NURS 8302 Quality Indicators

NURS 8302 Quality Indicators

NURS 8302 Quality Indicators

The American Nurses Association (ANA) established the National Database of Nursing Quality Indicators (NDNQI) in the late 1990s to outline the quality of nursing care and increase the nursing body of knowledge related to quality (Montalvo, 2007). Nursing tenets steer nurses to assess, calculate and enhance practice. Quality indicators help improve nursing practice by benchmarking data, trends, reports and education. Two particularly important quality indicators are the outcome measure of restraint prevalence and the process/outcome measure of patient falls. The national database works to track data regarding these issues for nursing to improve outcomes in these areas.

Two nursing sensitive indicators of significant importance is restraint prevalence and patient falls. The National Quality Form (NQF) establishes “…consensus standards for nursing-sensitive care, including evidence-based nursing-sensitive performance measures, a framework for measuring nursing-sensitive care, and related research recommendations” (National Quality Forum, 2020). Falls are especially problematic for hospitals and the nursing practice because they increase length of stay for patients, increase cost and decrease revenue related to falls because a hospital acquired condition (HAQ). Similarly, restraint prevalence is identified as a NDNQI by the NDF due to negative outcomes associated with use. Although restraints are utilized to help keep patients safe through restricting removal of lifesaving tubes and lines, the negative outcomes associated include agitation, emotional trauma, nerve and vascular injuries, bedsores, and loss of dignity (Kirk et al., 2015; Lagambi et al., 2021; Thomann et al., 2021).


            Restraint Reduction, Restraint Elimination, and Best Practice by Kirk et al., outlines the associated issues with restraint utilization that cause the NQF to establish it as a NDNQI. The authors outlined a unit specific program to decrease restraint utilization below the NDNQI mean for restraint utilization. This unit specific program utilized advanced practice nurses coupled with multidisciplinary rounding to utilize less-restraining options such as elbow boards and soft mitts in lieu of soft restraints (Kirk et al., 2015). Similarly, treating underlying medical conditions causative of agitation decreased restraint utilization. Resultant of the restraint reduction, as suggested by NDNQI, the unit was able to bring the rate of restraint utilization to 1.67% less than the NDNQI mean on the surgical step-down unit and 7.12% on the surgical intensive care unit within the first year (Kirk et al., 2015).

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The second text examined, Reliability and Validity of the NDNQI Injury Falls Measure, works to authenticate

NURS 8302 Quality Indicators
NURS 8302 Quality Indicators

the NDNQI guideline related to falls. The NDNQI collects unit-specific, nurse sensitive data from nearly 2,000 hospitals who benefit from reporting by using data to improve quality outcomes (Garrard et al., 2016). The authors utilized a survey of injury fall measure from NDNQI partner hospitals to validate the results manifested from the NDNQI measures. The measures were found to show robust evidence “…that the NDNQI falls with injury measure is reliable and valid in supporting hospitals’ fall prevention efforts and future injurious falls research” (Garrard et al., 2016). That is, the NDNQI injury falls measure is a consistent and legitimate means for non NDNQI hospitals and outside scholars to endorse potential quality improvement endeavors and falls investigation.

The salient points of nursing research based on NDNQI outline that data driven quality indicators evidence a need for nursing related change to increase quality care and decrease negative outcomes. Kirk et al., presents data related to measures to decrease restraint utilization as suggested by NDNQI. Likewise, Garrard et al., notes validation of NDNQI data through assessment of data from NDNQI partner hospitals. It is through continual assessment of data and utilization of NDNQI that nursing can improve patient outcomes and satisfaction with care.




Garrard, L., Boyle, D. K., Simon, M., Dunton, N., & Gajewski, B. (2016). Reliability and validity of the NDNQI® injury falls measure. Western Journal of Nursing Research38(1), 111–128.

Montalvo, I. (2007). The national database of nursing quality indicators. OJIN: The Online Journal of Issues in Nursing, 12(3). Retrieved from

National Quality Forum. (2020). Nursing-Sensitive Care: Initial Measures . Retrieved September 07, 2020, from

Kirk, A. P., McGlinsey, A., Beckett, A., Rudd, P., & Arbour, R. (2015). Restraint Reduction, Restraint Elimination, and Best Practice Role of the Clinical Nurse Specialist in Patient Safety. CLINICAL NURSE SPECIALIST29(6), 321–328.

Legambi, T. F., Doede, M., Michael, K., & Zaleski, M. (2021). A Quality Improvement Project on Agitation Management in the Emergency Department. Journal of Emergency Nursing47(3), 390–399.

Thomann, S., Zwakhalen, S., Richter, D., Bauer, S., & Hahn, S. (2021). Restraint use in the acute-care hospital setting: A cross-sectional multi-centre study. International Journal of Nursing Studies114.

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