Construction of nursing‐sensitive quality indicators for haemodialysis using Delphi method
Abstract
Aims and objectives: To provide a set of nursing‐sensitive quality indicators (NSQIs) for the evaluation of clinical nursing quality in haemodialysis unit. Background: There are no established objective indicators for evaluation of the quality of nursing care in haemodialysis units in China. Design and methods: We performed a literature search for eligible studies published from 2006–2016. A total of six studies were screened out from which 13 potential NSQIs were identified. Two rounds of Delphi surveys were conducted with the purpose of collecting opinions from a panel of independent experts. At last, 11 NSQIs were selected by consensus after exclusion of 8 NSQIs and addition of another 6 NSQIs. Results: Two rounds of expert inquiry were conducted; the questionnaire recovery rate was 100%. The average authoritative coefficients Cr for the two rounds were 0.79 and 0.90, respectively. The Kendall W values ranged from 0.273–0.388 (p < 0.001). Eleven NSQIs were identified: nurse‐to‐patient ratio, dialysis ultrafiltration rate compliance rate, KT/V compliance rate, incidence of emergency during haemodialysis, person‐time incidence rate of haemodialysis catheter‐related bloodstream infections, incidence of coagulation in extracorporeal circulation, incidence of blood loss in extracorporeal circulation, incidence of pseudoaneurysm induced by fistula puncture, incidence of falls among haemodialysis patients, emergency dialysis rate of outpatients and incidence of fistula complications. Conclusion: The identified NSQIs reflect three aspects of haemodialysis nursing quality: importance, rationality of calculation formula and applicability of data collection methods. Relevance to clinical practice: The study provides a reference for the evaluation of clinical nursing quality in haemodialysis units.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The studies by Li Yi (2019) and Gao et al. (2018) did not include process indicators.
“However, these two studies did not include process indicators, and because process quality is an important link to ensure nursing quality through the implementation of oversight in the nursing process, it should be included in the index system.”
From Construction of haemodialysis nursing‐sensitive quality indicators based on Donabedian theory: A Delphi method study (2023) · cites this paper as Gao et al. (2018)
Among structural indicators, the nurse-patient ratio is the most basic and important indicator.
“Among the structural indicators, the most basic and important indicator is the nurse–patient ratio, which has been confirmed in the studies of McIntyre et al. (2019) and Gao et al. (2018).”
From Construction of haemodialysis nursing‐sensitive quality indicators based on Donabedian theory: A Delphi method study (2023) · cites this paper as Gao et al. (2018)
In haemodialysis units, the ratio of nurses to patients can affect patient prognosis; fewer nurses directly affects treatment compliance, resulting in increased hospitalization and mortality.
“In haemodialysis units, the ratio of nurses to patients can affect the prognosis of patients, and having fewer nurses directly affects the treatment compliance of patients, resulting in an increased hospitalization rate and mortality rate.”
From Construction of haemodialysis nursing‐sensitive quality indicators based on Donabedian theory: A Delphi method study (2023) · cites this paper as Gao et al. (2018)
Gao et al. (2018) determined 11 sensitive indicators of haemodialysis nursing quality through two rounds of letter consultation.
“Gao et al. (2018) determined 11 sensitive indicators of haemodialysis nursing quality through two rounds of letter consultation.”
From Construction of haemodialysis nursing‐sensitive quality indicators based on Donabedian theory: A Delphi method study (2023) · cites this paper as Gao et al. (2018)
The 11 indicators identified by Gao et al. include only 3 items related to vascular access, without dimension-specific categorization.
“Among the 26 hemodialysis nursing quality indicators developed by McIntyre et al. (20), only 5 items are related to vascular access, and the 11 indicators identified by Gao et al. (21) include only 3 items related to vascular access, without dimension-specific categorization.”
From Construction of nursing-sensitive quality indicators for hemodialysis vascular access: a Delphi study (2026) · cites this paper as [21]
The constructed indicators in existing studies do not fully encompass the three dimensions of structure-process-outcome.
“Existing studies focus primarily on the construction of general hemodialysis nursing quality indicators, with only a few items related to vascular access, and the constructed indicators do not fully encompass the three dimensions of structure–process–outcome.”
From Construction of nursing-sensitive quality indicators for hemodialysis vascular access: a Delphi study (2026) · cites this paper as [21]
Existing studies focus primarily on the construction of general hemodialysis nursing quality indicators, with only a few items related to vascular access.
“Existing studies focus primarily on the construction of general hemodialysis nursing quality indicators, with only a few items related to vascular access, and the constructed indicators do not fully encompass the three dimensions of structure–process–outcome.”
From Construction of nursing-sensitive quality indicators for hemodialysis vascular access: a Delphi study (2026) · cites this paper as [21]
Inadequate nurse staffing will directly lead to an excessive number of patients per nurse, which in turn reduces the standardization of vascular access assessment and maintenance procedures, and elevates the risk of adverse events such as unplanned extubation and catheter-related infections.
“Inadequate nurse staffing will directly lead to an excessive number of patients per nurse, which in turn reduces the standardization of vascular access assessment and maintenance procedures, and elevates the risk of adverse events such as unplanned extubation and catheter-related infections.”
From Construction of nursing-sensitive quality indicators for hemodialysis vascular access: a Delphi study (2026) · cites this paper as Gao et al. [21]
Studies by McIntyre et al. (20) in Canada and Gao et al. (21) in China have verified the negative correlation between the nurse-to-patient ratio and the incidence of adverse events in hemodialysis patients.
“Additionally, studies by McIntyre et al. (20) in Canada and Gao et al. (21) in China have also verified the negative correlation between the nurse-to-patient ratio and the incidence of adverse events in hemodialysis patients.”
From Construction of nursing-sensitive quality indicators for hemodialysis vascular access: a Delphi study (2026) · cites this paper as Gao et al. [21]
Cites
An Experimental Application of the DELPHI Method to the Use of Experts
Dalkey, N., & Helmer, O. (1963) · Management Science · doi:10.1287/mnsc.9.3.458 · Cited by 6,061 · see citing works
Donabedian, A. (1988) · JAMA · doi:10.1001/jama.260.12.1743 · Cited by 5,895 · see citing works
Aiken, L. H., Sloane, D. M., Bruyneel, L., den Heede, K. V., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E. M. E. H., et al. (2014) · The Lancet · doi:10.1016/s0140-6736(13)62631-8 · Cited by 2,242 · see citing works
KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update.
Rocco, M., Daugirdas, J., Depner, T., Inrig, J., Mehrotra, R., Rocco, M. V., Suri, R. S., Weiner, D., Greer, N., Ishani, A., et al. (2015) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2015.07.015 · Cited by 905 · see citing works
Shoji, T., Tsubakihara, Y., Fujii, M., & Imai, E. (2004) · Kidney International · doi:10.1111/j.1523-1755.2004.00812.x · Cited by 653 · see citing works
Kalantar‐Zadeh, K., Regidor, D. L., Kovesdy, C. P., Wyck, D. V., Bunnapradist, S., Horwich, T. B., & Fonarow, G. C. (2009) · Circulation · doi:10.1161/circulationaha.108.807362 · Cited by 541 · see citing works
Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality
Flythe, J. E., Kimmel, S. E., & Brunelli, S. M. (2010) · Kidney International · doi:10.1038/ki.2010.383 · Cited by 517 · see citing works
The Role of Outcomes in Quality Assessment and Assurance
Donabedian, A. (1992) · QRB - Quality Review Bulletin · doi:10.1016/s0097-5990(16)30560-7 · Cited by 508 · see citing works
Malnutrition in Hemodialysis Patients
Hakim, R. M., & Levin, N. W. (1993) · American Journal of Kidney Diseases · doi:10.1016/s0272-6386(12)81083-3 · Cited by 355 · see citing works
Movilli, E., Gaggia, P., Zubani, R., Camerini, C., Vizzardi, V., Parrinello, G., Savoldi, S., Fischer, M. S., Londrino, F., & Cancarini, G. C. (2007) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfm466 · Cited by 242 · see citing works
Falls in hemodialysis patients: Prospective study of incidence, risk factors, and complications
Desmet, C., Beguin, C., Swine, C., & Jadoul, M. Y. (2005) · American Journal of Kidney Diseases · doi:10.1053/j.ajkd.2004.09.027 · Cited by 181 · see citing works
Nursing‐sensitive indicators: a concept analysis
Heslop, L., Lu, L., & Xu, X. (2014) · Journal of Advanced Nursing · doi:10.1111/jan.12503 · Cited by 169 · see citing works
Burston, S., Chaboyer, W. P., & Gillespie, B. M. (2013) · Journal of Clinical Nursing · doi:10.1111/jocn.12337 · Cited by 146 · see citing works
Increased risk of hip fracture among Japanese hemodialysis patients
Wakasugi, M., Kazama, J. J., Taniguchi, M., Wada, A., Iseki, K., Tsubakihara, Y., & Narita, I. (2013) · Journal of Bone and Mineral Metabolism · doi:10.1007/s00774-012-0411-z · Cited by 130 · see citing works
Nakrem, S., Vinsnes, A. G., Harkless, G., Paulsen, B., & Seim, A. (2008) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2008.11.005 · Cited by 127 · see citing works
Falls among hemodialysis patients: potential opportunities for prevention?
Kutner, N. G., Zhang, R., Huang, Y., & Wasse, H. (2014) · Clinical Kidney Journal · doi:10.1093/ckj/sfu034 · Cited by 64 · see citing works
Usvyat, L. A., Barth, C., Bayh, I., Etter, M., von Gersdorff, G. D., Grassmann, A., Guinsburg, A. M., Lam, M., Marcelli, D., Marelli, C., et al. (2013) · Kidney International · doi:10.1038/ki.2013.73 · Cited by 61 · see citing works
Arrhythmias in hemodialysis patients
Voroneanu, L. E., & Covic, A. C. (2009) · Journal of Nephrology · doi:10.1093/joneph/22.6.716 · Cited by 50 · see citing works
Barriers to and facilitators of care for hemodialysis patients; a qualitative study
Nobahar, M., & Tamadon, M. R. (2016) · Journal of Renal Injury Prevention · doi:10.15171/jrip.2016.09 · Cited by 49 · see citing works
Bray, B., Boyd, J., Daly, C., Doyle, A., Donaldson, K., Fox, J., Innes, A. J., Khan, I. H., Mackinnon, B., Peel, R. K., et al. (2013) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gft197 · Cited by 47 · see citing works
A descriptive report of errors and adverse events in chronic hemodialysis units.
Holley, J. L. (2006) · PubMed · Cited by 46 · see citing works
The vulnerable patient with chronic kidney disease
Schlieper, G., Hess, K., Floege, J., & Marx, N. (2015) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfv041 · Cited by 42 · see citing works
Moulin, M. F. M. T. D., van Haastregt, J. C. M., & Hamers, J. P. H. (2010) · Patient Education and Counseling · doi:10.1016/j.pec.2010.01.008 · Cited by 42 · see citing works
High fall incidence and fracture rate in elderly dialysis patients.
Polinder‐Bos, H. A., Emmelot‐Vonk, M. H., Gansevoort, R. T., Diepenbroek, A., & Gaillard, S. (2014) · PubMed · Cited by 37 · see citing works
Using the D elphi method to develop nursing‐sensitive quality indicators for the NICU
Chen, L., Huang, L., Xing, M., Feng, Z., Shao, L., Zhang, M., & Shao, R. (2016) · Journal of Clinical Nursing · doi:10.1111/jocn.13474 · Cited by 33 · see citing works
Wu, Q., Huang, L., Xing, M., Feng, Z., Shao, L., Zhang, Y., & Shao, R. (2016) · Australian Critical Care · doi:10.1016/j.aucc.2016.04.003 · Cited by 29 · see citing works
Feasibility of a hemodialysis safety checklist for nurses and patients: a quality improvement study
Thomas, A., Silver, S. A., Rathe, A., Robinson, P., Wald, R., Bell, C. M., & Harel, Z. (2016) · Clinical Kidney Journal · doi:10.1093/ckj/sfw019 · Cited by 27 · see citing works
Eventos adversos em hemodiálise: relatos de profissionais de enfermagem
de Sousa, M. R. G., Silva, A. E. B. D. C., Bezerra, A. L. Q., de Freitas, J. S., & Miasso, A. I. (2013) · Revista da Escola de Enfermagem da USP · doi:10.1590/s0080-62342013000100010 · Cited by 24 · see citing works
Development of quality of care indicators from systematic reviews: the case of hospital delivery
Bonfill, X., Figuls, M. R. I., Aller, M.-B., Osorio, D., Foradada, C. M., Vives, À., & Comas, D. R. (2013) · Implementation Science · doi:10.1186/1748-5908-8-42 · Cited by 22 · see citing works
Ultrafiltration rate as a nursing-sensitive quality indicator in haemodialysis
Lindberg, M., & Ludvigsen, M. S. (2012) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2012.02.018 · Cited by 17 · see citing works
Quality nephrology nursing care: beyond Kt/V.
Bennett, P. N., & Neill, J. (2008) · PubMed · Cited by 9 · see citing works
PREVENTION AND TREATMENT OF MICROVASCULAR AND NEUROPATHIC COMPLICATIONS OF DIABETES
Eastman, R. C., & GARFIELD, S. A. (1999) · Primary Care Clinics in Office Practice · doi:10.1016/s0095-4543(05)70131-7 · Cited by 6 · see citing works
The application of nursing-sensitive quality indicators in evaluating nursing efficacy.
Li, Z., Cheng, S., Lv, L., Xy, S., & Liu, X. H. (2014) · PubMed · doi:10.7417/ct.2014.1760 · Cited by 4 · see citing works
Self-citation
Flagged first, then by citations
2 of the 35 references couldn’t be matched to a known paper.
Cited by
Sorted by citations
Nursing-sensitive indicators: a concept analysis
Afaneh, T., Abu-Moghli, F. A., & Ahmad, M. M. (2021) · Nursing Management · doi:10.7748/nm.2021.e1982 · Cited by 48 · see citing works
The development of nursing-sensitive indicators: A critical discussion
Gormley, E., Connolly, M., & Ryder, M. (2024) · International Journal of Nursing Studies Advances · doi:10.1016/j.ijnsa.2024.100227 · Cited by 33 · see citing works
Chen, L., Zhang, Y., Li, C., Li, Q., & He, L. (2023) · Nursing Open · doi:10.1002/nop2.1349 · Cited by 28 · see citing works
“Among the structural indicators, the most basic and important indicator is the nurse– patient ratio, which has been confirmed in the studies of McIntyre et al. (2019) and Gao et al. (2018).”
BackgroundResultZhang, M., Chen, W., Liu, C., Sui, J., Wang, D., Wang, Y., Meng, X., Wang, Y., & Yue, C. (2021) · Nursing Open · doi:10.1002/nop2.895 · Cited by 19 · see citing works
Toward a Medication Information Literacy Indicator System for Older Adults: A Delphi Study
Zhou, X., Yi, J., Bai, L., Jiang, M., Peng, W., Liao, J. P., Wang, H., & Hou, X. (2024) · Health Expectations · doi:10.1111/hex.14127 · Cited by 12 · see citing works
Identifying nurse sensitive indicators specific to haemodialysis nursing: A Delphi approach
McIntyre, D., Coyer, F., & Bonner, A. (2020) · Collegian · doi:10.1016/j.colegn.2019.06.003 · Cited by 11 · see citing works
Design of assessment tool for unplanned endotracheal extubation of artificial airway patients
Zhang, P., & Liu, L. (2021) · Nursing Open · doi:10.1002/nop2.807 · Cited by 10 · see citing works
Li, Y., Zheng, D., Ma, L., Luo, Z., & Wang, X. (2022) · Annals of Palliative Medicine · doi:10.21037/apm-22-471 · Cited by 10 · see citing works
Chen, X., Liao, P., & Zhou, Y. (2023) · BMC Nursing · doi:10.1186/s12912-023-01505-4 · Cited by 8 · see citing works
Identifying Nursing-Sensitive Indicators for Hospitals: A Modified Delphi Approach
Afaneh, T., Abu-Moghli, F. A., & Mihdawi, M. (2024) · Cureus · doi:10.7759/cureus.59472 · Cited by 5 · see citing works
Establishment of a no-notice drill mode evaluation system for public health emergencies
Huang, S., Lin, Z., Lin, X., Li, L., Ruan, F., Mei, W., & Chen, S. (2022) · PLoS ONE · doi:10.1371/journal.pone.0266093 · Cited by 4 · see citing works
Ambulatory Care Nurse-Sensitive Indicators
Siaki, L., Patrician, P. A., Loan, L. A., Matlock, A. M., Start, R. E., Gardner, C. L., & McCarthy, M. S. (2022) · Journal of Nursing Care Quality · doi:10.1097/ncq.0000000000000660 · Cited by 4 · see citing works
Research on the Effect of 5Why-Based Nursing Intervention in Blood Purification Nursing
Cai, R., Fei, Y., Li, X., Xu, L., Wu, C. L., & Wu, N. (2021) · Journal of Healthcare Engineering · doi:10.1155/2021/6535238 · Cited by 4 · see citing works
RetractedUsing the Delphi Method to Construct a Promotion Plan for Clinical Nurse Specialists
Zhao, H., Li, W., Gao, M., & Shi, L. (2021) · Clinical Nurse Specialist · doi:10.1097/nur.0000000000000605 · Cited by 4 · see citing works
What digital competencies should medical students in China possess in the AI era?
Chen, J., Hou, X., Lv, Y., Liu, M., Yang, M., Zhou, X., Du, F., Yi, J., Zhang, L., & Li, G. (2025) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2025.106043 · Cited by 3 · see citing works
Chen, X., Zhang, P., Zhang, R., Li, S., Cao, R., Hu, F., Jin, Y., Lin, L., Cai, L., Feng, B., et al. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2022.1062199 · Cited by 3 · see citing works
Validation of the McIntyre Audit Tool to measure haemodialysis nurse sensitive indicators
McIntyre, D., Bonner, A., & McGuire, A. (2022) · Journal of Renal Care · doi:10.1111/jorc.12441 · Cited by 2 · see citing works
Xu, S., Chen, P., & ZHANG, G. (2024) · Journal of Educational and Social Research · doi:10.36941/jesr-2024-0025 · Cited by 1 · see citing works
Baillie, J., Bonner, A., Guillouët, S., Mikut, C., Punzalan, S., Kaczmarek, A., Wenzyl, L. C., & Finderup, J. (2025) · Journal of Renal Care · doi:10.1111/jorc.70008 · Cited by 1 · see citing works
Shi, Y., Zhuang, S., Hu, L., & Weng, Y. (2024) · Cellular and Molecular Biology · doi:10.14715/cmb/2024.70.5.30 · Cited by 1 · see citing works
Automatic control method of construction quality of geological survey in geotechnical engineering
Wu, H., Zhao, Y., & Zhang, D. (2020) · Arabian Journal of Geosciences · doi:10.1007/s12517-020-05809-6 · Cited by 1 · see citing works
Jiang, X., Chang, T., Wang, J., Xie, J., Miao, Q., Zhang, X., Liu, S., Zhang, Y., & Li, X. (2022) · Research Square · doi:10.21203/rs.3.rs-2215118/v1 · Cited by 1 · see citing works
Zhang, Y., He, L., Tang, S., Gao, Y., Chen, H., Shi, M., & Chen, L. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1858484
“Additionally, studies by McIntyre et al. (20) in Canada and Gao et al. (21) in China have also verified the negative correlation between the nurse-to-patient ratio and the incidence of adverse events in hemodialysis patients.”
Tang, S., Li, Q., Liu, L., He, L., Zhang, Y., & Chen, L. (2026) · Journal of Nursing Management · doi:10.1155/jonm/8833031
“Gao et al. identifed 11 NSQIs of HD through 2 rounds of expert consul-tation [14].”
Feasibility of the McIntyre audit tool for haemodialysis nurses
McIntyre, D., McGuire, A., & Bonner, A. (2023) · Journal of Renal Care · doi:10.1111/jorc.12477
Construction of Quality Evaluation Index System for Surgical Positioning: A Delphi Method
Guo, Y., Qu, X., Tiyu, Z., & Wang, Y. (2025) · Nursing Open · doi:10.1002/nop2.70352
Xu, Y., Wu, Y., & Cao, G. (2026) · SAGE Open Nursing · doi:10.1177/23779608251408227
Huang, C., Liu, H., Wenwen, Q. I., Shuyuan, Z. H. A. O., Xu, J., Jing, F., & Chen, E. (2026) · Frontiers in Medicine · doi:10.3389/fmed.2026.1815560
Zhao, H., Liu, C., Song, L., & Wang, W. (2026) · Patient Preference and Adherence · doi:10.2147/ppa.s609661
- Authors
- Gao, J., Liu, X., Che, W., & Xin, X.
- Affiliations
- Department of Hemodialysis The First Affiliated Hospital of Xi'an Jiaotong University Xi'an China
- First Affiliated Hospital of Xi'an Jiaotong University (CN)
- Corresponding author
- Xin, Xia
- ORCID
- Gao, Ju‐Lin
- Venue
- Journal of Clinical Nursing
- Publisher
- Wiley
- Published
- 2018-08-02
- Volume
- 27
- Issue
- 21-22
- Pages
- 3920-3930
- ISSN
- 0962-1067 (ISSN-L)
- 1365-2702
- OpenAlex
- W2809934159
- Cited by
- 29
- References
- 35
- Citations by year
- 2026: 4 · 2025: 3 · 2024: 5 · 2023: 3 · 2022: 7 · 2021: 5 · 2020: 1 · 2019: 1
- FWCI
- 0.62
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Clinical Nursing (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Natural Science Basic Research Plan in Shaanxi Province of China (2017JM8141)
- Topics
- Social Sciences › Sociology and Political Science › Delphi Technique in Research
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Health Sciences › Medicine › Nephrology › Dialysis and Renal Disease Management
- Keywords
- nursing-sensitive quality indicators, nursing quality assessment, nurse-to-patient ratio, catheter-related bloodstream infection, blood loss, pseudoaneurysm, fistula complications, falls, emergency dialysis, expert consensus
- MeSH terms
- China, Delphi Technique, Renal Dialysis, Humans, Patient Compliance, Surveys and Questionnaires, Nursing Evaluation Research, Quality Indicators, Health Care, Consensus
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
