Nursing-Sensitive Indicators

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Defined

Nursing-sensitive indicators reflect the structure, process and outcomes of nursing care. The structure of nursing care is indicated by the supply of nursing staff, the skill level of the nursing staff, and the education/certification of nursing staff. Process indicators measure aspects of nursing care such as assessment, intervention, and RN job satisfaction. Patient outcomes that are determined to be nursing sensitive are those that improve if there is a greater quantity or quality of nursing care (e.g., pressure ulcers, falls, and intravenous infiltrations). Some patient outcomes are more highly related to other aspects of institutional care, such as medical decisions and institutional policies (e.g., frequency of primary C-sections, cardiac failure) and are not considered "nursing-sensitive".

Development

Development of new indicators occurs when no acceptable existing indicator represents nursing’s contributions to patient care. The commitment in indicator development is that all NDNQI® indicators will be based on empirically-based research; therefore, all development efforts begin with the implementation of an in-depth literature review. Indicators with empirical support are identified for review by a panel of nurse experts. The panel determines the validity of said indicators to nursing practice. With the list of nursing-sensitive indicators, NDNQI® then talks with participating hospitals to determine the burden on the hospitals of collecting the data for the indicator. For those indicators which seem to be nursing-sensitive, are clinically meaningful and do not place undue burden upon the participating facilities, the next step is a full pilot test in a number of willing facilities. Those indicators which are deemed to provide the most value for the effort are added to the menu of NDNQI® nursing-sensitive indicators.

The process for developing an indicator includes the following steps:

1. Review of the peer-reviewed literature to determine which indicators have been shown to be nursing sensitive and if there have been reliability studies.

2. Discussions with topic experts to identify measurement issues and additional information that should be collected to support hospital reports or analysis, for example, patient risk level.

3. Develop a plan for data collection and reports.

4. Solicit comments from participating facilities on the feasibility of proposed data collection plan and the utility of the indicators.

5. Conduct pilot studies with volunteer hospitals to test the data collection guidelines and forms.

6. Revise plan for data collection and reports.

7. Develop the web data collection system, including administrative sections of the database, data entry screens, and tutorial.

8. Announce the availability of the new indicator to member hospitals so that staff may take the tutorial, begin data collection and submission.

9. Conduct data analysis and development of quarterly reports.

Indicator List

Over the last 3-5 years, NDNQI® has submitted nursing-sensitive quality indicator definitions to the National Quality Forum (NQF) (Web site Below) in response to requests for indicators. Several NDNQI® indicators have been endorsed through NQF’s consensus measure process (NQF). ANA collaborated with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) via a grant they received from the Robert Wood Johnson Foundation (RWJF) to develop the micro specifications of the NQF nursing measures. The Menu of Indicators Currently Being Collected:

  • Nursing Hours per Patient Day   NQF
    • Registered Nurses (RN) Hours per Patient Day
    • Licensed Practical/Vocational Nurses (LPN/LVN) Hours per Patient Day
    • Unlicensed Assistive (UAP) Hours per Patient Day
  • Nursing Turnover  
  • Nosocomial Infections NQF
  • Patient Falls  NQF
  • Patient Falls with Injury  NQF
    • Injury Level
  • Pressure Ulcer Rate
    • Community-acquired
    • Hospital-acquired
    • Unit-acquired
  • Pediatric Pain Assessment, Intervention, Reassessment (AIR) Cycle
  • Pediatric Peripheral Intravenous Infiltration
  • Psychiatric Physical/Sexual Assault
  • RN Education/Certification
  • RN Survey
    • Job Satisfaction Scales
    • Practice Environment Scale (PES) NQF
  • Restraints NQF
  • Staff Mix NQF
    • RN
    • LPN/LVNs
    • UAP
    • Percent Agency Staff
Additional Data Elements Collected:
  • Patient population – Adult or Pediatric.
  • Hospital Category, e.g. Teaching, Non-teaching, etc.
  • Type of Unit (Critical Care, Step-Down, Medical, Surgical, Combined Med-Surg, Rehab & Psychiatric).
  • Number of staffed beds designated by the hospital

National Comparison Groups and Reports

National comparison data for the indicators are grouped based on patient (Adult/Pediatric) and unit type: Critical Care, Step-Down, Medical, Surgical, Combined Med-Surg, Rehab, Psychiatric and Staffed Bed Size. Teaching and Magnet Status is identified as it relates to participating hospitals. The quarterly reports provide the national comparison along with unit performance data trended over 8 quarters. The benefits to participating in NDNQI are many, and hospitals have found the reports assist them in quality improvement efforts, RN retention efforts and recruitment, patient recruitment, research, staff education, nursing administration and to satisfy reporting requirements for regulatory agencies or magnet designation.

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