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aged, geriatric, nurse-sensitive measurement, nurse-sensitive outcomes, nursing quality indicators, nursing sensitive indicators, older person



  1. Griggs, Kim


Review question: The objective of the scoping review is to locate and describe the international literature relating to Nursing Sensitive Indicators (NSIs) and their use in evaluating geriatric care. Specifically the review question is: What definitions and key concepts of NSIs are identified in the current literature that are relevant in evaluating nursing care of the older person?


Findings from the review will inform future research and health care responses to support the provision of quality nursing care to the older person.


Article Content


Care of the older person in today's health system provides a unique opportunity to adapt and rejuvenate current approaches to nursing management as the health landscape continues to shift, accommodating real-time and anticipated demand. The complexity of clinical care of the older person requires staff to manage multiple co-morbidities and increasing frailty in a fragmented system that requires them to bring about quality care outcomes with unpredictable or finite resources.1 The older person has a greater likelihood of experiencing "delirium, functional decline, pressure ulcers, and poly pharmacy" whilst in our care.2(p.1706) Globally, by the year 2050, the number of people over the age of 60 years of age will have doubled close to a formidable 2.1 billion, creating significant clinical and fiscal challenges for health services internationally.3 These assertions pose a demand on nurses that entails a radical transformation in the current approach to health care. Nursing system and quality measures must be sensitive to the unique clinical need of the older person to ensure organizational responsiveness in meeting future demands.4


In addition to these challenges is the emergence of the pay-for-performance structures being introduced to health services globally, creating a new paradigm in which all clinical disciplines will practice.5 It is imperative that nursing strategically prepares for the health care environment that is going to demand a quantitative measure of its value in the broader health system.5 The literature suggests that the significance of nursing practice to overall patient outcomes is not well recognized, reinforcing the need for an objective measure of nursing value to rationalize the existence of nurses with the policy and decision makers of health systems.6


When considering these current and future challenges, how do nurses, nurse managers and executive nursing directors know that older patients are receiving nursing care that is efficient and effective, delivered within a professionally supportive environment? Health analytics are often "aggregated" across disciplines, making it difficult to provide nursing unit level analysis of performance data and in some instances the nursing data is "invisible" amongst the organizational data, making the identification of nursing specific outcomes incongruous.7(p.279)


Specific nursing quality measures are required to provide evidence of nursing value, an objective evaluation of nursing care and a framework for change.6 The introduction of NSIs will provide both the framework and the specificity to objectively evaluate nursing practice, the environment in which nurses function and the value that nursing contributes to health services.8 Simultaneously NSIs can be operationalized to provide a clinical nursing dashboard to guide improvements in nursing practice, quite separate from organizational efforts to improve system performance or outcome measures.9


The concept of nursing-specific data has been explored since the mid 1800 s when Florence Nightingale initiated comparative studies of soldier outcomes with environmental conditions.10 Health analytics have steadily advanced in empirical knowledge to deliver data that can accurately inform nursing practice. Theorists such as Donabedian in the 1960 s and Rantz and Maas in the 1990 s have contributed to the development of quality frameworks for accountability in clinical practice.11


The individual criteria associated with NSIs are about what nurses do in the health service and can be defined as "indicators that capture care or its outcomes, most affected by nursing care".12(p.2471) Duffy and Hoskins identify that nurses work as part of the health care team making their unique contribution at times hidden within certain patient outcomes.6 Some authors develop this concept further suggesting that nursing value needs to be "clearly articulated" or measured to ensure the profession receives acknowledgement for its expert practice.13(p.197)


Heslop and Lu comment that a number of "surrogate" terms are used to describe NSIs and they include outcome indicators or measures, nursing performance quality indicators, patient safety indicators and nursing sensitive outcomes.12 Donabedian's conceptual framework compartmentalizes health care into three main domains: structure, process and outcomes.14 Donabedian's domains are frequently utilized in the literature to expound the diversity and function of NSIs.15Structure is the setting of care (i.e. nursing staff numbers, skill mix, nurse perception of practice environment); Process is the means by which patient care is delivered (i.e. nursing process, assessment tools, clinical pathways); and Outcomes is the patient experience (i.e. patient outcomes, patient perception of care received).15


The framework articulated by Donabedian shows a functional relationship between each domain, where the structure in which the nurse functions, the nursing care processes and patient outcomes are interrelated, each having a direct impact on another.16


Nursing Sensitive Indicators must have clinical meaning and perspective, be developed within the principles of health metrics that requires "measurable, clear, objective and useful" criteria and at the same time reflect the identified data set that requires measurement.17(p.1249) Once established and standardized, the NSI allows for benchmarking within health services, providing the bed side nurse, nursing manager and executive nurse the opportunity to compare a nursing unit's effectiveness with similarly functioning heath units.18 Nursing Sensitive Indicators are the next step in efforts to quantify the value of nursing care, provide a supportive practice environment for dedicated staff and improve the quality of care older patients receive.19


An initial search of the literature using the words, nursing sensitive indicators, nursing quality indicators, aged, older person and geriatric, identified two systematic reviews expounding the concept of NSIs, with neither review exploring geriatric specific indicators. Heslop outlines the concept of NSIs from a theoretical perspective whilst Stalpers explores the connection between the nurse work environment and patient outcomes in the context of NSIs.12,20 An initial search of the literature identified over 800 articles for consideration and an approximate figure of 60 articles for inclusion in the scoping review, providing sufficient literature to support research into those nursing performance measures which are unique and/or relevant to those patients in the geriatric cohort.


A diversity of approaches in addressing geriatric NSIs is found in the initial search of the literature, with authors such as Bail proposing new NSIs for the acute sector and Head for the community and both authors having a geriatric specific focus.21,22 Literature set in the residential setting such as Bostick is valuable in identifying those existing NSIs specific to the older person, as the cohort is clearly defined as aged and in a few instances literature such as Arora clearly addresses care of the older person in the acute care sector.2,23 Other articles such as Duffy comment on a specific NSI in a general context with no identified setting or are focused on the concept of NSIs such as the work of Heslop to inform the foundational concepts of NSIs.12,24 All of these approaches will be integral in providing a comprehensive summary of the literature and valuable insight into evaluation of the care of the older person.


Inclusion criteria


Nursing staff, regardless of clinical setting or qualification level and those older patients within public or private health systems will be included in the study. Aged, older or geriatric patients are defined as those patients 65 years and over.



The concepts of interest are the types of indicators used for NSIs internationally in the evaluation of care of the older person. It is acknowledged that NSIs in this instance may be specific and/or relevant to care of the older person; relevant indicates they are not exclusively used for geriatrics but may be applied to other patient cohorts under 65.


Within the literature the phrasing NSIs and nursing quality indicators have been used interchangeably to describe a data set of measures that are specific to nursing care evaluation. For the purposes of this protocol, both phrases will be explored in the literature to describe the concept of NSIs. Clinical indicators which measure the effectiveness of a particular clinical task will not be the focus of the study.



The majority of hospital care for the older persons is not delivered in geriatric specific units but dispersed throughout other medical speciality or surgical wards. For the purposes of this study, inpatient, community and long term care settings will be considered. Developing and developed countries will both be included. Literature associated with NSIs in specialized healthcare units which are not geriatric in orientation will be excluded (e.g. NSIs developed for ICU, ICU being a specialized unit not specific to geriatrics.).


Type of studies

This scoping review will consider qualitative, quantitative and economic studies. In addition, literature reviews and systematic literature reviews that meet the inclusion criteria will also be retrieved. Gray (unpublished) literature will also be included. Text and opinion papers will not be considered for inclusion in this scoping review.



This scoping review will adopt the methodology for JBI scoping reviews as described in the 2015 JBI Reviewers' Manual.25


Search strategy

The search strategy aims to find both published and unpublished studies/papers. A three-step search strategy will be utilized in this review. An initial limited search of PubMed and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. The analysis of text words found that nurse-sensitive outcomes and nurse-sensitive measurement have been identified during the initial search of the literature as valuable additions to the keyword search parameters. Nurse-sensitive outcomes represent those patient outcomes specific to nursing care, and nurse-sensitive measurement is a broader term, encompassing those means by which nursing care is summarized in data descriptors. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. All studies published regardless of date will be considered to optimize the diversity of literature for potential inclusion. Studies published in English will be considered for inclusion in this review. An example search strategy has been appended (Appendix I).


Databases/sources to be searched will include: EBSCO CINAHL, Embase, PubMed, Scopus, Cochrane Library and JBI Database of Systematic Reviews and Implementation Reports.


The search for unpublished studies will include: ProQuest Dissertations and Theses, and Google Scholar.


Data extraction

Data will be extracted from papers included in the scoping review using the draft data extraction tool (Appendix II). The data extracted will include specific details about the author, publication year, country of origin, literature type, clinical setting of the studies, Donabedian's Domains and the geriatric relevant NSIs or geriatric specific NSIs significant to the scoping review question and objective. The geriatric specific indicators will be those identified in the literature to have a residential aged care or predominantly aged patient cohort. Furthermore, those NSIs that are relevant to geriatrics (are applicable to other patient cohorts as well as geriatrics) will require endorsement of their meaningfulness to geriatric nursing through an expert panel external to the literature. To expedite this purpose a Clinical Advisory Group (CAG) has been established consisting of representatives from the South Australian Nursing and Midwifery Office, Central Adelaide Local Health Network Medical Directorate and residential care. The CAG will consider those NSIs identified in the scoping review and determine their clinical relevance to geriatric nursing care based on internationally accepted geriatric syndromes and the geriatric expertise of the CAG.26 The CAG will be required to outline the rationale for exclusion or inclusion of each relevant NSI in tabular format. The scoping review will provide a comprehensive compendium of those NSIs that can be considered relevant and/or specific to geriatric care.


Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of primary studies will be contacted to request missing or additional data, where required. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report.


Data mapping

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective/s and scope of the scoping review. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the review's objective and question.



The Clinical Advisory Group was formed prior to the scoping review protocol publication with the specific role of providing a clinical lens to the academic findings of the scoping review and to ensure the clinical relevance of the scoping review conclusions.


The Geriatric Nursing Sensitive Indicator Advisory Group Membership includes:


* Lydia Dennett, Chief Nurse, Department for Health and Ageing, Nursing and Midwifery Office, South Australia (SA)


* Lindy Harkness, Director of Nursing, Broken Hill Hospital, New South Wales


* Karen Hales, Nursing Director Geriatric and Palliative Care Services, Central Adelaide Local Health Network (CALHN), SA


* Kathy Resilli, Community Nurse Practitioner, Community Geriatric Service CALHN, SA


* Jane Burgess, Advanced Clinical Practice Consultant, Medical Directorate, CALHN, SA


* Maureen Tremaine, Safety and Quality Coordinator, Medical Directorate, CALHN, SA


* Celine Heithersay, CN, Clinical Practice Unit, Medical Directorate, CALHN, SA


* Anna Jones, Nurse Education Facilitator, The Queen Elizabeth Hospital (TQEH), SA


* Sharon Berry, Clinical Services Consultant, Acute Medical Unit, TQEH, SA


* Carla Smythe, Clinical Nurse Geriatric Liaison, TQEH, SA


* Ben Cahill, Clinical Services Consultant, General Medical Ward, Royal Adelaide Hospital (RAH), SA


* Natalie Spence, Clinical Practice Consultant, Older Person Specialist Nurse, RAH, SA


* Fiona Quinn, Clinical Practice Consultant, Older Person Specialist Nurse RAH, SA.



Appendix I: Search strategy

CINAHL - All keywords search strategy

Appendix II: Draft extraction instrument



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