Nursing Quality Indicators
in Emergency Nursing
A Scoping Review
Meeri Mustonen, MNSc, RN; Maria Ameel, PhD, RN; Marita Ritmala, PhD, RN;
Helena Leino-Kilpi, PhD, MEd, RN, FAAN, FEANS, MAE
ABSTRACT
Background: Nursing quality indicators (NQIs) are essential for evaluating and managing care, yet few
validated NQIs exist for emergency nursing. The dynamic nature of this field demands specific, validated
indicators.
Purpose: The purpose of this review was to identify NQIs in adult emergency nursing using Donabedian’s
quality categories (structure, process, outcome) and explore their validation.
Methods: A scoping review was conducted including articles from 2010 to February 2023, using the
Cumulative Index to Nursing and Allied Health Literature and Medline (Ovid) databases.
Results: Among 936 screened articles, 18 were included, identifying 85 NQIs across structure (n = 14),
process (n = 45), and outcome (n = 26) in emergency nursing. However, the validation of these NQIs was
limited.
Conclusions: NQIs evaluate emergency nursing quality, primarily in process assessment. Future work
should validate the NQIs identified in this review for adult emergency nursing and search for potential new
ones.
Keywords: emergency nursing, healthcare evaluation, nursing quality indicators, quality improvement,
validation studies
Nursing quality indicators (NQIs) are cri-teria for assessing nursing quality, measur-
ing the impact of nursing actions on patient
outcomes. NQIs in nursing significantly impact
patient safety, patient satisfaction, adherence to
care plans, staffing ratios, and documentation,
thereby enhancing the safety and effectiveness of
health care delivery.1 Nurse leaders employ
NQIs to bolster nursing practice and cultivate
staff resilience.2,3 Donabedian’s framework,
with its components of structure, process, and
outcomes, offers a widely accepted model for
assessing health care quality.4-8 Within this fra-
mework, structures relate to organizational
aspects, processes denote health care provider
actions, and outcomes gauge care results.5
Through Donabedian’s lens, nurse leaders adopt
a systematic method to assess and enhance care
quality, guided by empirical evidence. This evi-
dence-based leadership empowers informed deci-
sion-making, efficient resource allocation, and
organizational enhancement, culminating in
improved patient outcomes and organizational
effectiveness.8
Emergency nursing is vital, with a significant
number of Europeans visiting emergency depart-
ments (EDs) annually.9 Delivering high-quality
emergency nursing requires comprehensive
knowledge, prompt responses, and effective
actions in critical situations.10-12 To assess emer-
gency nursing quality comprehensively, all cate-
gories of the Donabedian framework must be
evaluated.
Author Affiliations: Department of Nursing Science, University of
Turku (Ms Mustonen, Drs Ameel, Ritmala, and Leino-Kilpi);
Department of Psychiatry (Dr Ameel), Helsinki University Hospital (Dr
Ritmala); University of Helsinki (Dr Ameel); and Turku University
Hospital (Dr Leino-Kilpi).
This is an open access article distributed under the Creative
Commons Attribution License 4.0 (CC BY), which permits unrest-
ricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL
citation appears in the printed text and is provided in the HTML and
PDF versions of this article on the journal’s website (www.jncqjournal.
com).
Correspondence: Meeri Mustonen, MNSc, RN, Department of
Nursing Science, University of Turku, 20014, Turku, Finland (meeri.h.
mustonen@utu.fi).
Accepted for publication: May 14, 2024
Early Access: July 4, 2024
DOI: 10.1097/NCQ.0000000000000790
J Nurs Care Qual ● Vol. 00, No. 0, pp. 1–7 ● Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. www.jncqjournal.com 1
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An integrative review on emergency nursing
NQIs indicates a need for further research, high-
lighting the undefined nature of these indicators.13
While studies on quality indicators14-16 and frame-
works exist in emergency medicine,17,18 the same
cannot be said for emergency nursing. Research
and development of standardized NQIs, particu-
larly for elderly emergency patients, have been
proposed,19-21 emphasizing the need for nursing-
sensitive and well-validated indicators.19-23
This scoping review uses Donabedian’s
framework to assess NQI coverage in adult emer-
gency nursing, focusing on structures, processes,
and outcomes. NQIs, assessed within each
Donabedian category, are vital for evaluating
emergency nursing quality. The aim of this scop-
ing review was to identify NQIs in adult emer-
gency nursing within Donabedian’s quality
categories, explore their validation, and enhance
their utilization in this context. By reviewing
emergency nursing quality through Donabedian
categories (structures, processes, and outcomes),
a comprehensive assessment of quality can
be achieved. The following research questions
guided this review: (1) Which NQIs have been
used in quality assessment in adult emergency
nursing? (2) Under which Donabedian category
does each NQI fall? (3) Have the NQIs been
validated?
METHODS
This scoping review is reported using the
Preferred Reporting Items for Systematic
reviews and Meta-Analyses extension for
Scoping Reviews (PRISMA-ScR)24 guideline.
The review did not require registration,25 and
no institutional approvals were required.
Search strategy
In line with typical scoping reviews, the
broad question aims to summarize extensive
evidence.25,26 Due to emergency nursing’s com-
plex nature, the previously mentioned research
questions were used to guide the review. The
review applied the PCC (Populations, Concept,
Context) framework as suggested by Peters
et al.25: “Populations” as nursing professionals,
“Concept” as nursing-sensitive quality indica-
tors, and “Context” as emergency nursing.
Following Joanna Briggs Institute recommenda-
tions, the Cumulative Index to Nursing and
Allied Health Literature and Medline (Ovid)
databases were utilized, ensuring sufficient
coverage.27 The search protocol, detailed in
Supplemental Digital Content, Table 1, avail-
able at: http://links.lww.com/JNCQ/B272, was
developed with an information specialist. The
search, conducted in February 2023, focused
on English-language articles without timeline
restrictions; 2 additional articles were included
based on manual reference search.
Article selection
Included articles focused on NQIs for quality
assessment, evaluation, or improvement in
adult emergency nursing, encompassing both
research and non-research studies. Included
non-research articles had to contain new infor-
mation that was different from research articles.
Emergency nursing was defined as immediate
care for sudden illnesses, injuries, or medical
emergencies in clinical settings such as hospital
EDs or urgent care centers. NQIs measured out-
comes manageable by nursing practice.5 Two
reviewers independently selected articles, with
the third reviewer consulted in disagreements.
See Figure for a flow diagram of how articles
were included in the review.
Data charting
One reviewer extracted the following variables:
author(s), year of publication, country, purpose,
study aim, design, sample size, main results,
and NQIs used. Critical appraisal was not per-
formed, as it is not required in scoping reviews.25
See Supplemental Digital Content, Table 2,
available at: http://links.lww.com/JNCQ/B273
for an overview of the studies included in the
review.
Identifying and analyzing NQIs from data
To ensure that all NQIs were discovered, 2
of the researchers independently identified all
NQIs before jointly reviewing and analyzing
the results in the following way: (a)
Identification: the NQIs used in the empirical
analysis of the studies or NQIs that were the
result of a study were identified; (b) Coverage
of the quality: the NQIs identified were categor-
ized deductively into structure, process and
outcome5; (c) Validation: the protocols and/
or process for how each NQI was validated
were identified.
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RESULTS
A total of 917 articles were identified in the
search. Based on the screening of the titles and
abstracts, the first author chose 101 articles to be
independently reviewed in full by 2 of the
researchers. Included articles (n = 18), published
between 2010 and 2022, were from the USA
(n = 10), Australia (n = 5), Great Britain (n = 2),
and China (n = 1). Among the research articles,
there were 2 intervention studies; 2 Delphi stu-
dies; and 1 study with each of the following
designs: retrospective, observation, mixed-meth-
ods, feasibility, single-site, focus group interview,
integrative review, and systematic review. The
remaining 6 articles were non-research.
NQIs in adult emergency nursing
A total of 85 NQIs were identified, comprising
65 from research and 20 from non-research arti-
cles. The integrative review included in this
research article comprised 3 articles, which
were also identified through the literature search
for this scoping review. The results from both
systematic and integrative reviews identified
potential indicators for emergency nursing,
which are included in this review. Indicators
were categorized into quality categories: struc-
ture (n = 14), process (n = 45), and outcomes
(n = 26). In the following paragraphs, these indi-
cators are detailed; an overview can be found in
Supplemental Digital Content, Table 3, available
at: http://links.lww.com/JNCQ/B274.
Structural NQIs were least utilized in both
research and non-research articles (n = 14). In
research articles, they covered preventive
tools,13,28,29 observation protocols, patient char-
acteristics, and resources.13,30 Non-research
NQIs focused on staff skill mix,31 interventions
for specific diseases,29,32 and methods for col-
lecting reasons for ED visits.32 Both research
and non-research articles identified an availabil-
ity of falls prevention protocols (ie, risk assess-
ment protocols)28,31 and diversion hours32,33 as
structural NQIs.
Figure. PRISMA-ScR flow diagram. CINAHL = Cumulative Index to Nursing and Allied Health Literature; PRISMA-
ScR = Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews.
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The majority of NQIs were process indica-
tors (n = 45). In research articles, process NQIs
focused on documentation,13,28,30,34,35 patient
identification,13,35 suicidal patient identification,34
the risk for pressure injuries,28 standardized hand-
off reports,34 and ED patient medication.13,30
Rapid-response situations (eg, stroke, sepsis)
were evaluated with timeline-specific process
NQIs from research articles.13,30,34 Non-research
articles addressed process indicators focused on
managing treatment,29,36 screening for high blood
pressure,31,36 recognizing depression,29,31,36 screen-
ing for nutrition,31 telephone triage (providing
remote medical advice and coordinating care
over the phone during emergencies),29 and home
medication.29,36 Common process NQIs in both
research and non-research articles covered
pain,13,23,28-32,34-36 falls risk assessment,28,31,34
transitions,29,35 and triage.29,33
Outcome NQIs (n = 26) assessed both
nurses’ and patients’ perspectives, including
patient engagement. Exclusively in research
articles, these NQIs covered adverse events,
identifications of high-risk patients, triage
target response time attainment rate, identifi-
cation of the need for immediate isolation/
decontamination at triage, and immediate
recognition of high-risk patients. Outcome
NQIs in non-research articles focused on the
number of hospitalized and redirected patients
(ie, rerouted within the health care facility) and
patients that left the ED before completing treat-
ment. Both research and non-research articles
presented NQIs related to patient satisfaction,28-
31,37-40 nurses’ job satisfaction,33,39 accuracy of
triage,28,29,34 falls in the ED,13,30,31,34 and overall
length of time spent in the ED.
Validation of the NQIs
Validation of identified NQIs in adult
emergency nursing was limited. Out of 12
research articles, 313,41,42 lacked validation
information, while NQI validation occurred in
9 articles. Validation was made in 3 research
articles30,34,35 in the context of emergency nur-
sing, 335-43 in emergency services, and 324,28,33
in intensive care units or inpatient wards with-
out specifying the method. In a systematic
review,23 NQI validation was deemed insuffi-
cient for the emergency nursing field, posing
a challenge in assessing quality and requiring
further research for validation. Among 6
non-research articles, 2 lacked validation
information,39,40 1 used an expert panel for
validation,29 and 341-32 referred to a task force
and its work report. The validation protocols
used are presented in Supplemental Digital
Content, Table 4, available at: http://links.
lww.com/JNCQ/B275.
DISCUSSION
This scoping review aimed to identify and clas-
sify NQIs used in adult emergency nursing. The
objective was to analyze the validation of these
NQIs and assess how comprehensively they
cover the 3 Donabedian categories of structure,
process, and outcome, contributing to the
description of quality. The review identified 85
NQIs, with a notable emphasis on process indi-
cators, followed by outcome and structure indi-
cators. This highlights the prevailing focus on
evaluating the quality of adult emergency nur-
sing, particularly through widely reported pro-
cess indicators.Moving forward, it is essential to
ensure that all of Donabedian’s quality cate-
gories used in this context remain relevant.
Structural NQIs are measured through the
use of available preventive tools, observation
protocols, and resource utilization but lack spe-
cificity for emergency elements such as triage or
pain. Surprisingly, none of the research articles
employed NQIs to assess the competence or edu-
cation level of nurses; this aspect was addressed
in only one non-research article.31 It is imperative
to identify and specify structural competencies
in emergency nursing to assess professional
needs and plan education and training.5,13 As
a summary, present structural indicators seem
to inadequately reflect the specific nature of
adult emergency nursing. For example, structural
nursing NQIs have not yet undergone adequate
validation or clear definition from the perspective
of emergency nursing. Enhancing the description
and validation process will improve the relevance
of structural indicators in evaluating the quality
of adult emergency nursing.
Process NQIs are easily collected, as these
data are often readily accessible through the
electronic health record.39 Emergency nursing,
which unfolds in a dynamic environment,11
necessitates clear processes and protocols to
ensure patient safety and achieve optimal
patient outcomes. Process NQIs concentrate
on tools, protocols, and specific processes
associated with patient care, triage, pain
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management, medication administration, and
the quality of documentation. An important
positive discovery was the consistent use of
pain-related protocols.13,28-32,34-36 Pain stands
out as one of the most common reasons for ED
visits,44 and effective pain management contri-
butes to patient satisfaction45 and overall health
status. While pain is well-represented among
process NQIs, it is noteworthy there were no
pain specific NQIs identified within the structural
category.
Process indicators in adult emergency nursing,
including documentation and various delays, are
critical for ensuring patient safety and nursing
quality. Nevertheless, certain indicators con-
cerning timelines, such as the time from exam-
ination to decision or the time from the ED door
to transition, lack adequate validation.23,28,33,36
Further research is needed to establish their rele-
vance and identify precise measures for effective
emergency nursing. This exploration should
consider “nurse sensitivity,” which refers to
nurses’ capacity to deliver personalized care tai-
lored to individual patient needs in the ED.13,34
It emphasizes nursing excellence in achieving
positive outcomes in emergencies. Among pro-
cess NQIs, only 4 were patient-related, covering
aspects such as patients’ belongings in the ED,35
patient identification,35 communication,29,35
and managing patient self-care.29 Recognizing
patients’ belongings as a NQI is important,
reflecting care quality and enhancing satisfac-
tion. Patient engagement in care has proven
positive effects on satisfaction, outcomes,
and the meaningfulness of nurses’ work.46
Therefore, future efforts should concentrate
on integrating patient engagement into the
assessment of adult emergency nursing quality.
Outcome NQIs assess perspectives from both
nurses and patients, including patient engagement
in care. These indicators evaluate triage accuracy,
adverse events, and ED patient stay duration.
Patient satisfaction, a prominent outcome
indicator,13,28-31,38-40 is widely used in health care
and is integrated into organizational standards
with systematicmonitoring.6,47 Future exploration
should examine if assessing satisfaction alone
enhances emergency nursing quality. Balancing
patient satisfaction with nursing professionalism
means meeting patient needs while upholding pro-
fessional standards, crucial in the context of
patient-centered care in nursing. In non-research
articles, outcome NQIs often overlook vital
nursing care aspects, which reflects the structural
and process NQIs’ emphasis on specific, clearly
defined criteria or metrics for evaluation.
The outcome NQIs overlook critical nursing
issues, highlighting the necessity for greater sen-
sitivity to nursing concerns, particularly in
developing NQIs that capture nursing’s nuanced
impact on patient outcomes. Research articles
highlighted several adverse event-related NQIs,
underscoring the importance of examining both
structural and process NQIs to ensure they effec-
tively support patient safety and measure suc-
cess in nursing practice.
The validation of NQIs in adult emergency
nursing is limited, with only a subset of research
articles employing protocols such as the Delphi
method, existing quality frameworks, previous
studies, and validation based on medical cri-
teria, such as time-dependent outcomes. With
limited methodological solutions available, the
scope of validation remains constrained. While
some studies achieved consensus onNQIs,30,35,38
others did not. The widely used Delphi method
produced validated indicators of emergency
nursing quality,29,30,34,35 yet the lack of a clear
definition of emergency nursing and its charac-
teristics may have affected indicator consistency.
Further research is needed to validate already
existing NQIs specifically in the emergency nur-
sing setting.
This scoping review provides insights into the
NQIs applied in adult emergency nursing,
encompassing structure, process, and outcome
indicators. While this scoping review identified
NQIs used in adult emergency nursing, the find-
ings are limited. Often only the name of the NQI
was provided, but there was a lack of substantial
details regarding the NQI definition and con-
tent. Future exploration should delve into the
content of the utilized NQIs. Among identified
NQIs, process indicators emerged as the most
frequently used. However, the limited validation
of these indicators underscores the necessity for
additional research to ensure their reliability and
applicability in the context of nursing quality in
emergency settings. Moving forward, further
validation of these existing 85 NQIs and the
validation of new NQIs for adult emergency
nursing are topics for further research.
NQIs assess adult emergency nursing across
structures, processes, and outcomes, with process
indicators being prevalent. While certain indica-
tors like pressure injuries or falls were common
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across structure, process, and outcome categories,
many other indicators were not shared across all
categories. Donabedian’s framework facilitates
comprehensive assessment, identifying improve-
ment areas by linking structures to processes,
impacting outcomes.7 Not all categories require
an equal number of indicators; for example, nur-
sing professionals’ competence influences pro-
cesses, and patient involvement enhances both
structures and processes. Donabedian’s approach
allows for thorough examination, aiding nursing
management, education, and individual practice.
Limitations
The scoping review methodology was chosen
for a broad understanding,24 with reliability
ensured through systematic methods, including
manual and automatic searches on 2 databases.
Although we identified NQIs for assessing emer-
gency nursing care quality, content descriptions
in included articles, whether research or non-
research, were limited. The review aimed for
indicator identification and validation, and this
level of precision sufficed considering the avail-
able data. To enhance nurse sensitivity identifi-
cation, we defined nurse quality indicators,
narrowing down identifiable NQIs. Yet, nursing
sensitivity still requires further refinement.
The chosen method allowed inclusion of non-
research articles; however, a significant portion
lacked explicit mention of scientific methods
derived from the task force’s work. For this
review’s purpose of mapping indicators and
assessing validation, the scoping review method
sufficed. Future efforts should prioritize scienti-
fic validation to enhance reliability, ensuring
identified indicators are rigorously tested and
confirmed as accurate and effective measures of
emergency nursing quality.
CONCLUSIONS
This scoping review aimed to identify NQIs in
adult emergency nursing, examine their valida-
tion, and assess alignment with Donabedian’s
quality categories. Eighty-five NQIs were
identified, mostly process-related, but with lim-
ited content descriptions, indicating the need
for further exploration. Validation methods
for NQIs in adult emergency nursing varied,
with inconsistent consensus despite using
methodologies like the Delphi method. Future
research should focus on validation specific
to emergency nursing. Considering the usabil-
ity of Donabedian’s categories in quality assess-
ment is important. Exploring the relationship
between structure, process, and outcome
indicators is crucial for a holistic understand-
ing of nursing care quality. Future research
should prioritize validating existing NQIs and
exploring new indicators for comprehensive
assessment.
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