 8302 Discussion: Quality Indicators ANSWER
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.
References
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 Nursing, 23(13-14), 1785–1795. https://doi.org/ezp.waldenulibrary.org/10.1111/jocn.12337
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 Nursing, 46(6), 479–484. https://doi.org/10.1097/WON.0000000000000586
Montalvo, I. (2007). The National Database of Nursing Quality Indicators. The Online Journal of Issues in Nursing, 12(3), Article 2. https://doi.org/10.3912/OJIN.Vol12No03Man02
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 Nursing, 26(1-2), 115–124. https://doi.org/ezp.waldenulibrary.org/10.1111/jocn.13401
Quality of care. (2021). World Health Organization. Retrieved September 5, 2021, from https://www.who.int/health-topics/quality-of-care#tab=tab_1
Sample Answer 3 for NURS 8302 Discussion: Quality Indicators ANSWER
Quality Indicator 1 – Pressure Ulcer Prevalence and Incidence
Nurses pay attention to pressure ulcers or bedsores. A pressure ulcer is a tiny skin and/or tissue damage caused by pressure, shear, or both. Pressure ulcer incidence and prevalence are essential for assessing prevention strategies and nursing treatment. Pressure ulcer indicators were influenced by the Donabedian model and other early quality improvement theories that evaluated healthcare structure, method, and outcomes (Chen, Liao, & Zhou, 2023). This pressure ulcer prevention paradigm prioritizes outcomes, which patients need.
Influence of Early Quality Improvement Theories:
Pressure ulcer indicators are shaped by the Donabedian approach, which emphasizes comprehensive quality evaluation. Structures (such as resources and staff), processes (such as preventative measures), and results (such as pressure ulcer prevalence and incidence) are examined. As part of a complete pressure ulcer prevention strategy, the model emphasizes how these factors interact and affect patient outcomes.
Nursing Research Article:
Taylor, Mulligan, and McGraw’s article “Barriers and enablers to the implementation of Evidence-based Practice in pressure ulcer prevention and management in an integrated community care setting” (2021) explores factors affecting the adoption of evidence-based practices in pressure ulcer prevention. This research is relevant to my profession since it sheds light on pressure ulcer prevention challenges and opportunities. The study’s findings could help my company enhance quality by revealing issues like finances and personnel education.
Quality Indicator 2 – Patient Falls
Nurses also include patient falls when assessing nursing care quality and safety. Falls can cause injuries and impact patient outcomes. Fall indicators are influenced by Deming’s PDSA cycle, which emphasizes repeating cycles of planning, doing, studying, and acting to enhance quality (Brandrud, 2019).
Influence of Early Quality Improvement Theories:
The PDSA cycle has advanced fall indicators by promoting a deliberate and iterative quality improvement technique. Continuous outcome evaluation allows nursing interventions to be implemented, evaluated, and adjusted to avoid falls. Constant improvement and adaptability increase nursing care and patient safety.
Nursing Research Article:
The study “Quality Indicators for the care and Outcomes of adults with atrial fibrillation” by Arbelo et al. (2021) highlights quality indicators in patient care, but not specifically in falls. It shows how quality indicators are used in healthcare. This and similar studies can inspire interdisciplinary teams to establish comprehensive quality improvement initiatives to prevent patient falls in my practice using proven strategies from other areas.
To summarize, the creation of nurse-sensitive indicators necessitates comprehension and use of early quality improvement ideas. The selected papers provide valuable insights into the challenges and opportunities for improving patient care and preventing pressure ulcers. These criteria are essential for guiding quality improvement programs to ensure that patients receive high-quality nursing care.
Reference:
Arbelo, E., (Chair), Aktaa, S., Bollmann, A., D’Avila, A., Drossart, I., … & Martins Oliveira, M. (2021). Quality indicators for the care and outcomes of adults with atrial fibrillation: task force for the development of quality indicators in atrial fibrillation of the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC): developed in collaboration with the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), and the Latin-American Heart Rhythm Society (LAHRS). EP Europace, 23(4), 494-495.
Brandrud, A. S. (2019). Learning about the conditions for improvement and excellent care from high performing clinical networks.
Chen, X., Liao, P., & Zhou, Y. (2023). Construction of nursing-sensitive quality indicators for the care of patients with prone position ventilation using the Delphi method. BMC nursing, 22(1), 336.
Evangelou, E., Middleton, N., Kyprianou, T., Kouta, C., Merkouris, A., Raftopoulos, V., … & Lambrinou, E. (2021). Nursing quality indicators for adult intensive care: a consensus study. Nursing in Critical Care, 26(4), 234-243.
Taylor, C., Mulligan, K., & McGraw, C. (2021). Barriers and enablers to the implementation of evidence‐based practice in pressure ulcer prevention and management in an integrated community care setting: A qualitative study informed by the theoretical domains framework. Health & Social Care in the Community, 29(3), 766-779.
Sample Answer 5 for NURS 8302 Discussion: Quality Indicators ANSWER
Florence Nightingale introduced research to the nursing field, and research has continued to be at the forefront of nursing practice. Nurse-sensitive indicators are influenced by nursing care, including patient falls, hospital-acquired pressure ulcers, catheter-associated urinary tract infections (CAUTI), and central line associated blood stream infections (CLABSI). This discussion will tackle patient falls and hospital-acquired pressure injuries.
Fall prevention is a system and study of strategies for preventing accidental falls by older people. Falls are not only more common in older adults than the general population, older adults also have more severe implications like osteoporosis (Kte, 2023). When older adults fall, any injury can be considered more serious than it would have been due to longer healing time, weaker immune system, etc. Heightened risk for fall include gait abnormalities, balance problems, impaired vision and cognition, and a previous history of fall.
Morse Fall Scale is what can be used to assess fall risk. As of 2017, the assessment consists of six risk factors: history of falling, secondary diagnosis, ambulatory aid, IV, gait, and mental status (Kte, 2023). There are several strategies for fall prevention. Older adults should list all the prescription and over-the-counter (OTC) medications and then review the list with their doctor so they can go over side effects and possible interactions. Handrails and grab bars could be installed in bathrooms and stairs. Nonslip mats can be added to bathtubs and showers. Good lighting can help patients with degrading vision. Patients can receive walkers, canes, non-slip socks, and more.
Another nurse-sensitive indicator is hospital-acquired pressure injuries (HAPI); HAPIs seriously affect patients’ prognosis and quality of life (Zhou et al., 2023). Pressure injuries are enduring complications of hospitalization. The initial assessment or upon transfer with Braden Scale score is vital in preventing pressure injuries (Fulbrook & Lovegrove, 2023). Turn team, which should come around every two hours while in bed and every 15-20 minutes in chair, should be implemented. Incontinence management or toileting should be scheduled. Check on the patients during turn team to see if they need to be changed.
References:
Fulbrook, P., & Lovegrove, J. (2023). Reporting accuracy of pressure injury categorisation in an acute tertiary hospital: A four‐year analysis. Journal of Clinical Nursing (John Wiley & Sons, Inc.), 32(17/18), 6403–6414. https://doi.org/10.1111/jocn.16662
Kte, pi, B. M. (2023). Fall prevention. Salem Press Encyclopedia of Health.
Zhou, Y., Yang, X., Ma, S., Yuan, Y., & Yan, M. (2023). A systematic review of predictive models for hospital-acquired pressure injury using machine learning. Nursing open, 10(3), 1234–1246. https://doi.org/10.1002/nop2.1429Links to an external site.
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