Consistency of Nursing Directors, Nursing Supervisors, and Nursing Quality Specialists’ Perception about Nursing-Sensitive Indicators in Acute Care Settings

Introduction: Nursing-Sensitive Indicators (NSIs) is a critical concept for the advancement of the nursing profession. However, different managerial positions may have a different perspective on the appropriate NSIs that should be used in hospitals for the monitoring of nursing care quality. This study aims to find if there is a difference between three groups of nursing managerial positions on the appropriateness of NSIs for the monitoring of nursing care quality. Methods: Descriptive cross-sectional approach was employed to evaluate if there is a difference among the three managerial groups in their evaluation for the appropriateness of using a cluster of NSIs in acute care settings. The study was conducted in Jordan between February and March 2020. Result: The study participants were 60 nurses from different managerial positions. The mean scores of the participants were: directors of nursing (200.6), nursing supervisors (199.1), and nursing quality specialists (198.62). The findings revealed no statistical difference between the three groups of their evaluation of the appropriateness of the NSIs. Conclusion: Standardizing the nursing mangers perspectives of NSIs may advance utilization of the NSIs for the monitoring and reporting of nursing care quality. Implications for Nursing Management: Consistent understanding of the measures that can be used to monitor quality of nursing care can establish the foundation for quality measurement and quality improvement in acute care settings.


Introduction
During the Crimean ware, the British government sent Florence Nightingale and a group of nurses to Turkey to care for the soldiers. Cholera and diarrhea were responsible for mortality of many soldiers. Within six months from their arrival, mortality rate dropped from 42.7% to 2.2% [1]. Nightingale accomplishments included improving of ventilation, preventing patients crowding by separating their beds, removing of Calvary horses that were being stabled in the hospital provision, and guaranteeing the hospital drains were flushed several times a day and disinfecting them [2]. She was the first to publish suggestions on improving the outcomes of care based on a statistical measurement approach [3].
In 1995, the American Nursing Association launched the Nursing's Safety and Quality Initiative. This effort proposed and implemented nursing quality indicators (Thomas-Hawkins, 2017). The concept "nursing-sensitive outcome indicator" was first prescribed in 1996 by Mas et al., not as a quantitative system indicator, but to describe patient states that are sensitive to nursing interventions (Maas, Johnson, & Moorhead, 1996). Dubois and D'Amour [4] advocate that conceptualization of nursing performance can create an advantage of combining more than one model guided by theoretical foundation that can provide "accurate picture of nursing system performance.
Despite its importance, the fuzzy use of NSIs concept hinders comprehensive organized efforts for improving quality of nursing performance [5]. Burston and Chaboyer [6] conducted a literature review of NSIs and found that despite the regular use of Donabedian's [7] framework of quality assessment, there is inconsistency between the concept and the use of commonly identified indicators. This inconsistency is related to variation in conceptual definition of NSIs and methodological approach for developing sets of NSIs. Agencies like the National Quality Forum, the American Nurses Association and the Agency for Healthcare Research and Quality attempted to standardize the development and measurement of NSIs, but there is no agreement on what constitute NSIs [6].
In practice, healthcare organizations still select potentially nursing-sensitive indicators among enormous list of indicators which deprive policy makers and nursing leaders from viewing the full and accurate picture of nursing contribution to quality of healthcare [8]. Therefore, nurses in the managerial positions need to have a standardized approach for measuring quality of nursing performance based on a carefully selected set of NSIs.
Failure to provide nursing leaders with an approach for quantifying quality of nursing performance deprives them from the opportunity of owning measurable evidence on the impact of nursing system characteristics on patient outcomes [6]. This study aims to explore if there is a difference between three groups of managers on the appropriateness of NSIs for the monitoring of nursing care quality in acute care setting.

Methods
A systematic literature review was conducted to identify potential NSIs. The search A 5-points scale; strongly disagree, disagree, don't know, agree, and strongly agree was used to evaluate level of agreement of the participants for the appropriateness of NSIs in monitoring nursing care quality. The 5-point scale is most common scale when the level of agreement is investigated [9]. Psychometric properties of the developed tool were observed using a group of procedures. Cohen's kappa coefficient (K) is used to measure inter-rater for categorical items. [10]. Cohen's kappa (K) was used to assess Inter-rater reliability. The K value is 0.47 which indicates moderate agreement [11]. Internal consistency reliability was evaluated using Cronbach's Alpha. The structure indicators subscale Cronbach's Alpha values is 0.90, the process indicators subscale Cronbach's Alpha values is 0.91, while the outcomes indicators subscale Cronbach's Alpha values is 0.89. The total scale Cronbach's Alpha value is 0.94 indicating excellent Internal Consistency Reliability. The Content Validity Index (CVI) of the instrument was 0.83.
The sample of the present study includes 65 nurses in managerial positions (Directors of nursing, nursing supervisors, and nursing quality specialist). The study used proportionate purposive sampling to determine the sample size. Hospitals with highest 15% -20% of nursing workforce among different healthcare sectors are identified. Directors of nursing, nursing supervisors, and nursing quality specialist of those hospitals were invited to participate in the study. Based on this sampling strategy, the expected number of the participants was 57 -72.
The selection criteria were developed based on a group of expert attributes. The criteria included nursing academic background with a minimum of bachelor degree qualification, being a registered nurse, current position as director of nursing, nursing supervisor, or nursing quality officers, English language proficiency, and willingness to participate in the study.
The participants were invited to participate in the study through using Internet Data Collection (IDC). IDC provides an access to unique and diverse respondents in cost effective manner while providing instant data capturing in an electronic formats [10].
Participants' responses were transferred to SPSS Statistics 22.0 for Windows [12]. One-Way Analysis of Variance (ANOVA) was utilized to examine if there is a significant statistical difference between mean scores on rating NSIs among Open Journal of Nursing three groups. The dependent variable "total score" was calculated by addition of the participants' responses for the 5 points Likert scale made from 52 items, the scale measured patient this addition yielded a possible scores ranging from 52 to 260.
Data collection process took place on February and March 2020. The study took place in 27 hospitals from both public and private sectors hospitals in Jordan. IRB Approvals of the participating hospitals where obtained. Informed consents were secured from all participants prior to sending the study questionnaire.

Results
Of the 65 participants of the workshop, 60 completed the study equivalent to a response rate of 92.3%. The demographic characteristics are presented in Table   1. The findings indicate that the participants represent various nursing adminis- To run an ANOVA test, three assumptions were tested, these assumptions are: The dependent variable is continuous and approximately normally distributed, this assumption was tested using skewness test which revealed a skewness value of (0.54) which indicates moderate skewness, mean (199.32), median, (198.00), and standard deviation (7.62) (Wegner, 2016). The independent variable "participant position" has independent observation "mutually exclusive observations" this assumption was met for the independent variable as each participant was assigned to one group only. Homogeneity of variance, the Levene test for homogeneity of variance was used to examine whether there were serious violations of the assumption of homogeneity of variance across groups, no significant violation was found: F(2, 52) = 2.80, P = 0.07. The findings presented in

NSIs
NSIs provide nursing leaders with an approach to quantify and monitor quality of nursing care and the quality of nursing system as a whole to enhance decision-making [5]. Furthermore, NSIs play an important role in identifying priority areas for improving nursing care and to direct improvement efforts towards these priority areas [13]. Measuring and monitoring the quality of nursing care in hospitals is viewed as a prerequisite for improving the quality of care provided to patients. NSIs form the basis for monitoring the quality of nursing performance. They provide nursing mangers with a tool to guide organizational improvement and with a common ground for national benchmarking of nursing performance between healthcare organizations [8]. Additionally, as nursing is a profession that has its unique scope of practice, nurses must have their unique system for monitoring the quality of care provided to patients.
Discrepancy across different nursing staff roles in the perception about meaning of NSI may lead to problems with implementation of quality improvement efforts. Establishing structures, process, and outcome NSIs could facilitate cross understanding of measuring quality of nursing within nursing workforce to convey explicit interpretations for quality of nursing care. Eventually, achieving an understanding of NSIs requires a holistic approach to training that enables individuals to learn not only the concept of quality measurement but also how to operationalize the concept. Previous Studies found perspectives on quality vary between nursing managers from one side and practicing nurses on the other side. [14]. In addition, frontline staff use of data for quality improvement on a department level was found to be different from the use of nursing managers [15].
Findings of the present study shows that there is no statistical difference between the three group of participants; directors of nursing, nursing supervisor, nursing quality officers in their evaluation of the appropriateness of the NSIs for

Implications
Consistency by the nursing managers on the appropriateness of NSIs is an im- Nursing directors, nursing supervisors, and nursing quality specialist share a common ground of monitoring and improving nursing care quality. Therefore, Nursing research that aims to strengthen the understanding and use of NSIs and for developing NSIs for clinical practice must continue because nursing managers need a standardized approach for measuring the quality of nursing performance.

Limitations
The present study has some limitations. First, the survey was conducted in hospitals in Jordan, restricting generalization of the study findings to other countries. Second, the sample size of the study was minimal as it was limited to a unique population. Third, psychometric evaluation of the tool was conducted using inter-rater reliability, internal consistency reliability, content validity. Further validation using other methods, such as construct validity assessment confirmatory factor analysis or known-groups method, is needed to strengthen the validity of NSIs tool. In addition, only internal consistency reliability of NSIs was assessed using Cronbach's alpha coefficient.

Conclusion
In order to provide solid evidence on the impact of the quality of nursing performance on health and healthcare systems, nurses from different managerial positions need to speak the same language. Maturation of NSIs concept, agreement on the appropriate NSIs, and adopting NSIs to monitor quality of nursing care can advance a shared vision towards the impact of nursing profession on

Tareq Afaneh
Conceived and conducted the study.

Fathieh Abu-Moghli
Provided overall supervision of the work and critical revision of the paper, and contributed to the conception and conduction of the study.

Funding
This research received no grant from any funding agency in the public, commercial, or not-for-profit sectors.