Nursing sensitive quality indicators for nursing home care: International review of literature, policy and practice

doi:10.1016/j.ijnurstu.2008.11.005

International Journal of Nursing Studies

Volume 46, Issue 6, June 2009, Pages 848-857

https://doi.org/10.1016/j.ijnurstu.2008.11.005 Get rights and content

Abstract

Objectives

To review nursing sensitive indicators used for nursing home care across seven nations with similar elder care (USA, Australia, Norway, New Zealand, England, Sweden and Denmark), and to evaluate their validity.

Design

Systematic search in the literature and other sources to find descriptions of development and validity testing of national quality indicators.

Data sources

Papers from scientific databases, relevant websites, additional papers and reports, and personal communication with experts in the field. The material was included if it contributed to the description of each country’s processes in defining nursing sensitive quality indicators for nursing home care, and the main focus was use, developing and/or testing of quality.

Review methods

An overview of each country’s utilization of nursing sensitive quality indicators was obtained. The evidence for the validity in development and testing procedures was analyzed using a set of evaluation criteria.

Results

All countries, except Sweden, have nationally standardized assessment of the patient before admission to the nursing home. There is large variation in the way these data collection tools were developed and how the data is used. Only the USA has systematically developed quality indicators on the basis of resident assessments. Twenty-three indicators used nationally in USA, thirteen in Australia, four in Norway, three in New Zealand and three in England were selected for review, and were evaluated for their validity as described in the literature. All selected indicators had satisfactory face validity, and for the twenty-three indicators used in the USA there was evidence for reliability testing. None of the quality indicators met all the criteria for validity. Evidence that the quality indicators can demonstrate meaningful differences in care and that the information can be extracted with minimal extra efforts was not found. Thresholds for high or low quality were determined only for the US quality indicators.

Conclusions

There are concerns about the validity and reliability of nursing sensitive quality indicators for nursing home care. The indicator development is sparsely documented. It is recommended that the development of quality indicators follows a sound process and that extensive empirical testing of the indicators is done.

Introduction

Nursing homes in developed countries have evolved over the past half-decade from being places of custodial care to facilities responsible for the management of an ever increasing range of complex nursing and medical conditions (OECD, 2005, Sosial- og helsedirektoratet, 2006). Globally, nursing homes are challenged to meet the dual demands of providing a home for older people while providing professional care for these complex health challenges as frail and vulnerable older people move through their end of life trajectory (Hauge, 2004, Helsetilsynet, 2005, Paulsen et al., 2004). Knowing when these challenges have been successfully met requires monitoring and audit. Determining what aspect of nursing homes should and can be measured is the current work of many national health care systems and the need for this has become more acute. Countries have long-term care systems bound to their own culture, history and financial resources but virtually all developed nations share the challenges of limitless demand within the context of finite resources and are struggling to bridge the quality gap in nursing home care (Iglehart, 2001).

As nursing care is the common service provided worldwide in nursing homes, it is important to understand how nursing care is evaluated. Using quality indicators that capture the outcomes of nursing care, is one way to monitor the quality of nursing homes (Norwegian Knowledge Centre for the Health Services, 2004). Efforts are underway to do this across developed nations. Gaining an understanding of the state of these varied efforts may help to provide important insights to more efficiently and effectively build coherent local, national, and international nursing sensitive quality indicators for nursing homes.

Therefore, this study aims to describe nursing sensitive quality indicators used in nursing homes across seven developed nations that have a similar system for elder care: access to nursing homes when needed, payment subsidized by tax or insurance, comparable cultural conditions, and a national system for monitoring nursing home quality. A convenience sample of seven countries, USA, Australia, Norway, New Zealand, United Kingdom (UK), Sweden and Denmark, were selected which met these criteria. Across UK there are different approaches and the study focused on England. Although the USA has an elder care system with a larger private market influence than the other six countries, USA was included because there is a large amount of research concerning the development of nursing home quality indicators (Capitman et al., 2005). Nursing sensitive quality indicators used in these countries were evaluated for their validity and applicability. As the cost of developing and validating new quality measures is significant, a strong case can be made for international cooperation. The purpose of this work is to contribute to this effort.

Section snippets

Quality indicators as a measure of quality

Over a decade ago, a conference convened by World Health Organization (WHO) and the Milbank Memorial Fund resulted in an agreement to develop a coherent international policy on long-term care, including nursing home care, with an emphasis on quality assurance designed to satisfy both care recipients and caregivers (WHO, 2000). Toward this end, countries have made variable efforts to determine markers of quality care in nursing homes and to develop measures to evaluate its achievement. An

Research questions

The research questions were as follows:

1.
What nursing sensitive national quality indicators are used for monitoring the clinical quality of nursing homes for older (>65) long-term residents in nursing homes in USA, Australia, Norway, New Zealand, England, Sweden and Denmark?
2.
What is the validity of these indicators?

Methods

Material was restricted to English or Nordic language. The abstract of the articles and reports were first read to find whether they met the inclusion criteria. Reviews were first retrieved, and then additional papers concerning evaluation and validity testing were included for data extraction.

Results

All countries, except Sweden, require that a nationally standardized evaluation of each patient be completed before admission to the nursing home (Table 1). However, there is little uniformity in how these data collection tools were developed and how the data are used. In USA the Resident Assessment Instrument Minimum Data Set (RAI-MDS) has been in place since 1991 and is used in all nursing homes in the U.S. (Hawes et al., 1997). This minimum set of clinical and demographic data are used not

Discussion

This review shows that quality indicators for nursing homes are in use and do play an important role in certification and funding. In other words, there seems to be substantial use of nursing sensitive quality indicators, although they have been adopted with little formal testing (Arling et al., 2005, Berg et al., 2002, Sainfort et al., 1995). Even the quality indicators developed in the USA from the RAI-MDS lack evidence of construct and content validity (Hawes et al., 1997, Karon et al., 1999

Conclusions

The use of nursing sensitive quality indicators to monitor care quality in nursing homes is held back because of concerns about validity and reliability of these measures. The review found that indicator development and testing is sparsely documented, and gaps in knowledge exist. It is recommended that the development and evaluation of quality indicators follows a psychometrically sound process. Research that study how quality is conceptualized, integrating patient, family, and professional

Conflict of interest

None declared.

Acknowledgement

The study was supported with grants from the Norwegian Nurses Organisation.

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ReviewNursing sensitive quality indicators for nursing home care: International review of literature, policy and practice

Abstract

Objectives

Design

Data sources

Review methods

Results

Conclusions

Introduction

Section snippets

Quality indicators as a measure of quality

Research questions

Methods

Results

Discussion

Conclusions

Conflict of interest

Acknowledgement

Jt. Comm. J. Qual. Improv.

J. Am. Med. Dir. Assoc.

Results and Processes in relation to the Expected Outcomes of the Accreditation Standards

AHRQ Quality Indicators - Guide to Inpatient Quality Indicators: Quality of Care in Hospitals - Volume, Mortality, and Utilization. Revision 4

Individbasert pleie- og omsorgsstatistikk (IPLOS) i KOSTRA. Forslag til informasjonssystem for pleie- og omsorgstjenesten

Future development of nursing home quality indicators

Gerontologist

Aged Care Assessment Program Data Dictionary Version 1.0

The Minimum Data Set bedfast quality indicator: differences among nursing homes

Nurs. Res.

The minimum data set pressure ulcer indicator: does it reflect differences in care processes related to pressure ulcer prevention and treatment in nursing homes?

J. Am. Geriatr. Soc.

Identification and evaluation of existing nursing homes quality indicators

Health Care Financ. Rev.

Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set

J. Am. Geriatr. Soc.

Profiling nursing homes using Bayesian hierarchical modeling

J. Am. Geriatr. Soc.

A minimum data set prevalence of pain quality indicator: is it accurate and does it reflect differences in care processes?

J. Gerontol. A Biol. Sci. Med. Sci.

Long-Term Care Quality: Historical Overview and Current Initiatives

The MDS-HC and the Single Assessment Process

Performance Ratings for Social Services in England

The Definition of Quality and Approaches to Its Assessment

An Introduction to Quality Assurance in Health Care

The single issue

Nurs. Older People

Development of the nursing home resident assessment instrument in the USA

Age Ageing

Reliability estimates for the Minimum Data Set for nursing home resident assessment and care screening (MDS)

Gerontologist

Foreign lessons: is there value added?

Health Aff. (Millwood)

International Classification for Nursing Practice

Review
Nursing sensitive quality indicators for nursing home care: International review of literature, policy and practice