Question

How do quality indicators in The National Database of Nursing Quality Indicators affect the nursing profession?

Answer 1

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Answer:

INTRODUCTION

The National Database of Nursing Quality Indicators^TM (NDNQI^®) is the only national nursing database that provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level. Linkages between nurse staffing levels and patient outcomes have already been demonstrated through the use of this database. Currently over 1100 facilities in the United States contribute to this growing database which can now be used to show the economic implications of various levels of nurse staffing. The purpose of this article is to describe the work and accomplishments related to the NDNQI as researchers utilize its nursing-sensitive outcomes measures to demonstrate the value of nurses in promoting quality patient care. After reviewing the history of evaluating nursing care quality, this article will explain the purpose of the NDNQI and describe how the database has been operationalized. Accomplishments and future plans of the NDNQI will also be discussed.

Quality is a broad term that encompasses various aspects of nursing care. Various health care measures have been identified over the years as indicators of health care quality (American Nurses Association, 1995; Institute of Medicine, 1999, 2001, 2005; Joint Commission, 2007). In 2004, the National Quality Forum (NQF), via its voluntary consensus standards process, endorsed 15 national standards to be used in evaluating nursing-sensitive care. These standards are now known as the NQF 15 (Kurtzman & Corrigan, 2007). The purpose of this article is to describe the work and accomplishments related to the National Database of Nursing Quality Indicators^TM (NDNQI^®) as researchers utilize its nursing-sensitive outcomes measures to demonstrate the value of nurses in promoting quality patient care. After reviewing the history of evaluating nursing care quality, this article will explain the purpose of the NDNQI and describe how the database has been operationalized. Accomplishments and future plans of the NDNQI will also be discussed.

History of Evaluating Nursing Care Quality

Evaluating the quality of nursing practice began when Florence Nightingale identified nursing's role in health care quality and began to measure patient outcomes. She used statistical methods to generate reports correlating patient outcomes to environmental conditions (Dossey, 2005; Nightingale, 1859/1946). Over the years, quality measurement in health care has evolved. The work done in the 1970s by the American Nurses Association (ANA), the wide dissemination of the Quality Assurance (QA) model (Rantz, 1995), and the introduction of Donabedian's structure, process, and outcomes model (Donabedian, 1988, 1992) have offered a comprehensive method for evaluating health care quality.

The workforce restructuring and redesign prevalent in the early 1990s demonstrated the need for the ANA to evaluate nurse staffing and identify linkages between nurse staffing and patient outcomes.The workforce restructuring and redesign prevalent in the early 1990s demonstrated the need for the ANA to evaluate nurse staffing and identify linkages between nurse staffing and patient outcomes. In 1994 the ANA Board of Directors asked ANA staff to investigate the impact of these changes on the safety and quality of patient care. In 1994, ANA launched the Patient Safety and Quality Initiative (ANA, 1995). A series of pilot studies across the United States were funded by ANA to evaluate linkages between nurse staffing and quality of care (ANA, 1996a, 1997, 2000a, 2000b, 2000c). Multiple quality indicators were identified initially. Evidence of the effectiveness of these indicators was used to adopt a final set of 10 nursing-sensitive indicators to use in evaluating patient care quality (Gallagher & Rowell, 2003). Implementation guidelines were subsequently published (ANA, 1996b, 1999).

Nursing-sensitive indicators identify structures of care and care processes, both of which in turn influence care outcomes. Nursing-sensitive indicators are distinct and specific to nursing, and differ from medical indicators of care quality. For example, one structural nursing indicator is nursing care hours provided per patient day. Nursing outcome indicators are those outcomes most influenced by nursing care.

Purpose of the NDNQI^®

In 1998, the National Database of Nursing Quality Indicators was established by ANA so that ANA could continue to collect and build on data obtained from earlier studies and further develop nursing's body of knowledge related to factors which influence the quality of nursing care. Linkages between nurse staffing and patient outcomes had already been identified, but continued data collection and reporting was necessary to evaluate nursing care quality at the unit level and thus fulfill nursing's commitment to evaluating and improving patient care.

Nursing's foundational principles and guidelines identify that as a profession, nursing has a responsibility to measure, evaluate, and improve practice. This is stated in two of nursing's guiding documents:

The Code of Ethics for Nurses with Interpretative Statements states: The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (ANA, 2001, p.12).

Nursing: Scope & Standards of Practice, Standard 7 states: The registered nurse systematically enhances the quality and effectiveness of nursing practice (ANA, 2004. p. 33).

The Utilization Guide for the ANA Principles for Nurse Staffing recognizes that in order to measure sufficiency of staffing on an ongoing basis, at a minimum, unit level nursing-sensitive structure, process, and outcome indicators need to be collected (ANA, 2005). NDNQI's mission is to aid the nurse in patient safety and quality improvement efforts...NDNQI's mission is to aid the nurse in patient safety and quality improvement efforts by providing research-based, national, comparative data on nursing care and the relationship of this care to patient outcomes.

Operationalization of the National Database

The NDNQI^® database is managed at the University of Kansas Medical Center (KUMC) School of Nursing under contract to ANA with fiscal and legal support provided by KUMC Research Institute (KUMCRI). A health care facility that is interested in joining the NDNQI submits a signed contract and fee, based on hospital size, to KUMCRI, along with information on the person who will be the facility's NDNQI^® primary point of contact. This person is then identified as the NDNQI Site Coordinator. The NDNQI Site Coordinator serves as the interface between the participating facility and the NDNQI liaisons working at the University of Kansas. The NDNQI^® liaisons provide ongoing assistance and support to health care facilities at multiple levels. For example they provide help in identifying nursing units appropriately for data entry; offer web-based, data-entry tutorials; conduct pilot testing; and answer questions about definitions and the reading of reports. NDNQI^® researchers are also available to answer questions related to the database or the nursing measures.

Education on NDNQI and nursing-sensitive indicators has been ongoing for participating facilities since 1999. Facilities have quarterly conference calls with NDNQI^® staff to review any changes or updates to the indicators or database. They also have the opportunity to participate in pilot studies performed when an indicator is being evaluated for implementation.

Once access to the database has been provided, the facility NDNQI^® Site Coordinator will work with NDNQI staff from the University of Kansas to correctly classify the nursing units. This is an important step to ensure nursing units are classified appropriately prior to data entry. The facility NDNQI Site Coordinator and other authorized hospital staff also complete web-based tutorials to learn about each indicator prior to initial data submission.The facility NDNQI Site Coordinator has continuous access to the indicator definitions and is responsible for aligning the hospital data collected to NDNQI definitions. The facility NDNQI Site Coordinator has continuous access to the indicator definitions and is responsible for aligning the hospital data collected to NDNQI definitions. On average, it takes three months to join the database and start data submission. The NDNQI is then dependent on hospitals correctly submitting the data on a quarterly basis. All data is submitted electronically via the intranet in a secure website or by XML submission. Data checks and error reports are conducted on an ongoing basis by participating facilities and by NDNQI staff to ensure data integrity.

As of the writing of this article, the NDNQI has implemented six of the ten original ANA-endorsed NDNQI indicators (See Table 1). The initial set of indicators used in establishing the database was selected based on feasibility testing. These indicators included: Falls, Falls with Injury, Nursing Care Hours per Patient Day, Skill Mix, Pressure Ulcer Prevalence, and Hospital-Acquired Pressure Ulcer Prevalence. The RN job satisfaction indicator was pilot tested in 2001 and subsequently implemented in 2002. The RN satisfaction survey is an important indicator to assist nursing leaders and staff in evaluating the work environment so as to facilitate nursing retention and recruiting efforts.

Table 1. NDNQI Indicators
Indicator	Sub-indicator	Measure(s)
1. Nursing Hours per Patient Day1,2	a. Registered Nurses (RN) b. Licensed Practical/Vocational Nurses (LPN/LVN) c. Unlicensed Assistive Personnel (UAP)	Structure
2. Patient Falls1,2		Process & Outcome
3. Patient Falls with Injury1,2	a. Injury Level	Process & Outcome
4. Pediatric Pain Assessment, Intervention, Reassessment (AIR) Cycle		Process
5. Pediatric Peripheral Intravenous Infiltration Rate		Outcome
6. Pressure Ulcer Prevalence1	a. Community Acquired b. Hospital Acquired c. Unit Acquired	Process & Outcome
7. Psychiatric Physical/Sexual Assault Rate		Outcome
8. Restraint Prevalence2		Outcome
9. RN Education /Certification		Structure
10. RN Satisfaction Survey Options1,3	a. Job Satisfaction Scales b. Job Satisfaction Scales – Short Form c. Practice Environment Scale (PES)2	Process & Outcome
11. Skill Mix: Percent of total nursing hours supplied by1,2	a. RN’s b. LPN/LVN’s c. UAP d. % of total nursing hours supplied by Agency Staff	Structure
12. Voluntary Nurse Turnover2		Structure
13. Nurse Vacancy Rate		Structure
14. Nosocomial Infections(Pending for 2007) a. Urinary catheter-associated urinary tract infection (UTI)2 b. Central line catheter associated blood stream infection (CABSI)1,2 c. Ventilator-associated pneumonia (VAP)2		Outcome
1 Original ANA Nursing-Sensitive Indicator 2 NQF Endorsed Nursing-Sensitive Indicator “NQF-15” 3 The RN Survey is annual, whereas the other indicators are quarterly

Pediatric and psychiatric indicators have been added more recently because participating hospitals requested indicators for these areas. Additional NQF endorsed measures (Table 1) were then added to the database because these represented additional nursing measures available that had already gone through a consensus measure approval process. ANA supported the addition of these measures to the database because they were of interest nationally to the nursing profession and were in concert with ANA's seminal work and ongoing support of nursing measures.

Implementing an indicator is a multi-step process (Table 2) that includes evaluating the evidence that a specified indicator is nurse sensitive and then pilot testing (Table 3) of the indicator by participating facilities. In addition, ...there is ongoing monitoring and testing for validity and reliability per NDNQI standard operating procedure.there is ongoing monitoring and testing for validity and reliability per NDNQI standard operating procedure. An outcome indicator is deemed to be nursing sensitive if there is a correlation or multivariate association between some aspect of the nursing workforce or a nursing process and the outcome. The NDNQI utilizes state-of-the-science methods, such as the hierarchical mixed model, to assess the strength of correlation between nursing workforce characteristics and outcomes (Gajewski et al., 2007; Hart, et al., 2006).

Table 2. Indicator Development Process

Review scientific literature for: (a) evidence that some aspect of nursing case has an effect on a patient outcome; (b) specific definitions of the indicators; and (c) evidence that the indicators can be validly and reliably measured Collect information from researchers in the field on threats to reliability and validity Conduct expert review of draft indicator definitions, data collection guidelines, and data collection forms Distribute revised definitions, guidelines, and forms to clinical experts for comments on face validity and feasibility of reliable data collection Incorporate clinical expert feedback and develop revised versions of definitions, guidelines, and forms Conduct a pilot study (Table 3) using the draft data collection materials and review data; also interview hospital study coordinators to identify additional threats to reliability and validity Finalize definitions, data collection guidelines, and forms Train database participants in standardized data collection practices

Table 3. Pilot Testing Process

Develop the indicator with draft guidelines and data collection instruments Recruit pilot testers via e-mail and phone Select pilot sites from those interested. Sites are selected for hospital/unit diversity Guide pilot sites in collecting data according to the draft guidelines Analyze data submitted by pilot sites Collect written and telephone evaluations to assess for clarity, feasibility, and assessment of threats to validity and reliability Analyze pilot data for indicator refinement Finalize guidelines and instruments for dissemination

Quarterly Reports are downloaded electronically from the web by participating facilities. Reports can be downloaded in Adobe PDF, or Microsoft Excel format to facilitate data sharing and dissemination within a given institution. Figure 1 provides a sample of two tables from the report. The reports range from 25-200+ pages based on the number of nursing units and indicators for which hospitals submit data. The reports provide the most current eight quarters worth of data and a rolling average of those eight quarters with national comparisons at the unit level based on patient type, unit type, hospital bed size, and statistical significance of unit performance. For example, patient falls with injury could be reported for each adult medical unit of a 100-199 bed facility. The means for all medical units in a given-size facility can be compared with national standards for a given, nursing-sensitive indicator. The process measures associated with falls are collected and reported as well as the outcome measure of a patient fall.

The significance of offering the reports at the unit level is that such reports provide data regarding the specific site where the care occurs and provides a better comparison among like units. The significance of offering the reports at the unit level is that such reports provide data regarding the specific site where the care occurs and provides a better comparison among like units.Nursing leaders at participating facilities have used the information to advocate for more staff or a different mix of staff based on their comparisons of units in comparable facilities nation wide. Staff are also able to identify whether their performance improved after they intervened in an area needing improvement, e.g., a decrease in the fall rate due to implementation of a new protocol.

Some facilities join NDNQI as part of their Magnet^TM Journey to report nursing-sensitive indicators. The Magnet facilities represent about 20% of the database. The remaining 80% of NDNQI-participating facilities join because they believe in the value of evaluating the quality of nursing care and improving outcomes, activities which are both basic responsibilities of the profession. NDNQI is also used to aid in the recruitment and retention of nurses by hospitals that use the annual RN Survey data and quarterly data to improve work environments, to staff based on patient outcomes, and to meet regulatory or state reporting requirements.

Broad Accomplishments

NDNQI accomplishments include development of nationally accepted measures to assess the quality of nursing care, improvements in training procedures for data submission, identification of nursing workforce structures and processes that influence outcomes, and sharing best practices for improving outcomes. Each will be discussed in turn.Nursing leaders at participating facilities have used the information to advocate for more staff...

To date the NDNQI has already developed a number of standards. Four of the 15 standard nursing measures endorsed by the NQF have been NDNQI measures. Thirteen indicators already have been implemented in NDNQI, and at the time of this writing three additional measures, which are also NQF-endorsed measures, are scheduled for implementation. Of the 13 implemented indicators, eight are NQF consensus measures. NQF uses a consensus process to endorse measures. This process includes (a) consensus standard development, (b) widespread review, (c) member voting and member council approval, (d) board of directors action, and (e) evaluation. The importance of the NQF-endorsed indicators is that they provide a standard measure for evaluating nursing care and are the only nursing measures that have been endorsed for public reporting.

Data training procedures and submissions have advanced from a telephone call for 1:1 training and submission using a CD, to use of comprehensive, web-based tutorials training participants to submit data using electronic means. Data submission now involves specification of unit types and various patient types, such as adult, pediatric, neonatal, psychiatric, and rehabilitation patient populations.

Research on the database has yielded meaningful information on both workforce characteristics which influence quality outcomes and the importance of evaluating the data based on unit type. Identification of important correlations between structures and processes and observed nursing outcomes can help facilities improve their nursing care outcomes.Dunton et al. (2004) evaluated nurse staffing and patient falls and noted important correlations. They observed that lower fall rates were associated with higher staffing on certain types of units, and noted a strong relationship between fall rates, nursing hours, and skill mix. Hart, et al.(2006) studied the incidence of pressure ulcers among NDNQI hospitals, and reported a difference in quality outcomes based on the nursing workforce element of certification. As a result of the Hart et al. study an additional, web-based tutorial on pressure ulcers was created by NDNQIto educate the staff nurse on wound assessment. It is available publicly on the NDNQI web-site for any nurse to complete. Both of these studies demonstrated the value of reporting nursing-sensitive indicator data at the unit level, recognizing that variability of outcomes occurs at the unit level based on patient type, nurse staffing, and the nursing workforce characteristics. The NDNQI database enables researchers to identify various nursing workforce elements that can impact patient outcome, such as nurse staffing, skill mix, and specific nursing processes. It also enables researchers to identify process elements that can influence patient outcomes. Identification of important correlations between structures and processes and observed nursing outcomes can help facilities improve their nursing care outcomes. The database provides the end user with a powerful tool to aid in decision making related to improving the nursing work environment and patient outcomes.

...80% of NDNQI-participating facilities join because they believe in the value of evaluating the quality of nursing care and improving outcomes, activities which are both basic responsibilities of the profession.NDNQIstaff have also helped facilities improve patient care by sharing best practices. In 2006 NDNQIstaff identified facilities that had sustained an improvement in a given nursing-sensitive indicator. These facilities were asked to share what they had done to bring about this improvement. Fourteen facilities were profiled in a monograph identifying their experience with the database, their use of the data, and improvement strategies they had implemented to improve nursing performance in a given measure (Montalvo & Dunton, 2007). For example, in one facility the hospital-acquired pressure ulcer (HAPU) rate dropped from 6.31 to 3.04 after implementing a quality improvement process that included assigning wound/ostomy/ continence specialists to specific nursing units to help all staff improve their surveillance for HAPUs and adopt a zero tolerance for HAPU. The opportunity for varying-size facilities to share these best practices adds to nursing's knowledge base and helps nurses nation wide to improve nursing practice and patient outcome. The First Annual NDNQI Data Use Conference was held in January 2007 and was highly successful with 900 attendees being able to walk away with practical tools and tips in utilizing NDNQI data and to improve nursing-sensitive indicator outcomes. The monograph by Montalvo and Dunton, along with the annual national conference, have aided in disseminating such helpful information to all interested parties.

The current consumer-driven health care environment requires accountability for the health care decisions made and the impact of these decisions on patients. Although direct financial cost/benefits have not been fully calculated with NDNQI globally, the staff nurses and nurse leaders now have a valuable nursing tool to aid them in decision making about staffing, skill mix, patient care processes, and workforce characteristics that affect patient outcomes, thus influencing directly and indirectly the cost of patient care. The facility now has the data necessary to calculate their cost/benefit ratio based on their improvements and outcomes.

Future Plans and Goals for NDNQI^®

The NDNQI database continues to grow in the number of facilities participating and in methodological sophistication. The database has grown from the original 30 facilities to over 1100 facilities in 2007, and ongoing investment and database enhancements continue. Two key developments are slated to begin in 2007. One is to develop methods for measuring unit-level acuity. This will provide mixed acuity units (units having more than 10% of patients representing a different patient population, such as rehabilitation patients on medical units [NDNQIoperational definition, 2007]) and universal bed units (those having patient rooms equipped to care for any patient regardless of acuity [Brown, 2007]) with the ability to receive comparisons from NDNQI.

The second enhancement is to improve reporting features of NDNQI, so that more finite or granular comparisons of a very specific type of unit can be made. An example of a more finite comparison for particular facilities would be comparing coronary critical care units in the 100-bed to 199-bed hospitals. More enhanced reporting will provide more specific comparisons, the ability to download and post different sections of the report, new color graphics, single report cards, and hospital-level summaries. These value-added enhancements will provide the end user with a more powerful tool to evaluate nursing care, improve quality, and influence outcomes for both the patient and the nursing staff alike.

New indicators are added to the database on an annual basis. Additionally, over the next 18 months, existing indicators in the database will become available for all appropriate nursing units. For example, the current psychiatric assault indicator could be pertinent in the Emergency Department (ED) because the ED is a point of entry for these patients. As the demand for data increases, expanding existing indicators to relevant areas will facilitate the ability of facilities to respond to patient and staff needs.

Researchers will also continue to benefit from these enhancements. These developments will enable researchers to fine-tune their research questions and identify additional associations between nursing workforce characteristics and processes and the observed patient outcomes.

Conclusion

The NDNQI has made considerable progress since the ANA Board of Directors asked ANA staff to investigate the impact of workforce restructuring and redesign on patient care and to quantify the relationship between nurse staffing and patient outcomes. Today's national spotlights on patient safety and public reporting have increased the need for nursing to collect and monitor data related to patient outcomes. It is also critical to continue these efforts to ensure nursing has the appropriate workforce to render the care necessary to optimize patient outcomes at the unit level. NDNQI studies have demonstrated the value of nursing care and the significance of nursing's contribution to positive patient outcomes. NDNQI data now has the validity and reliability to be used to evaluate nursing care, improve patient outcomes, and identify the linkages between nurse staffing and patient outcomes at the unit level. NDNQI has indeed become the seminal nursing database that is used to influence nursing policy and improve nursing care.

ITS IMPACT ON NURSING PROFESSION

The NDNQI is a voluntary database of unit-specific quality indicators that are directly related to nursing care. These data are important because they're reflective of the correlation between staffing ratios, direct patient care, and quality outcomes. Additionally, there are controls and processes for collecting and reporting the data that help ensure we're truly comparing apples to apples and not apples to oranges. You can compare your organization, unit, or service line to similar organizations or see how you benchmark against all organizations nationally.

The quality indicators are falls; falls with injury; pressure injuries (community-, hospital-, and unit-acquired); skill mix; nursing hours per patient day; RN surveys, including job satisfaction; restraint use; pain management; pediatric pain management; pediatric I.V. infiltrations; nursing turnover and vacancy rates; psychiatric patient assault rates; RN certification rates and education levels; and healthcare-associated infections, including ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections. Many of these indicators are part of the National Quality Forum's nursing care measure set—evidence-based standards that drive quality and excellence, and now affect reimbursement.

Within the database there are separate classifications: structure, process, and outcomes. This is useful because it assists with noting where an issue may be arising. For example, nursing turnover and nursing hours per patient day are structural and relate to staffing ratios and finance, whereas falls and infection rates relate to nursing policy, process, compliance, and outcomes.

The American Nurses Association (ANA) established the NDNQI in 1998 to meet the need to evaluate nursing's impact on healthcare, along with what effect workload, workflow, and nurse-patient ratios have on patient outcomes. The ANA determined that data collection should be ongoing as part of the profession's responsibility to monitor itself and promote quality outcomes.

The University of Kansas Medical Center School of Nursing manages the database under contract with the ANA. The University assists organizational site coordinators to label and classify each unit, and arranges educational tutorials on data tools, collection, and reporting so that the process is understood and followed as required for participation.

The NDNQI is essential for evaluating processes and outcomes, and driving evidence-based practice. It remains a critical tool in the nursing professional toolkit to ensure accountability, transparency, and quality improvement.

It is observed that, according to the CQH, the created quality indicators for good nursing practices can be applied and can portray the reality of nursing services. Moreover, an evaluation requires a minimal number of indicators that can reveal the main characteristics of the reality of the health service and its practices.

It is worth mentioning that the identified key indicators are defined as data or numeric information that seeks to quantify the performance of nursing services and processes. Indicators that evaluate the structure or results of the provided services were not reported.

With regard to the opinion of the nurses on the importance of using nursing care quality indicators, the participants stressed the following constitutive elements in their statements: assessing the provided service, improving the quality of care and defining strategies to reach goals.

The category evaluating nursing care was evident in the following statements:

It makes us observe how the work is progressing, and identify the problems such as staff shortage.

The indicators are considered instruments to measure the quality of healthcare because they help to identify faults in the process, but the action of measuring alone is not enough. It must be the first step toward establishing standards of excellence and the continuous improvement of care.

According to JCAHO, the indicators can be used as a guide for monitoring and evaluating care and the activities of a service. The nurses showed that they have a correct understanding of the real importance of quality indicators, as illustrated below:

they best analyze the standards, so to speak. They have to have a practical application. Based on my experience, oftentimes, some indicators are created for scientific purposes, to collect data. But they do not necessarily focus on the quality of care.

However, it was observed that the nurses do not always use the indicators to improve care, and seem to stall at the stage of collecting or monitoring and analysis without reaching the stage of implementing actions. Measurements should not be merely regarded as an interesting methodological exercise. They must enable the improvement of health practices by establishing working standards and reference points for continuous enhancements.

Another category identified in the statements of the nurses about the importance of using quality indicators was improving the quality of care. Below, some of the statements:

It is useful because it helps to improve our routine, improve the service that we provide to patients, I think a lot of it is valid.

By analysing the indicators, you can see the points we need to improve, the points we don't need to improve, complete an evaluation process, what's working, what isn't working, what we can improve, the critical points.

In my view, the importance of using them is ... we can detect the points that should be outlined, the points we should emphasize or even to fix errors, improve the care that we will provide, so we become aware of the risks to our patients and our practices can improve(27).

It is very important, it helps to improve care. The problem is that the indicators are evaluated, but they are not always carried out. It's really important! Because it is a tool and an instrument we can use to improve care(32).

The nurses showed that they are aware that indicators are instruments to improve healthcare practices and monitor the quality of assistance. However, they seemed unable to incorporate all the stages of indicator management and did not always know what to do with the numbers. It should be noted that the desire to improve the quality of care should be a collective attitude, rather than an isolated attitude. This requires the implementation of a quality policy in the organizations and greater commitment at management level.

Quality indicators are tools that can be used to improve the quality of care by identifying intervening factors in the work processes of nursing teams. This identification can guide actions to revert the detected scenario and support analysis of non-compliance with standards that are considered desirable. It can also guide attention toward the key points of care that must be reviewed.

The category defining strategies to reach goals emerged from the following statements:

We have goals in the indicators. If we haven't reached our goal, we have to know why we didn't reach it and find a justification. Right... We have to explain why we didn't reach that goal. And try to improve.

Then, when it solely depends on care, we need a critical analysis and we make suggestions, and from those suggestions we work and try to reach the goals. It's a guide that helps me analyse what is working, what I can improve, what depends on care, what depends on the hospital, what my goal is, and it directly influences the quality of care.

It should be noted that the information obtained with the quality indicators can be used for the subsequent evaluations and adjustments of goals that target the best possible quality and result in better management⁽¹⁵⁾. The implementation of indicators should be considered a critical factor for management and for transforming healthcare, education and research. The information extracted from these data helps to recognize, document and evaluate a given situation and support decision making. The internal comparison, such as between sectors, and the external comparison, between different services, helps to review goals and present and future decisions⁽¹⁵⁾.

The statements reveal the difficulties that nurses encounter when they use quality indicators in nursing services. The statements allowed the detection of the following constitutive elements: lack of time, inadequate number of professionals and lack of knowledge on the subject.

The nurses considered lack of time as a factor that hindered the implementation of all the stages of indicator management:

Lately it's been more about having time for us to sit down and actually do it. Because, in this case, we are responsible for three sectors during the week. The weekend comes and we are responsible for five sectors, so it´s difficult for us to sit and do it.

When the pressure increases, I manage to sit and fill in the numbers, but I don´t have time to think about the data.

[...] It's a lot of forms to fill out. We have way too much paperwork. It´s difficult, because sometimes it takes time we don't have, but that's all really.

[...] Sometimes, it's a question of time, and we have to attend to the urgent things and the things that aren't urgent are put in the back burner.

The statements showed that the biggest challenge is not merely to understand the importance of the indicators or of obtaining good indicators, but whether to maintain and improve them. The debate on the lack of time can be related to demands of the care that patients require and the number of professionals hired by the institutions. In this context, another frequently mentioned aspect was the inadequate number of professionals, which reveals an excessive word load that directly affects the results of quality healthcare.

It´s quite tough in our sector because there are only two nurses [...].

The work load here is huge. We have to deal with this entire sector. We don´t have time to do those little things [...]

We can talk about my sector, and the work load is huge....

Sometimes, we have to work as secretaries and answer the phone, talk to the family because sometimes there is no psychologist or other professionals.

The workload of the nursing staff and the lack of workers compromises quality, which has repercussions on the infection rate and the mortality rate.

The reduced number of workers in the nursing unit is considered a hindrance for the use of quality indicators and for the performance of other activities in the work process. A study conducted at the surgical centre of a large hospital identified that a reduced number of nurses hinders the systemization of perioperative nursing care. In light of so much evidence, it was observed that a reduced number of nursing professionals prevents the implementation of quality and safety actions. Consequently, the administration of institutions should become more aware of this demand in order cause a more positive impact for the institution, its professionals and its users.

Another difficulty mentioned by the nurses was the lack of knowledge regarding the indicators. The participants reported difficulties in using the quality indicators because they lacked knowledge on how to apply the indicators. The indicators should therefore be easy to understand by the users of the information. The importance of the using indicators is justified by the need to monitor and measure their results, to verify alignment with the goals of the institution, and the possibility of assessing the planned actions for the achievement of goals. They need to be generated and handled on a regular and systemic basis so they can become a valuable tool for evaluation and management. This situation was revealed in the following statements:

The lack of knowledge.

... the problem of professionals that do not understand the importance of this, so they don't support it.

When you don't have the knowledge, it gets harder and more time-consuming. If you know how to use them, it's quicker and more practical to do.

It's all about knowing exactly how to do it. To do it anyway, at the end of our shift we just fill in the indicators, but sometimes, we don't know why or what it´s for, or the results that it will bring later.