Nursing research is necessary to implement evidence-based practice and improve the quality of nursing research [1, 2]. Research priority-setting and gap analysis are the main steps in developing research strategies. Nursing research priority-setting assists nursing researchers and policymakers in targeting essential research areas [3].

Healthcare organizations have developed nurse-sensitive indicators (NSI) to measure the quality of nursing care and patient outcomes [4]. The American Nurses Association defines nursing-sensitive indicators as: “those indicators that capture care or its outcomes most affected by nursing care”. Nursing-sensitive indicators identify structures and processes affecting care outcomes. The effect of quality of nursing care on patient outcomes is not a new concept. Since the 1850s, Florence Nightingale has admitted the necessity of the quality of nursing care and measuring patient outcomes statistically [5]. In addition, nurses need to identify a set of indispensable indicators for monitoring their practices [6]. Therefore, nurse leaders must develop tools and collect reliable, consistent, and systematic information to assess the outcomes [6].

The National Database of Nursing Quality Indicators provides frequent reports of structure, process, and outcome indicators that evaluate nursing care in health care systems [7]. Measuring nursing-sensitive indicators helps guide quality improvement strategies [8]. There should be adequate research evidence on clinical effectiveness, safety, and efficiency based on indicators [8].

Nursing research is “a scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences the delivery of evidence-based nursing” [9]. Nursing research enhances nursing leadership, cost-effective patient care, and quality outcomes in the nursing profession and the healthcare system [12, 13]. The nursing research journey started in the 1930s when Florence Nightingale developed studies to investigate patient morbidity, mortality, and nursing education. The development of evidence-based nursing practice has been of great concern in nursing research [9]. Evidence-based practice (EBP) aligns the best research evidence with clinical expertise, patient needs, and values.

The systematic reviews and meta-analyses conducted in nursing have been limited compared with other disciplines [9]. One of the most severe barriers to the EBP movement is the lack of research evidence regarding the effectiveness of nursing interventions [9, 14, 15]. Recognizing the areas lacking research is a significant step in developing the evidence needed for practice [9].

Research prioritization is a crucial part of the efforts required to strengthen health research systems [3]. In addition, the development of research priorities helps meet professional and practice needs [16]. Nursing research priority-setting processes assist researchers and policymakers in effectively targeting nursing research that has an optimal impact on public health [3]. The systems-based research priorities include quality and safety indicators, resource management, health systems structure and functioning, and patient safety [16]. For example, in the United States, nursing research priorities for emergency nursing have included staff-to-patient ratios, human resource management, emergency department overcrowding and patients waiting in the emergency department for hospital beds, and education strategies [17].

To evaluate the best practice and evidence-based practice, qualitative and quantitative measures are needed [6]. The development of the clinical indicators must be after reviewing adequate research evidence relevant to the quality of care [8]. These indicators based on research evidence can be helpful to guide research priorities setting in clinical nursing research. The American Nurses Association defines the clinical indicators sensitive to nurses as: “those indicators that capture care or its outcomes most affected by nursing care”.

The indicators are significant for the quality of nursing care in the hospital [4]. The impact of nursing care on patient outcomes is not a new concept. Since the 1850s, Florence Nightingale has admitted the necessity of the quality of nursing practice and evaluation and measuring patient outcomes through statistical methods [5]. Clinical indicators are an essential component of effective monitoring and evaluation of patient safety and quality within the health care system. Healthcare institutions seeking accreditation aim to provide patient-centered care through monitoring indicators [4].

The nurse-sensitive indicators measure patient-related outcomes affected by nursing care [5]. Based on the quality assessment framework, including structure, process, and outcome, the American Nurses Association has grounded its work on developing NSI on 'Donabedian's framework’ [5]. The characteristic of the structure is that the interventions conducted by nurses are a process of providing beneficial outcomes for their patients [6]. Therefore, it is challenging for the nurse manager to decide which data to measure and improve the quality of nursing care related to patient outcomes.

Nursing-sensitive indicators identify structures and processes affecting care outcomes [7]. Nursing-sensitive indicators are specific to nursing and differ from medical care quality indicators. The National Database of Nursing Quality Indicators TM (NDNQI^®) provides quarterly and annual reporting of structure, process, and outcome indicators that evaluate nursing care in healthcare systems [7].

The use of NSI provides direction for nurse managers on measuring and improving nursing services and discussing the issues related to research on NSI. Most of the research on NSI is in acute care settings. A small number of studies have focused on specialist units, such as neonatal care, chronic hemodialysis, and intensive care [5, 18]. Standardized NSIs improve patient safety and workforce planning through enhanced knowledge that can help decision-making [18]. As nurse leaders, developing NSIs as standardized nursing data continues as a critical and expanding area of research to establish associations between nursing practice and patient outcomes.

Nurse leaders must use nursing reflection, evaluation, benchmark, and participation in research as one of their responsibilities [19]. The systems-based research priorities include quality and safety indicators, resource management, health systems structure and functioning, and patient safety [16]. Health organizations track up to 12-18 nursing-sensitive quality measures to provide significant insights based on structure, process, and outcome data [20]. For example, the National Quality Forum (NQF) from the United States suggested NSIs as “processes and outcomes and structural proxies for these processes and outcomes, e.g., skill mix, and nurse satisfaction, that are influenced by nurses but not exclusively responsible for them ” [21]. Nursing research/ evidence-based practice projects are one of the critical concepts of nursing shared governance [22-30]. Improved job satisfaction among nurses, improved patient outcomes, and other nursing-sensitive indicators, such as catheter-associated urinary tract infections, hospital-acquired pressure ulcers, falls with injuries, and central line-associated bloodstream infections, have the most significant clinical impacts when implementing shared governance structures and processes [30]. The National Institute of Nursing Research is one of the leading institutions in guiding nursing research and developing innovative questions for future research directions, such as promoting health, preventing illness, and self-management [31-33].

The study aims to explore nurse-sensitive indicators to find significant areas of research and prioritize them. The study design is exploratory research conducted through scoping review for electronic databases to identify key concepts and evidence with a broad approach to the scope or map topics. Scoping review method is typically systematic but without assessing the quality of included studies [22]. The Delphi Consultation was conducted to identify clinical indicators applicable in the Saudi Arabia health care system and prioritize them as research areas. The sampling technique is a purposive sample 41 participants. We used The PRISMA flow diagram in data collection through databases [23]. For eligibility criteria, we included the following types of papers:

• Papers discussing the clinical nursing indicators.
• Papers discussing the nursing-sensitive indicators.
• Papers discussing clinical nursing indicators and nurse-sensitive indicators in Saudi Arabia.

The comprehensive literature searches were performed from 1^st January, 2021, until 31^st March, 2021, in the following electronic databases: PubMed, CINAHL, Scopus, and the Nursing and allied health database. Search terms are as follows: “clinical nursing indicators” or “clinical nursing measures”, “nursing-sensitive indicators “or “nursing-clinical nursing,” “nursing-sensitive indicators or measures in Saudi Arabia,” “nursing clinical indicators or measures in Saudi Arabia.” All duplicated literature was removed after searching and eligibility screening. All study designs were considered eligible, including those that utilize qualitative or quantitative methods, methodology, or guideline reports. The study included 32 articles discussing NSIs and meeting the eligibility criteria.

Delphi consultation prioritized the research based on clinical nursing indicators conducted in two rounds. Round (1) identified the research themes important to nurses’ nursing clinical indicators based on review results. The experts were qualified nurses working in King Fahad Medical City in Riyadh, representing a tertiary health hospital accredited by national and international agencies. The total number of experts was 41 quality nurses working in different units. The survey included 106 NSIs summarized from the comprehensive literature reviews. In round (2), the research works identified in the round (1) were ranked and prioritized. Interviews were conducted individually with eight nursing research experts working within the general directorate of health affairs and the Ministry of Health. The list of NSIs, along with their dimensions, was explained and discussed during the interviews. The dimensions of research were based on a literature review, and four of them were selected based on expert consensus: patient-centeredness, patient safety, work environment, and informatics nursing.

The scoping review was conducted within four selected databases (PubMed, CINAHL, Scopus, and Nursing and allied health database). The articles included in the review were 32, as presented in Tables 1 and 2. All included studies were related to nursing-sensitive indicators and (100%) nursing-related studies. When we reviewed the studies’ designs, it was found that 38% of the studies were literature reviews, and 19% used the Delphi technique. About 22% were cross-sectional surveys, and the same percentage was for quality improvement project-related studies. Furthermore, 6% of the studies were conducted in the Arab Gulf countries, and 84% were international studies. Finally, about 60% of the studies were conducted in the ICU setting, 15% in ambulatory care, and 25% in general units of the hospital.

Fig. (1). *The PRISMA extension for scoping reviews [23].

Table 1 provides the literature review of 16 articles that have discussed NSI from 2018 to 2021, as well as represents the numbers of NSI cited in each article and their study aim. Table 2 provides the literature review of 16 articles that have discussed NSI from 2013 to 2017, as well as details the numbers of NSI cited in each article, their study aim and research methods.

The review studies published between 2013 – 2021 cover nurse-sensitive indicators. Through a comprehensive review and combining similar NSIs, a total of 106 nurse-sensitive indicators met the review criteria. The researcher followed Donabedian’s (1988) framework in classifying the NSIs. Donabedian’s (1988) quality assessment framework includes structure, process, and outcome.

To answer the question of which NSIs effectively measure the quality of nursing care globally and locally, a comprehensive review was performed by screening all included studies that listed NSIs, collecting the result in one spreadsheet, removing duplication, and combining similar NSIs.

Based on the review, we prepared a comprehensive list of nursing-sensitive indicators that measure nursing care quality. The most frequently cited indicators were patient falls, medication error, patient satisfaction, catheter-associated infection, pain, pressure ulcer, arrest/ shock rate, incidence of deep vein thrombosis or pulmonary embolism, educational level, wound infection, working conditions (employment conditions, workload), adverse incident rates, appropriate levels of nursing skill mix, incidence of complication, duration of care, postoperative complications, and nursing initial and need assessment.

In terms of expertise at the advanced nursing level, the skill mix was reported to be a nurse-sensitive indicator applicable to KSA. The nursing profession’s development of competencies and skills should be studied more extensively [25]. In addition, professional issues, such as nurses’ skills and knowledge, are considered the most crucial research areas [27].

In terms of implementation, it is important to pay more attention to translating research evidence into clinical nursing practice [25]. Relevant studies focus on the following clinical areas: critical care, emergency nursing, mental health, oncology nursing, nephrology, medical-surgical nursing, as well as pediatric nursing [25]. In this study, in terms of the informatics system, the NSIs, such as initial nursing assessment, nursing care plan, and documentation, consider research topics. Researchers should use large health registers of data and patient-reported outcomes in nursing research because this data set analysis from the nursing perspective gives apparent consideration to patient interventions [25].

Patient-centeredness is a vital area that needs to study further. Based on the finding of this study, the NSIs can cover the following topics: patient satisfaction rate, patient involvement, nurse-patient communication and collaboration, patient education compliance rate, responsiveness to patients’ needs and expectations, self-dependence assessment, patient hygiene, and comfort in daily life care. It has been suggested that further studies will increase awareness and expand knowledge of evidence-based nursing care by addressing essential nursing areas, such as bathing and dressing, communication, mobility, nutrition, and patient self-management [26]. In addition, it is crucial to study pain assessment, management, and associated outcomes [26].

In terms of patient safety, the patient’s identification, the incidence of pressure ulcers, patient falls, medication errors, physical restraint, hand hygiene compliance, incidence of catheter-related bloodstream infection, the incidence of catheter-associated urinary tract infections rate, rates of infected vascular access, wound infection and incidence of deep vein thrombosis are clinical indicators and have an impact on the quality of patients care and outcome.

Reassessing these essential nursing activities will positively influence patient, nurse, and organizational outcomes [26]. However, some areas require more research from the nursing perspective, such as stroke, wound management, and pressure injury [25].

In terms of a healthy working environment, nurse job satisfaction and occupational health indicators are considered important research areas [27]. In general, it can be observed that most of the studies focused on outcome indicators, and there is a need to study patient-reported indicators as a significant patient-centered concept [28]. However, an association between the quality of nursing care provided and its direct impact on patient outcomes was reported in a study [29-32]. An improvement in nurse-sensitive indicators and patient outcomes measures was also observed after applying the nursing system framework that included the research as the main element [33].

The most frequently cited indicators were patient fall, medication error, patient satisfaction, catheter-associated infection, pain, pressure ulcer, arrest/ shock rate, incidence of deep vein thrombosis or pulmonary embolism, educational level, wound infection, working conditions, adverse incident rates, appropriate levels of nursing skill mix, incidence of complication, duration of care, postoperative complications, and nursing initial and need assessment. The nursing research experts suggested four research dimensions: healthy work environment, nursing informatics system, patient safety, and patient-centeredness. In general, it can be observed that most of the studies focused on outcome indicators, and there is a need to study patient-reported indicators as a significant patient-centered concept

The possibility of missing some relevant studies attributed to database selection, gray literature, time constraints, and the exclusion of studies published in a language other than English; the numbers of evidence-based nursing research in Saudi Arabia are challenging. Also, the sampling technique involving the Delphi technique is a purposive sample that may introduce bias. It is a procedure that depends on the quality of the feedback provided, and the researcher’s analysis of the responses is a big responsibility.