OBJECTIVES: To review nursing sensitive indicators used for nursing home care across seven nations with similar elder care (USA, Australia, Norway, New Zealand, England, Sweden and Denmark), and to evaluate their validity. DESIGN: Systematic search in the literature and other sources to find descriptions of development and validity testing of national quality indicators. DATA SOURCES: Papers from scientific databases, relevant websites, additional papers and reports, and personal communication with experts in the field. The material was included if it contributed to the description of each country's processes in defining nursing sensitive quality indicators for nursing home care, and the main focus was use, developing and/or testing of quality. REVIEW METHODS: An overview of each country's utilization of nursing sensitive quality indicators was obtained. The evidence for the validity in development and testing procedures was analyzed using a set of evaluation criteria. RESULTS: All countries, except Sweden, have nationally standardized assessment of the patient before admission to the nursing home. There is large variation in the way these data collection tools were developed and how the data is used. Only the USA has systematically developed quality indicators on the basis of resident assessments. Twenty-three indicators used nationally in USA, thirteen in Australia, four in Norway, three in New Zealand and three in England were selected for review, and were evaluated for their validity as described in the literature. All selected indicators had satisfactory face validity, and for the twenty-three indicators used in the USA there was evidence for reliability testing. None of the quality indicators met all the criteria for validity. Evidence that the quality indicators can demonstrate meaningful differences in care and that the information can be extracted with minimal extra efforts was not found. Thresholds for high or low quality were determined only for the US quality indicators. CONCLUSIONS: There are concerns about the validity and reliability of nursing sensitive quality indicators for nursing home care. The indicator development is sparsely documented. It is recommended that the development of quality indicators follows a sound process and that extensive empirical testing of the indicators is done.
