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Critical care nurses' perceptions of their experience with nursing quality assurance 1990

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CRITICAL CARE NURSES' PERCEPTIONS OF THEIR EXPERIENCE WITH NURSING QUALITY ASSURANCE by MARY BARBARA PERRY B.N. Dalhousie University, 1984 THESIS SUBMITTED IN PARTIAL FULFILLMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH August 1990 Mary Barbara Perry, COLUMBIA 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) Abstract The purpose of t h i s study was to describe c r i t i c a l care nurses' perceptions of t h e i r experiences with nursing quality assurance a c t i v i t i e s . Using an exploratory, descriptive design, data were c o l l e c t e d i n a survey, u t i l i z i n g a self-administered questionnaire. A convenience sample of c r i t i c a l care nurses, who are members of the Canadian Association of C r i t i c a l Care Nurses, was used. The results showed that these p a r t i c u l a r nurses knew what comprised the components of a nursing qua l i t y assurance program, however, t h e i r p a r t i c i p a t i o n i n these a c t i v i t i e s was low. In addition, the majority i d e n t i f i e d that the primary purpose of nursing qu a l i t y assurance a c t i v i t i e s was to meet the accreditation requirements of the h o s p i t a l . F i n a l l y , the re s u l t s also i d e n t i f i e d that a l l of t h i s p a r t i c u l a r group of nurses f e l t that nursing quality assurance a c t i v i t i e s involved them, and the majority f e l t that these a c t i v i t i e s were part of t h e i r professional r e s p o n s i b i l i t i e s . i i i TABLE OF CONTENTS Page Abstract i i Table of Contents i i i L i s t of Tables v L i s t of Figures v i Acknowledgements v i i Chapter One - Introduction Background to the Problem 1 Purpose of the Study 4 Conceptual Base 4 Research Questions 7 Def i n i t i o n s 7 Assumptions 9 Limitations 9 Delimitations . . . 10 Significance 10 Overview of Thesis Content 10 Chapter Two - Review of the Literature Nursing Quality Assurance 12 Quality Assurance i n C r i t i c a l Care 13 Directions and Trends i n Nursing Quality Assurance 14 Studies Concerning Nurses' Attitudes and Perceptions of Nursing Quality Assurance 15 Summary of Literature Review 18 Chapter Three - Methods and Procedures Design 19 Sample Selection 20 Instrument 2 0 V a l i d i t y Testing 21 E t h i c a l Considerations 22 Administration of Questionnaire 23 Data Analysis 24 Chapter Four - Findings and Discussion Demographic Ch a r a c t e r i s t i c of the Sample 2 6 Findings 32 Discussion Response Rate.. 41 Research Question One 42 Research Question Two 4 6 Research Question Three 4 8 Supplemental Findings 4 9 Limitations i n t h i s Study 51 Summary . 52 i v C h a p t e r F i v e - Summary, C o n c l u s i o n s and I m p l i c a t i o n s Summary 53 C o n c l u s i o n s 56 I m p l i c a t i o n s : N u r s i n g P r a c t i c e 58 N u r s i n g E d u c a t i o n 59 N u r s i n g A d m i n i s t r a t i o n 60 N u r s i n g R e s e a r c h 63 B i b l i o g r a p h y 64 A p p e n d i c e s : Appendix A. Agency Consent Form 70 Appendix B. L e t t e r o f I n t r o d u c t i o n 71 Appendix C. Q u e s t i o n n a i r e 72 Appendix D. L e t t e r o f P e r m i s s i o n 7 6 V LIST OF TABLES Page Table 1. Questionnaire Response Rate 24 Table 2. Age D i s t r i b u t i o n 27 Table 3. Time i n Present Position 27 Table 4. Employment Status 2 8 Table 5. Educational Level 29 Table 6. Current Nursing Position 30 Table 7. Areas of C r i t i c a l Care Employment 31 Table 8. Components of a Nursing Quality Assurance Program 34 Table 9. Involvement i n Quality Assurance A c t i v i t i e s 36 Table 10. Purpose of Nursing Quality Assurance A c t i v i t i e s 38 Table 11. Preferred C l i n i c a l A c t i v i t i e s 40 v i LIST OF FIGURES Page Figure 1. Interrelatedness of the nurse administrator, s t a f f nurse, and nursing qu a l i t y assurance a c t i v i t i e s 6 v i i Acknowledgements I would l i k e to acknowledge the assistance and d i r e c t i o n provided by the members of my thesis committee, Dr. Sonia Acorn and Dr. A l i c e Jope. Their patience, f l e x i b i l i t y , and constant encouragement, made the experience a very p o s i t i v e one. I owe a very special thankyou to my family and close friends, who, throughout the process were always ready to l i s t e n and o f f e r words of encouragement and support. In p a r t i c u l a r , Bernie and Lynda, Thanks! I would also l i k e to express my gratitude to the Department of National Defence, and i n p a r t i c u l a r the Nursing Core, for providing me with t h i s opportunity to grow i n my professional knowledge and experience. F i n a l l y , to Tiffany and Sam, whose devotion and acceptance throughout t h i s long process has kept me r e a l i t y orientated, Thanks! 1 CHAPTER ONE Background to the Problem Inherent i n the practice of health care i s the fact that health care providers have the p r i v i l e g e and the r e s p o n s i b i l i t y of determining what constitutes qua l i t y care. This p r i v i l e g e has been granted by society to professional groups with the expectation that they w i l l honour t h e i r obligation to provide a high standard of care through s e l f - r e g u l a t i o n . The provision of quality care, and the standards that determine that care, have concerned the nursing profession since Florence Nightingale described her experiences during the Crimean War (Baker, 1983; Lang & Clinton, 1983) . However, over the past several decades, an increase i n the need for cost accountability of health care and an increase i n professionalism has resulted i n a demand for empirical evidence that q u a l i t y health care i s being provided. As noted by Wilson (1987), the new standards for hospital accreditation "demand that q u a l i t y and i t s pursuit come out of the clo s e t " (p.4). In other words, quality assurance programs that provide empirical evidence of the quality of care being 2 delivered are now a necessity to the practice of health care professionals and to the i n s t i t u t i o n s that provide care. More recently, there has been, within the nursing profession, an increased emphasis on defining what constitutes nursing practice and an i n d i v i d u a l ' s accountability for that p r a c t i c e . Several authors have i d e n t i f i e d nursing q u a l i t y assurance a c t i v i t i e s as a mechanism that can provide e x p l i c i t evidence that addresses these two areas (Blake, 1981; Schmadl, 1979; S l i e f e r t , 1985; Smeltzer, 1983) . However, the general attitude of s t a f f nurses about the performance of qu a l i t y assurance a c t i v i t i e s , as noted i n a recent study by Edwardson and Anderson (1983), i s that they are "often l i t t l e more than an exercise i n compliance..." (p.39). This investigator has been involved with various nursing q u a l i t y assurance a c t i v i t i e s since 1983 and can attest to the lack of enthusiasm and p a r t i c i p a t i o n of s t a f f nurses i n q u a l i t y assurance a c t i v i t i e s . As further noted by Edwardson and Anderson (1983), "a discouraging r e a l i t y for nurses who hold q u a l i t y assurance positions i n hospitals i s the conclusion that t h e i r nurse colleagues are ambivalent about the quality assurance process" (p.33). One area that has a high p r o f i l e i n the nursing d i v i s i o n i s the c r i t i c a l care unit. Nursing qu a l i t y 3 assurance a c t i v i t i e s become high p r o f i l e i n t h i s area because of the c r i t i c a l conditions of the patients and the heavy reliance on s p e c i a l i z e d nursing knowledge, combined with advanced medical technology. As noted by K i e l l e r (1985), "today, c r i t i c a l care nurses are confronted with mind-boggling, resource-demanding, technology-overloaded, moral-confronting challenges... [and that] QA [quality assurance programs]...have been expanded to cover every aspect of every department..." (p.20). This increased emphasis i n q u a l i t y assurance r e l i e s on the cooperation of the nurse to ensure that safe, e f f e c t i v e care i s provided and documented. There are numerous a r t i c l e s on the reasons why qua l i t y assurance programs are necessary and how i n d i v i d u a l agencies have established t h e i r programs. In addition, many a r t i c l e s o f f e r suggestions and plans of action to nurse administrators on how to obtain nursing s t a f f s ' cooperation and compliance with qu a l i t y assurance a c t i v i t i e s (Kelly, 1984; Lowe-Serge, M a r c i l l i & O'Brian, 1988; Taylor & Haussman, 1988). However,', i n a review of over 1,000 a r t i c l e s and books written on nursing quality assurance, (Lang & Clinton, 1983), there appeared to be l i m i t e d research i n the area of nurses' attitudes and/or perceptions of nursing qu a l i t y assurance. With t h i s lack of research and an increase 4 i n the need to demonstrate that qu a l i t y care i s being provided, a study that deals with qu a l i t y assurance i s timely. Information gathered from t h i s type of study could help the nurse administrator prepare and implement nursing quality assurance programs that i n d i v i d u a l nurses might use more e n t h u s i a s t i c a l l y to monitor t h e i r nursing care and the nursing care of others, and thereby meet the requirements for assuring that qu a l i t y care i s being provided to patients. Purpose of the Study The purpose of t h i s study was to describe c r i t i c a l care nurses' perceptions of t h e i r experiences with nursing qu a l i t y assurance a c t i v i t i e s . This information was sought for the purpose of enhancing the knowledge base of nursing quality assurance and improving the l e v e l of quality assurance programs. Conceptual Base This study was conducted within a conceptual base that d i r e c t s the nurse administrator to seek out and understand s t a f f nurses' perceptions of t h e i r experiences with nursing quality assurance. The 5 components, and key factors involved i n the relationships of these components, are shown i n Figure 1. Nursing quality assurance a c t i v i t i e s are required by the nurse administrator i n order to provide evidence that quality nursing care i s being given. Information i s compiled by the s t a f f nurse, who i s charged with monitoring his/her own nursing care and the care provided by peers, using nursing qu a l i t y assurance c r i t e r i a . In order to ensure p o s i t i v e outcomes for patients, nursing s t a f f s , and the nurse administrator, there should be a measure of agreement and cohesiveness concerning nursing qu a l i t y assurance a c t i v i t i e s between the s t a f f nurse and the nurse administrator. Therefore, the need exists to seek out and explore the perceptions, attitudes, and p o t e n t i a l motives of the s t a f f nurse i n r e l a t i o n to nursing q u a l i t y assurance. Furthermore, i t i s generally accepted that there are several components that constitute nursing qu a l i t y assurance programs. These components consist of the establishment of acceptable standards of care, methods of determining compliance with these standards, analysis of the data collected, and the u t i l i z a t i o n of r e s u l t s obtained. Exploration of attitudes, interests, p o t e n t i a l motives, and needs. Nurse Administrator Posxtive Outcome Pos i t i v e Perceptions Nursing Quality Assurance Nursing Quality Assurance Figure 1: Interrelatedness of the nurse administrator s t a f f nurse, and nursing quality assurance a c t i v i t i e s 7 Research Questions 1. What do c r i t i c a l care nurses i d e n t i f y as components of a n u r s i n g q u a l i t y assurance program? 2. What do c r i t i c a l care nurses i d e n t i f y as the purposes of n u r s i n g q u a l i t y assurance a c t i v i t i e s ? 3. What i s the involvement of c r i t i c a l care nurses i n n u r s i n g q u a l i t y assurance a c t i v i t i e s ? D e f i n i t i o n s 1. Nu r s i n g q u a l i t y assurance: n u r s i n g q u a l i t y assurance i n v o l v e s a s s u r i n g the consumer of a s p e c i f i c degree of [nursing] e x c e l l e n c e through continuous measurement and e v a l u a t i o n of s t r u c t u r a l components, a g o a l - d i r e c t e d n u r s i n g process, and/or consumer outcome, u s i n g p r e - e s t a b l i s h e d [nursing] c r i t e r i a and standards and a v a i l a b l e norms, and f o l l o w e d by a p p r o p r i a t e a l t e r a t i o n with the purpose of improvement (Schmadl, 1979, p.465). 2. Nursing q u a l i t y assurance program: a method of formal m o n i t o r i n g (composed of components) which d e f i n e s and e v a l u a t e s the q u a l i t y of n u r s i n g care b e i n g given, and takes a c t i o n t o ensure t h a t the q u a l i t y remains at an optimum l e v e l (Campbell, 1982; C o n l i n e , 1983; Smith & Powers, 1990). 8 3. Nursing quality assurance a c t i v i t i e s : those designated a c t i v i t i e s that are the components of a nursing qu a l i t y assurance program. For example, nursing audits, performance appraisals, credentialing, continuing education, and u t i l i z a t i o n of qu a l i t y assurance findings. 4. General duty nurse: a registered nurse whose primary r e s p o n s i b i l i t y i s directed to patient care and the a c t i v i t i e s that are involved i n the provision of that care. 5. Nurse administrator: a nurse who i s employed i n a management po s i t i o n within a health care i n s t i t u t i o n or agency and whose primary r e s p o n s i b i l i t i e s are to supervise , di r e c t , and counsel other nurses i n the performance of di r e c t patient care (Douglas & Bevis, 1983; Epstein, 1982; G i l l i e s , 1989). 6. C r i t i c a l care: refers to the care of c r i t i c a l l y i l l patients i n s p e c i f i c s p e c i a l i z e d areas of a hospital that are structured to deal with l i f e - threatening ph y s i o l o g i c a l c r i s e s . These include intensive care units, coronary care units, s u r g i c a l intensive care units, post-open heart recovery units, p a e d i a t r i c care units and neonatal intensive care u n i t s . 7. Experiences: d i r e c t personal p a r t i c i p a t i o n or observation, actual knowledge or contact... (Hanks, 1986, p.536). 8. P e r c e p t i o n s : the process by which an organism d e t e c t s and i n t e r p r e t s i n f o r m a t i o n from the e x t e r n a l world by means of sensory r e c e p t o r s . . . (Hanks, 1986, p.1139) . Assumptions 1. Q u a l i t y assurance a c t i v i t i e s are used i n c r i t i c a l care t o p r o v i d e evidence t h a t q u a l i t y n u r s i n g care i s b e i n g p r o v i d e d . 2. Nurses working i n c r i t i c a l care areas have had some experi e n c e with n u r s i n g q u a l i t y assurance. 3. N u r s i n g q u a l i t y assurance i s e s s e n t i a l t o the n u r s i n g p r o f e s s i o n t o ensure a h i g h q u a l i t y of care t o the consumer ( p a t i e n t ) . L i m i t a t i o n s and D e l i m i t a t i o n s L i m i t a t i o n s Since the p a r t i c i p a n t s i n the study are a convenience sample, the r e s u l t s of the study are a p p l i c a b l e only t o those i n d i v i d u a l s i n v o l v e d . The study was l i m i t e d by the q u e s t i o n n a i r e instrument used and the extent t o which i t was a measure of the v a r i a b l e s t u d i e d . 10 Delimitations The study was delimited to the c r i t i c a l care nurses i n the Lower Mainland of B r i t i s h Columbia who are members of the l o c a l chapter of the Canadian Association of C r i t i c a l Care Nurses. Significance The study w i l l provide information on the process of q u a l i t y assurance and i t s rela t i o n s h i p to nursing. By i d e n t i f y i n g nurses' perceptions of t h e i r experiences with q u a l i t y assurance the nurse administrator can develop an understanding of the knowledge and expectations nurses have of the quality assurance process. It i s hoped that t h i s understanding w i l l allow the development and/or enhancement of those programs that w i l l be b e n e f i c i a l to the c l i e n t s by assuring a s p e c i f i c standard of quality care, and w i l l benefit the i n d i v i d u a l nurse and the profession of nursing. Overview of the Thesis Content This thesis i s comprised of f i v e chapters. In Chapter One, the background to the problem, purpose, conceptual base, research questions, d e f i n i t i o n s , assumptions, and significance of the study are o u t l i n e d . In Chapter Two, a review of s e l e c t e d l i t e r a t u r e on q u a l i t y assurance a c t i v i t i e s and programs i n n u r s i n g , i s presented. Chapter Three addresses the r e s e a r c h methods used, i n c l u d i n g the r e s e a r c h design, sampling procedure, data c o l l e c t i o n instrument, e t h i c a l c o n s i d e r a t i o n s , and s t a t i s t i c a l procedures used i n data a n a l y s i s . In Chapter Four, the d e s c r i p t i o n of the sample, a r e p o r t of the f i n d i n g s and a d i s c u s s i o n of the r e s u l t s are presented. The summary, c o n c l u s i o n s , i m p l i c a t i o n s , and recommendations f o r f u t u r e r e s e a r c h are p r e s e n t e d i n Chapter F i v e . 12 CHAPTER TWO Literature Review A s e l e c t i v e l i t e r a t u r e review was conducted to provide the scope of what i s currently available concerning nursing quality assurance. Four areas were reviewed: the l i t e r a t u r e concerning the need for and establishment of nursing quality assurance programs, nursing qu a l i t y assurance i n c r i t i c a l care, directions and trends i n nursing quality assurance, and studies concerning nursing and nursing quality assurance. Nursing Quality Assurance There i s a large body of l i t e r a t u r e that addresses nursing qu a l i t y assurance. Many of the authors, a f t e r addressing the need for nursing quality assurance programs, explain how t h e i r p a r t i c u l a r i n s t i t u t i o n s are meeting qua l i t y assurance requirements. Some authors define qu a l i t y assurance programs as a management process that i s established to define and evaluate the qu a l i t y of care provided to the consumer [patient] (Campbell, 1982; Coyne & K i l l i e n , 1987; Conline, 1983; Kerfoot & Watson, 1985; Maciorowski, Larson & Keane, 1985). Components of the quality assurance process are i d e n t i f i e d as the establishing of standards of care, implementing and monitoring those standards, and evaluating the results of the monitoring ( B i l l i n g s , 1983; Campbell, 1982; Giovannetti, 1979; Marker, 1987; Migleozzi, 1990; Smeltzer, Feltman, & Rajki, 1983; Thurston & Best, 1990). In addition, the mechanisms used for the formation, orientation, and function of committees that coordinate qu a l i t y assurance a c t i v i t i e s are described (Harris, Kreger & Davis, 1989; Judkins, 1982; O'Brian, 1988). For the most part, the l i t e r a t u r e regarding nursing qu a l i t y assurance involves authors defining q u a l i t y assurance and o f f e r i n g advice on what s p e c i f i c a l l y has worked for them i n the establishment of t h e i r programs. Quality Assurance i n C r i t i c a l Care Nursing In a review of the li m i t e d a r t i c l e s on qu a l i t y assurance i n c r i t i c a l care nursing, the information centred mainly on the components of the qual i t y assurance process i n c r i t i c a l care and mechanisms that have been successful i n establishing q u a l i t y assurance programs (Finley-Cottone & Link, 1985; Hirth & Lauzon, 1989; Kaplow & Bendo, 1989; McGee, 1988; Mudd, 1988). In a survey on the state of the art i n c r i t i c a l care nursing standards, conducted by Kidd, Whitely, and Scherer (1987) for the Canadian Association of C r i t i c a l Care Nurses (CACCN), a number of mechanisms were i d e n t i f i e d which were used i n establishing standards to assess the quality of nursing care delivered i n c r i t i c a l care (p.12). Using a questionnaire designed by the authors, 217 hospitals, with intensive c a r e / c r i t i c a l care units, were surveyed with a response rate of 147. A c t i v i t i e s such as equipment and environment audits, patient c l a s s i f i c a t i o n systems, patient s a t i s f a c t i o n surveys, continuing education programs, and transfer of function descriptions were i d e n t i f i e d as mechanisms for establishing standards of care to assure qu a l i t y i n nursing care (p.12). In addition, nursing audits and performance appraisals were i d e n t i f i e d as methods to evaluate the qual i t y of nursing care. Other than the above survey, no other studies were found on quality assurance i n c r i t i c a l care nursing. Directions and Trends i n Nursing Quality Assurance Several authors address the need to implement qu a l i t y assurance programs as a method to maintain accountability and autonomy i n nursing practice (Curtis & Simpson, 1985; Devet, 1986; Kelly, 1984; M i g l i o z z i , 1990; O'Brian, 1988; Ott, 1987; S l i e f e r t , 1985; Smeltzer, 1983). The authors emphasize that through qua l i t y assurance and peer review a c t i v i t i e s , nursing care i s r e f i n e d and the p r o v i s i o n of q u a l i t y care enhanced. Furthermore, F i n l e y - C o t t o n e and L i n k s (1985) emphasised t h a t , with r e g u l a r involvement i n q u a l i t y assurance a c t i v i t i e s , the a b i l i t y e x i s t s f o r nurses t o i n c o r p o r a t e q u a l i t y assurance p r i n c i p l e s i n t o t h e i r d a i l y p r a c t i c e (p.49). Beyers (1988) expanded t h i s f u r t h e r by n o t i n g t h a t the p r a c t i c e h a b i t s of nurses are b e i n g i n f l u e n c e d and changed by the q u a l i t y assurance movement. No longer i s i t focused on the s p e c i f i c needs of management, but g r e a t e r and g r e a t e r emphasis i s p l a c e d on the i n d i v i d u a l p r a c t i c e of each nurse. Beyers (1988) emphasizes t h a t we are moving away from the e v a l u a t i o n of the p r a c t i c e of a l l nurses on one u n i t , and s t a r t i n g t o focus on q u a l i t y assurance a c t i v i t i e s as an i n t e g r a l p a r t of i n d i v i d u a l p r a c t i c e . S t u d i e s Concerning Nurses' A t t i t u d e s and P e r c e p t i o n s of Nur s i n g Q u a l i t y Assurance L i t t l e evidence i s a v a i l a b l e i n the n u r s i n g l i t e r a t u r e r e g a r d i n g nurses' a t t i t u d e s toward and/or p e r c e p t i o n s of t h e i r experiences with n u r s i n g q u a l i t y assurance. Many authors, i n d i s c u s s i n g the mechanisms used t o e s t a b l i s h n u r s i n g q u a l i t y assurance programs, address n u r s i n g s t a f f s ' a t t i t u d e s by su g g e s t i n g t h a t s t a f f s ' c o o p e r a t i o n and compliance can be ob t a i n e d by i n v o l v i n g them i n the c r e a t i o n and o r g a n i z a t i o n of the programs ( K e l l y , 1984; Lowe-Serge, M a r v u l l i & O ' B r i a n , 1988; T a y l o r & Haussmann, 1988). In a d d i t i o n , d i s c u s s i o n s on s t a f f i n v o l v e m e n t u s u a l l y emphasise t h e c r e a t i o n o f u n i t s p e c i f i c q u a l i t y a s s u r a n c e programs (Acorn, Love & M i l l s , 1990; Beyerman, 1987; F i n l e y - C o t t o n e & L i n k , 1985; H i r t h & Lauzon, 1989; K i e l l e r , 1985; McGee, 1988; S c h r o d e r , Maibusch & Anderson, 1982). These a u t h o r s note t h a t w i t h u n i t s p e c i f i c q u a l i t y a s s u r a n c e programs, i s s u e s and c o n c e r n s unique t o t h e u n i t a r e a d d r e s s e d . T h i s makes t h e p a r t i c i p a t i o n i n and u t i l i z a t i o n o f r e s u l t s o f q u a l i t y a s s u r a n c e a c t i v i t i e s more m e a n i n g f u l t o g e n e r a l n u r s i n g s t a f f . A s t u d y by Edwardson and Anderson (1983) a t t e m p t e d t o e s t a b l i s h why n u r s e s , who b e l i e v e q u a l i t y a s s u r a n c e i s a v i t a l p a r t o f t h e i r n u r s i n g r o l e , do not demonstrate t h i s b e l i e f by s e e k i n g out and p a r t i c i p a t i n g i n q u a l i t y a s s u r a n c e a c t i v i t i e s . The a u t h o r s ' h y p o t h e s i s was t h a t s t a f f n u r s e s who had e x p e r i e n c e w i t h q u a l i t y a s s u r a n c e would show a p o s i t i v e a t t i t u d e t o w a r d q u a l i t y a s s u r a n c e , would v a l u e q u a l i t y a s s u r a n c e a c t i v i t i e s , and would be more l i k e l y t o v i e w such a c t i v i t i e s as p a r t o f t h e n u r s e ' s r o l e . U s i n g t h e i r own i n s t r u m e n t , t h e y c o l l e c t e d d a t a from 308 n u r s e s i n 10 h o s p i t a l s i n t h e g r e a t e r M i n n e a p o l i s and S t . P a u l a r e a . The f i n d i n g s suggest t h a t , a l t h o u g h s t a f f nurses thought involvement i n qua l i t y assurance a c t i v i t i e s was an important part of the professional role and a r e s p o n s i b i l i t y of a l l nurses, i n a ranking of nurses' duties and a c t i v i t i e s , i t consistently f e l l f ar below patient care a c t i v i t i e s . Apparently, these nurses valued patient care a c t i v i t i e s as part of t h e i r professional role and r e s p o n s i b i l i t y , but did not value monitoring the quality of these a c t i v i t i e s . In addition, less than half the s t a f f nurses who responded would choose to p a r t i c i p a t e i n quality assurance a c t i v i t i e s i f they had the opportunity. In discussing the implications of t h e i r findings, the authors suggest that administrators investigate the causes of nurses' d i s s a t i s f a c t i o n with quality assurance a c t i v i t i e s and that t h e i r attitudes toward quality assurance be assessed i n order to e f f e c t a commitment to t h i s aspect of the nurse's role (Edwardson & Anderson, 1983). Although the 10 hospitals used i n the survey have qu a l i t y assurance a c t i v i t i e s , by virt u e of being represented on the Metropolitan Nurses i n Quality Assurance (MNQA) group, no description was given regarding the types of quality assurance programs at each i n s t i t u t i o n . Since quality assurance i s a concept subject to various interpretations, differences between the programs might have accounted for some of the r e s u l t s . In addition, the questionnaire used was 18 c r e a t e d by the MNQA group and, though p i l o t t e s t e d , the f i n d i n g s are only g e n e r a l i z a b l e to the n u r s i n g p e r s o n n e l who p a r t i c i p a t e d i n the study. Beyond t h i s study, no other l i t e r a t u r e was found t h a t d e a l t s p e c i f i c a l l y with nurses' a t t i t u d e s and/or p e r c e p t i o n s of t h e i r e x periences with q u a l i t y assurance. Summary of L i t e r a t u r e Review Q u a l i t y assurance a c t i v i t i e s have become an important concern f o r n u r s i n g p r a c t i c e over the past two decades. Much of the l i t e r a t u r e t o date d i s c u s s e s the need f o r these a c t i v i t i e s from a management and c l i e n t s ' p o i n t of view. Emphasis has been on the e s t a b l i s h m e n t of q u a l i t y assurance programs and on the many methods a v a i l a b l e which have been s u c c e s s f u l f o r p a r t i c u l a r n u r s i n g departments. However., one area t h a t has not been addressed and i s v i t a l t o the success of a q u a l i t y assurance program i s the p e r c e p t i o n and a t t i t u d e s of the s t a f f nurses. I t i s t h i s group who u l t i m a t e l y are r e s p o n s i b l e f o r o b t a i n i n g and u t i l i z i n g n u r s i n g q u a l i t y assurance i n f o r m a t i o n i n t h e i r p r a c t i c e . Knowledge of these nurses' a t t i t u d e s and p e r c e p t i o n s of t h e i r experiences with n u r s i n g q u a l i t y assurance a c t i v i t i e s w i l l p r o v i d e u s e f u l i n f o r m a t i o n f o r the development of programs and a c t i v i t i e s i n n u r s i n g q u a l i t y assurance. 19 CHAPTER THREE Methods and Procedures This chapter includes a review of the methods used i n t h i s study. The research design, sample selection, data c o l l e c t i o n instrument, v a l i d i t y t e s t i n g , e t h i c a l considerations which guided the design, procedure for data c o l l e c t i o n , and the data analysis methods are presented. Design An exploratory, descriptive design was used as a research approach for t h i s study. As noted by Burns and Groves (1987) , "the purpose of exploratory research i s the exploration and description of phenomena. This approach i s used to generate new knowledge about concepts on topics about which l i t t l e i s known" (p. 58- 59). The data c o l l e c t i o n technique employed was a survey u t i l i z i n g a self-administered questionnaire. A survey, as further explained by Burns and Groves (1987) , " i s used to describe a technique of data c o l l e c t i o n i n which questionnaires (collected by mail or i n person)... are used to gather data about an 20 i d e n t i f i e d population" (p.250). Sample Selection A convenience sample of c r i t i c a l care nurses was used for t h i s study. Permission was obtained from the l o c a l chapter of the Canadian Association of C r i t i c a l Care Nurses (CACCN) for access to t h e i r mailing l i s t of approximately 78 current members (Appendix A). C r i t i c a l care nurses were selected for t h i s study because qu a l i t y assurance a c t i v i t i e s within these units have a high p r o f i l e due to the c r i t i c a l conditions of the patients and the heavy reliance on s p e c i a l i z e d nursing knowledge combined with medical technology. Furthermore, l i m i t i n g the study to c r i t i c a l care nurses provided a r e a l i s t i c expectation i n the type and amount of data c o l l e c t e d . This l i m i t a t i o n also f a c i l i t a t e s easier i n t e r p r e t a t i o n and u t i l i z a t i o n of the r e s u l t s . Instrument The instrument (Appendix C) used was a s e l f - administered, structured questionnaire developed by the investigator. The questionnaire contained modified questions used with the permission (Appendix D) of the authors of the Edwardson and Anderson (1983) study. The q u e s t i o n n a i r e was d e s i g n e d t o c o l l e c t the f o l l o w i n g types o f d a t a . F i r s t , the knowledge l e v e l t h a t c r i t i c a l c a r e nurses have o f the components o f a n u r s i n g q u a l i t y a s surance program was sought ( q u e s t i o n 1 ) . Then, t h e i r l e v e l o f p a r t i c i p a t i o n i n n u r s i n g q u a l i t y a s surance a c t i v i t i e s was sought ( q u e s t i o n 2 ) . Q u e s t i o n t h r e e a d d r e s s e d t h e i r p e r c e p t i o n s and a t t i t u d e s towards n u r s i n g q u a l i t y a s surance a c t i v i t i e s and, f i n a l l y , g i v e n the c h o i c e , on which a c t i v i t i e s l i s t e d would these nurses choose to spend more t ime ( q u e s t i o n 4 ) . Demographic d a t a , i n c l u d i n g . e d u c a t i o n l e v e l , a r e a o f employment, l e n g t h o f employment, p r e s e n t p o s i t i o n , age, and employment s t a t u s was r e q u e s t e d ( q u e s t i o n 5 t h r o u g h 10) . V a l i d i t y T e s t i n g The i n i t i a l d r a f t o f the c o v e r i n g l e t t e r and the i n s t r u m e n t were rev iewed f o r content v a l i d i t y by f i v e nurse s c u r r e n t l y e n r o l l e d i n the Mas ter o f S c i e n c e i n N u r s i n g program at the U n i v e r s i t y o f B r i t i s h C o l u m b i a . A l l f i v e nurse s had had e x p e r i e n c e i n n u r s i n g q u a l i t y a s surance a c t i v i t i e s i n p r e v i o u s employment. Comments were sought r e g a r d i n g c l a r i t y o f meaning, e f f e c t i v e n e s s o f i n s t r u c t i o n s , o v e r a l l p r e s e n t a t i o n , t ime r e q u i r e d f o r c o m p l e t i o n , and r e l e v a n c e o f i tems t o the r e s e a r c h 22 questions. Construct v a l i d i t y was established by sel e c t i n g items that corresponded with the t h e o r e t i c a l constructs of quality assurance a c t i v i t i e s and programs. Furthermore, i t was estimated that i t would take approximately 20 minutes to complete the questionnaire. A revised questionnaire was then produced incorporating the suggestions of the reviewers. E t h i c a l Considerations Burns and Groves (1987) noted that "conducting research e t h i c a l l y requires that researchers and reviewers of research recognize and protect the rights of human research subjects" (p.74). The following measures were taken to ensure the protection of the rights of the individ u a l s who pa r t i c i p a t e d i n t h i s study. F i r s t , the study proposal was approved by the U.B.C. Behaviourial Sciences Screening Committee to ensure that the study complied with the guidelines established by the University for the protection of human r i g h t s . The participants were rec r u i t e d from a chapter of the Canadian Association of C r i t i c a l Care Nurses rather than from an agency so that the decision regarding p a r t i c i p a t i o n i n the study was not influenced by t h e i r employment. It was f e l t that recruitment of p a r t i c i p a n t s i n t h i s manner allowed for increased willingness to p a r t i c i p a t e since there would be no l i n k between the researcher and the i n s t i t u t i o n i n which the nurses were employed. Each p o t e n t i a l subject received a l e t t e r of explanation (Appendix B), along with the questionnaire, (Appendix C) i n the mail. The l e t t e r explained that each questionnaire was i d e n t i f i e d with a code number in order to f a c i l i t a t e follow-up e f f o r t s i n r e t r i e v a l of questionnaires. The i d e n t i f i c a t i o n number was con t r o l l e d by and known only to the researcher. The covering l e t t e r also stated that the responses given would not be i d e n t i f i e d with the subjects and that t h e i r names would not appear i n any document or report. Administration of Questionnaire On February 1, 1990 each of the 78 persons whose names appeared on the current mailing l i s t of the l o c a l chapter of the CACCN, was mailed a questionnaire package. A two week period was allowed for return of the questionnaires. During t h i s time, 38 of the questionnaires were returned, 36 (4 6.2%) of which were f i l l e d out and useable. Two were returned to the investigator because the individuals had moved with no 24 forwarding address. At t h i s time a reminder postcard was mailed to those indiv i d u a l s on the mailing l i s t who had not returned the questionnaire. This resulted i n an additional 21 questionnaires being returned, of which 20 (25.6%) were useable. One questionnaire was returned unanswered because the i n d i v i d u a l , an associate member of the chapter, was not a registered nurse. A summary of the questionnaires returned i s i n Table 1. Table 1: Questionnaire Response Rate Number Percentage Useable questionnaires returned 56 71.8% Non-useable questionnaires returned 3 3.8% Questionnaires not returned 19 24.4% Total 78 100.0% Data Analysis Data were analyzed using the S t a t i s t i c a l Package for the Social Sciences available through the computer centre at the University of B r i t i s h Columbia. The type of data c o l l e c t e d was at the nominal l e v e l and therefore, the s t a t i s t i c a l techniques that were appropriate for the type of data c o l l e c t e d i n t h i s research design, were frequencies, percentages, and means of i n d i v i d u a l items. 26 CHAPTER FOUR Findings and Discussion In t h i s chapter, the study findings and a discussion of those findings w i l l be presented. The f i r s t part of the chapter w i l l present the demographic data. Next, the findings from the f i r s t four questions, of the questionnaire, w i l l be presented. Then, these findings w i l l be discussed i n r e l a t i o n to each of the research questions. Supplemental findings w i l l then be discussed and, f i n a l l y , l i m i t a t i o n s of the study i d e n t i f i e d . Demographic Charact e r i s t i c s of the Sample Demographic information c o l l e c t e d included, age c h a r a c t e r i s t i c s of the sample, time spent i n present position, employment status, educational l e v e l , current nursing p o s i t i o n held, and area of c r i t i c a l care i n which the part i c i p a n t s were employed. The age c h a r a c t e r i s t i c s of the sample are presented i n Table 2. The most frequent age group represented was the 31-35 year group, with a representation of 32.1% of the p a r t i c i p a n t s . The lowest 27 r e p r e s e n t a t i o n f o r age groups was i n the 20-25 year group ( 1 . 8 % ) , and the 46 + year group ( 1 2 . 5 % ) . Table 2: Age D i s t r i b u t i o n Number Percentaqe 20-25 years 1 1.8% 26-30 years 11 19.6% 31-35 years 18 32.1% 36-40 years 10 17.9% 41-45 years 9 16.1% 46 + years 7 12.5% T o t a l 56 100.0% Table 3 p r e s e n t s the data c o l l e c t e d on the time spent, by the s u b j e c t s , i n t h e i r present n u r s i n g p o s i t i o n . Table 3: Time i n Present Nursing P o s i t i o n Number Percentaqe 0-1 year 17 30.3% 2-3 years 14 25.0% 4-5 years 10 17. 9% 6 + years 15 2 6.8% T o t a l 56 100.0% 28 The largest number, 17 (30.3%), have been i n t h e i r present p o s i t i o n for less than one year. The next highest categories, 2-3 years and 6 + years, have a s i m i l a r number of subjects with 14 (25.0%) and 15 (26.8%) respectively. The lowest category i n Table 3 i s the 4-5 year category with 10 (17.9%). Table 4 presents the data c o l l e c t e d on the subjects' current nursing employment status. The question i d e n t i f i e d three s p e c i f i c employment classes: f u l l - t i m e , part-time, and casual. Table 4: Employment Status Number Percentage 46 82.1% 6 10.7% 4 7.1% 0 0 . 0% Total 56 100.0% Of the nurses who responded, the majority, 82.1%, c l a s s i f i e d themselves as being i n f u l l - t i m e employment. However, of t h i s group, two participants indicated that they would be changing to casual employment status within a month of f i l l i n g i n the questionnaire. In addition, another participant wrote, that, i n order "to maintain my broad knowledge base and s k i l l s I work casual at other i n s t i t u t i o n s as" well as f u l l time...". Full-time Part-time Casual Other The f o l l o w i n g t a b l e , T a b l e 5, p r e s e n t s a summary of the d a t a c o l l e c t e d on the e d u c a t i o n a l l e v e l o f the s u b j e c t s . A l t h o u g h , a l l the p a r t i c i p a n t s were i n one o f the t h r e e c a t e g o r i e s l i s t e d , a number o f them e l a b o r a t e d on a d d i t i o n a l e d u c a t i o n a l e x p e r i e n c e s i n the "other" c a t e g o r y . T a b l e 5: E d u c a t i o n a l L e v e l Number P e r c e n t a g e 30 53.6% 22 39.3% _4 7 .1% T o t a l .56 100.0% Under the "other" c a t e g o r y , 32.1% o f the s u b j e c t s n o t e d , t h a t , i n a d d i t i o n , they had a l s o t a k e n a p o s t - b a s i c c r i t i c a l c a r e c o u r s e . F u r t h e r , 10.7% i n d i c a t e d t h a t they were work ing on a b a c c a l a u r e a t e degree i n n u r s i n g . In a d d i t i o n , t h e r e were a v a r i e t y o f s i n g l e r e s p o n s e s , i n d i c a t i n g o t h e r e d u c a t i o n a l e x p e r i e n c e s such as the e f f e c t i v e head nurse c o u r s e , d ip loma p a e d i a t r i c n u r s i n g and p a e d i a t r i c e d u c a t i o n c o u r s e s , and CHA d i p l o m a . The c u r r e n t n u r s i n g p o s i t i o n s o c c u p i e d by the s u b j e c t s are d i s p l a y e d i n T a b l e 6. N u r s i n g Diploma B a c c a l a u r e a t e Degree M a s t e r ' s Degree 30 Table 6: Current Nursing Position Number Percentage Staff Nurse 22 39.3% Assistant Head Nurse 4 7.1% Head Nurse 7 12 .5% Other: Instructor 16 28.6% Industry 2 3.6% Director of Nursing 1 1.8% CNS/Clinical resource/ Nurse C l i n i c i a n 4 7.1% Total 56 100.0% As can be seen i n Table 6, 22 (39.7%) of the pa r t i c i p a n t s i d e n t i f i e d , are f i l l i n g a s t a f f nurse's p o s i t i o n . The next highest number appears i n the "other" category, where 16 (28.6%) of the subjects i d e n t i f i e d t h e i r p o s i t i o n as a c r i t i c a l care i n s t r u c t o r . F i n a l l y , demographic data were c o l l e c t e d on where, in c r i t i c a l care, the subjects were employed. The questionnaire offered six d e f i n i t e choices, with a seventh being the "other" category. Thirty six (64.3%) of the subjects i d e n t i f i e d that they were employed i n one area of c r i t i c a l care (Table 7-A). The remaining 20 (35.7%) l i s t e d two or more c r i t i c a l care areas as employment areas (Table 7-B). 31 Table 7: Areas of C r i t i c a l Care Employment A: Sinqle areas of C r i t i c a l Care Employment Number Percentage Intensive Care Unit Coronary Care Unit 8 6 14 10 • 3 % .7% Surgical Intensive Care Unit 1 1 • 8 % Post-open Heart Recovery Unit 6 10 .7% Paediatric Intensive Care Unit 4 7 .1% Neonatal Intensive Care Unit 0 0% Other: C r i t i c a l Care Areas Recovery Room Education Emergency Baro Medical 3 2 2 1 5 3 3 1 • 3 % • 5 % • D ̂ • 8 % Other: None C r i t i c a l Care Areas Head Nurse Med/Surg Area Private Industry Not Presently Employed 1 1 1 1 1 1 . 8 % . 8 % . 8 % B: Multiple Areas of C r i t i c a l Care Employment Number Percentaqe Intensive care/Coronary Care 16 28 . 6% Intensive care/Coronary Care/ Surgical care/Post-open Heart Recovery Unit 2 3 • D 15 Intensive care/Coronary Care/ Surgical Intensive Care Unit 1 1 . 8 % Coronary Care/Surgical Intensive Care 1 1 . 8 % Total 56 100 .0% 32 The next section of the chapter w i l l present the findings from the f i r s t four questions of the questionnaire. Findings Information c o l l e c t e d on the subjects' perceptions, attitudes, knowledge, and p a r t i c i p a t i o n l e v e l i n nursing quality assurance are presented i n the following tables. The f i r s t question requested that the subjects i d e n t i f y i t e m s / a c t i v i t i e s , on the l i s t provided, that they considered components of a nursing q u a l i t y assurance program. The re s u l t s are presented i n Table 8. Nine of the twelve i t e m s / a c t i v i t i e s l i s t e d were i d e n t i f i e d by over 80% of the part i c i p a n t s as a component of a nursing quality assurance program. The remaining three: regular checks and maintenance of biomedical equipment, suggestions by nursing s t a f f of topics for nursing quality assurance a c t i v i t i e s , and a nursing workload measurement system were i d e n t i f i e d by over 70% of the p a r t i c i p a n t s . Moreover, a number of the participants added, i n the "other" category, additional i t e m s / a c t i v i t i e s which they considered as components of a nursing q u a l i t y assurance program. A summary of the l i s t includes, e d u c a t i o n based on a u d i t r e s u l t s , s e l f - a u d i t i n g , r o u t i n e updates t o n u r s i n g s t a f f r e g a r d i n g new p o l i c i e s and procedures, mandatory c r i t i c a l care t r a i n i n g and work experience, n u r s i n g r e s e a r c h , s k i l l s assessment, budget a n a l y s i s a c t i v i t i e s , and minimum number of p a t i e n t s per nurse per s h i f t . 34 T a b l e 8: Components o f a N u r s i n g Q u a l i t y A s s u r a n c e Program Q u e s t i o n 1: I f e e l the i t e m s / a c t i v i t i e s l i s t e d below are components o f a n u r s i n g q u a l i t y a s surance program: (check as many as you t h i n k are a p p l i c a b l e ) (N = 56) Number checked P e r c e n t a g e a . N u r s i n g c a r e a u d i t s 55 b . R e g u l a r s t a f f performance a p p r a i s a l s 51 c . A u d i t or q u a l i t y a s surance committee 55 d . I n c i d e n t r e p o r t s 51 e. U t i l i z a t i o n o f q u a l i t y a s surance f i n d i n g s 55 f . R e g u l a r h o s p i t a l - b a s e d i n s e r v i c e 49 g . R e g u l a r checks and maintenance o f b i o m e d i c a l equipment 43 h . V e r i f i c a t i o n o f c u r r e n t n u r s i n g r e g i s t r a t i o n 47 i . N u r s i n g p r a c t i c e s t a n d a r d s 52 j . Sugges t i ons by n u r s i n g s t a f f o f t o p i c s f o r n u r s i n g q u a l i t y a s s u r a n c e a u d i t s / s t u d i e s 44 k . O r i e n t a t i o n programs f o r new s t a f f 52 1. N u r s i n g work load management systems (eg.GRASP) 42 98 .2% 91.1% 98 .2% 91.1% 98.2% 87.5% 76.8% 83. 9% 92.9% 78. 6% 92. 9% 75.0% Responses to the second question provided information on how many of the i t e m s / a c t i v i t i e s l i s t e d i n question one the subjects had been involved i n over the past year. The data c o l l e c t e d are presented i n Table 9. The highest responses were: producing evidence of current r e g i s t r a t i o n (87.5%) and orientation of new s t a f f (85.7%). The lowest response rate were: performing audits on biomedical equipment (12.5%) and serving on an audit or quality assurance committee (25.0%). Several of the remaining i t e m s / a c t i v i t i e s had been p a r t i c i p a t e d i n by approximately one t h i r d of the subjects over the past year. These i t e m s / a c t i v i t i e s included: conducting a nursing audit (37.5%), incorporating findings of quality assurance studies into practice (35.7%), developing nursing practice standards for measuring the quality of nursing care (35.7%), and suggesting topics for nursing qu a l i t y assurance audits/studies (28.6%). A number of subjects noted, i n the "other" category, additional a c t i v i t i e s that they considered as nursing qu a l i t y assurance a c t i v i t i e s . These include: presenting evidence of currency i n BCLS (basic cardiac l i f e support), successfully completing the ACLS (advanced cardiac l i f e support) course, and p a r t i c i p a t i n g i n the selection of a nursing model. 36 Table 9; Involvement i n Quality Assurance A c t i v i t i e s Question 2: In the past year I have been involved i n the following a c t i v i t i e s : (check as many as you wish) (N = 56) A c t i v i t i e s Percentage I d e n t i f i e d a. Conduct a nursing audit 21 37.5% b. Received a performance appraisal about my work 37 66.1% c. Served on an audit or qua l i t y assurance committee 14 25.0% d. I n i t i a t e d incident reports 30 53.6% e. Incorporated findings of quali t y assurance studies into practice 20 35.7% f. Regularly attended h o s p i t a l - based nursing inservice 44 78.6% g. Performed audits on biomedical equipment 7 12.5% h. Produced evidence of current nursing r e g i s t r a t i o n 49 87.5% i . Developed nursing practice standards for measuring the qua l i t y of nursing care 20 35.7% j . Suggested topics for nursing q u a l i t y assurance audits/studies 16 28.6% k. Oriented new s t a f f 48 86.7% 1. U t i l i z e d a nursing workload measurement system ( i . e . , GRASP) 18 32.1% 37 The t h i r d q u e s t i o n sought the o p i n i o n s of the s u b j e c t s r e g a r d i n g the purposes of n u r s i n g q u a l i t y assurance a c t i v i t i e s . The r e s u l t s are summarized i n Table 10. In i d e n t i f y i n g who should be i n v o l v e d i n n u r s i n g q u a l i t y assurance a c t i v i t i e s , 91.1% f e l t t h a t n u r s i n g q u a l i t y assurance a c t i v i t i e s s hould i n v o l v e a l l l e v e l s of n u r s i n g p e r s o n n e l . A l l of the s u b j e c t s , (100.0%), i d e n t i f i e d t h a t n u r s i n g q u a l i t y assurance a c t i v i t i e s i n v o l v e d them, with 87.5% i d e n t i f y i n g these a c t i v i t i e s as p a r t of t h e i r p r o f e s s i o n a l r e s p o n s i b i l i t i e s (Table 10). However, when responding t o whether or not n u r s i n g q u a l i t y assurance a c t i v i t i e s • were p a r t of t h e i r d a i l y a c t i v i t i e s , o n l y 62.5% responded t o t h i s item, and only 42.9% i n d i c a t e d t h a t n u r s i n g q u a l i t y assurance a c t i v i t i e s were a p r i o r i t y on the n u r s i n g u n i t . I n formation was a l s o c o l l e c t e d on who r e q u i r e d the data c o l l e c t e d by n u r s i n g q u a l i t y assurance a c t i v i t i e s . As can be seen i n Table 10, 69.6% f e l t t h a t these a c t i v i t i e s are r e q u i r e d by the h o s p i t a l q u a l i t y assurance d i r e c t o r / c o o r d i n a t o r , 60.7% f e l t t h a t they are r e q u i r e d by the q u a l i t y assurance committee, and 35.7% f e l t t h a t they are r e q u i r e d by s u p e r v i s o r y - l e v e l n u rses. Furthermore, 58.9% f e l t t h a t n u r s i n g q u a l i t y assurance a c t i v i t i e s are used p r i m a r i l y t o meet a c c r e d i t a t i o n requirements f o r the h o s p i t a l . 38 T a b l e 10; Purpose o f N u r s i n g Q u a l i t y A s s u r a n c e A c t i v i t i e s Q u e s t i o n 3: I f e e l n u r s i n g q u a l i t y a s surance a c t i v i t i e s : (check as many as you f e e l are a p p l i c a b l e ) (N = 56) Items P e r c e n t a g e Checked a . are r e q u i r e d by the q u a l i t y a s surance d i r e c t o r / c o o r d i n a t o r 39 69.6% b . are p r i m a r i l y used t o meet a c c r e d i t a t i o n requ irements f o r the h o s p i t a l 33 58.9% c . are r e q u i r e d by the q u a l i t y a s surance committee 34 60.7% d . are r e q u i r e d by s u p e r v i s o r y - l e v e l nurse s 20 35.7% e. do not i n v o l v e me 0 0.0% f . are a waste o f t ime 2 3.6% g . take up t ime t h a t s h o u l d be spent on p a t i e n t care 4 7.1% h . i n v o l v e a l l l e v e l s o f n u r s i n g p e r s o n n e l 51 91.1% i . are p a r t i f my d a i l y a c t i v i t i e s 35 62.5% j . improve n u r s i n g c a r e 48 85.7% k. are p a r t o f my p r o f e s s i o n a l r e s p o n s i b i l i t i e s 49 87.5% 1. are a p r i o r i t y i n the n u r s i n g d i v i s i o n / u n i t 24 42 . 9% 39 Question four asked the subjects, i f they had the choice, on which a c t i v i t i e s would they spend more time? The responses are summarized i n Table 11. No one a c t i v i t y l i s t e d was i d e n t i f i e d by the majority of the pa r t i c i p a n t s as one i n which they would l i k e to spend more time. However, there were three a c t i v i t i e s that did receive a higher response than the others. The most frequently i d e n t i f i e d a c t i v i t y was spending more time teaching patients and/or t h e i r families (71.4%) The next was involving patients i n planning t h e i r own care, with a 69.6% response, followed by the writing of nursing care standards for s p e c i a l i t y area with a 64.3% response. Three a c t i v i t i e s : improving my s k i l l s i n performing nursing care procedures, spending more time planning patient care, and reviewing the care given by other registered nurses, were i d e n t i f i e d by approximately 50% of the participants, as ones that they would spend more time on given the opportunity. A c t i v i t i e s least frequently i d e n t i f i e d were getting to know my fellow workers (23.2%), and being an active member on a qua l i t y assurance committee (23.2%). 40 Table 11: Preferred C l i n i c a l A c t i v i t i e s Question 4: If I could, I would: (check as many as you wish) (N = 56) Number Percentage I d e n t i f i e d a. Spend more time planning patient care 30 b. Be an active member on a qua l i t y assurance committee 13 c. Spend more time teaching patients and/or families 40 d. Involve patients i n planning t h e i r care 39 e. Spend more time getting to know my fellow workers 13 f. Write nursing care standards for s p e c i a l i t y area 36 g. P a r t i c i p a t e i n reviewing the nursing care given by other registered nurses 29 h. Improve my s k i l l s i n performing nursing care procedures 30 53.6^ 23.2^ 71. 4! 69.6^ 23. 2s 64 .3% 51. 8! 53. 6% Additional a c t i v i t i e s that the subjects l i s t e d _in the "other" space were p a r t i c i p a t i n g i n further education, teaching nurses the importance of maintaining standards of care, incorporating peer performance appraisals, and involving fellow workers i n qua l i t y assurance functions. 41 The next section of the chapter w i l l present a discussion on the study findings. Discussion The response rate to the questionnaire w i l l be discussed f i r s t . Following t h i s , the re s u l t s of the study w i l l be discussed i n rel a t i o n s h i p to each of the three research questions. F i n a l l y , there w i l l be a discussion on the supplemental findings and the l i m i t a t i o n s of the study. Response Rate Table 1 (p.23) presents the re s u l t s of the response rate to the survey. The response rate of 71.8% for useable questionnaires was higher than what i s generally experienced by researchers u t i l i z i n g t h i s method of data c o l l e c t i o n . As noted by Burns & Groves (1987), "the response rate for mailed questionnaires i s usually small (25 to 30 percent)..." (p.314). This high response suggests that nursing quality assurance i s a topic that i s meaningful and important to t h i s p a r t i c u l a r group of c r i t i c a l care nurses. RESEARCH QUESTION ONE: WHAT DO CRITICAL CARE NURSES IDENTIFY AS COMPONENTS OF A NURSING QUALITY ASSURANCE PROGRAM? The re s u l t s that t h i s p a r t i c u l a r group of c r i t i c a l care nurses considered to be components of a nursing qua l i t y assurance program are found i n Table 8. A l l but three of the i t e m s / a c t i v i t i e s l i s t e d were i d e n t i f i e d by over 80% of the participants as components of a nursing q u a l i t y assurance program. The remaining three items were i d e n t i f i e d by over 70% of' the p a r t i c i p a n t s . The high response to i d e n t i f y i n g these i t e m s / a c t i v i t i e s , as components of a nursing quality assurance program, i s encouraging for nurses and nursing d i v i s i o n s who are esta b l i s h i n g and managing nursing qu a l i t y assurance programs. There could be several reasons why there was such a high response rate to the i t e m s / a c t i v i t i e s l i s t e d . The high rate of i d e n t i f i c a t i o n could be a r e f l e c t i o n of s p e c i f i c activities/programs i n which the part i c i p a n t s have been involved, and which they believe to be components of a nursing quality assurance program. Another explanation for t h i s response rate may involve the question and i t s wording, i n that, several of the choices offered u t i l i z e d the phrase "quality assurance." The use of the same wording i n the choices may have provided the participants with information that helped them answer the question. F i n a l l y , the 43 structure and v i s u a l presentation of the question may have influenced the participants to check o f f responses without r e f l e c t i n g on whether or not the response was appropriate. The component that was selected the least, by 75%, was the nursing workload management system. In the Kidd, Whiteley and Scherer (1987) survey, a patient c l a s s i f i c a t i o n system (workload management system) was one method, s p e c i f i e d under quality assurance, for esta b l i s h i n g standards of care. Further, several authors have noted that workload measurement systems are an e f f e c t i v e t o o l that provides a method for monitoring the nurse/patient r a t i o to ensure that equitable safe workloads are assigned to nursing s t a f f ( B i l l i n g s , 1983; Giovannetti, 1979: Marker, 1987). Several possible reasons exist for the low response rate to a nursing workload measurement system as a component of a nursing quality assurance program. F i r s t , not a l l hospitals currently u t i l i z e a workload measurement system to determine s t a f f i n g l e v e l s required on t h e i r nursing units. In addition, rapidly changing patient acuity lev e l s i n c r i t i c a l care areas can a f f e c t the e f f i c i e n t u t i l i z a t i o n of a workload measurement system, prompting some hospital not to extend t h e i r system'to include c r i t i c a l care areas. F i n a l l y , i f the information gathered u t i l i z i n g such a t o o l i s not used to adjust s t a f f i n g l e v e l s to workload demands when required, then, i t can not be considered as a component of a nursing quality assurance program. This f i n a l reason was noted by one subject who stated, "[a nursing workload management system] would be a useful t o o l i f i t would be followed up on. Our hospital ignores i t i f the points are too high showing a need for extra s t a f f . If i t i s ignored, then i t i s a waste of valuable nursing time when you're already busy." The item/activity with the next lowest rate of response, regular checks and maintenance of biomedical equipment, was i d e n t i f i e d by 76.8% of the c r i t i c a l care nurses as a nursing qu a l i t y assurance a c t i v i t y . This a c t i v i t y was i d e n t i f i e d as a quality assurance standard for c r i t i c a l care nursing i n the Kidd, Whiteley and Scherer (1987) survey. The fact that t h i s a c t i v i t y was i d e n t i f i e d less frequently than the others l i s t e d was unexpected for t h i s p a r t i c u l a r group of nurses. In c r i t i c a l care nursing, the reliance on biomedical equipment to a s s i s t i n the assessment and monitoring of the p h y s i o l o g i c a l status of the patients i s a v i t a l component of the nurses' routine. One possible explanation was noted by one subject, who stated "...[biomedical equipment] i f other personnel do [i t ] then no, otherwise yes". Therefore, i t would appear that auditing and monitoring biomedical equipment may 45 not always be the r e s p o n s i b i l i t y of the c r i t i c a l care nurse. Hospitals may have special technicians who are responsible for providing routine maintenance and audits of t h i s equipment. However, another reason for a low response rate with t h i s a c t i v i t y could be i n the wording of the question, which may have been interpreted d i f f e r e n t l y by the participants, depending on t h e i r experiences. The t h i r d lowest item/activity, suggestions by nursing s t a f f of topics for nursing qu a l i t y assurance audits/studies, was i d e n t i f i e d by 78.6% of the p a r t i c i p a n t s . The reasons why t h i s a c t i v i t y was not selected as frequently as other a c t i v i t i e s are not cl e a r . However, as noted by Christensen (1990), " . . . i t i s of utmost importance that s t a f f nurses be involved in s e t t i n g standards, or at least choosing them...active p a r t i c i p a t i o n i n the development of a program assures i t s success" (p.50). The lack of involvement i n the complete qua l i t y assurance process was commented on by one nurse, who stated, "not enough bedside nurses... understand i t [nursing q u a l i t y assurance] or the a c t i v i t i e s have not d i r e c t l y involved them! They have been audited (passive), not included (acti v e ) ! " . Consequently, a f a i l u r e to include nurses in the t o t a l process may explain why t h i s a c t i v i t y was not selected as frequently as the others l i s t e d . RESEARCH QUESTION TWO: WHAT DO CRITICAL CARE NURSES IDENTIFY AS THE PURPOSE OF NURSING QUALITY ASSURANCE ACTIVITIES? The re s u l t s of the survey that address t h i s research question can be found i n Table 10. Over 69% of the subjects i d e n t i f i e d that nursing qua l i t y assurance a c t i v i t i e s are required by a quality assurance director/coordinator, with 60.7% i d e n t i f y i n g that these a c t i v i t i e s are required by a quality assurance committee. Although the survey did not seek s p e c i f i c information on the structure of the qua l i t y assurance programs with which they have been involved, the responses to t h i s question could be r e f l e c t i v e of what the subjects have experienced. Many of the qua l i t y assurance programs described i n the l i t e r a t u r e deal with esta b l i s h i n g programs where the a c t i v i t i e s are organized and coordinated by either a qu a l i t y assurance committee or coordinator (Harris, Kreger, & Davis, 1989; Judkins, 1982; O'Brian, 1988). Therefore, what these c r i t i c a l care nurses i d e n t i f y as the purpose of nursing qu a l i t y assurance programs may be r e f l e c t i v e of how the program has been established and i s functioning i n t h e i r present employment. Another purpose for nursing qua l i t y assurance a c t i v i t i e s , i d e n t i f i e d by 58.9% of the par t i c i p a n t s , was to meet the accreditation requirements of the h o s p i t a l (Table 10). The h i g h response r a t e f o r t h i s a c t i v i t y a l s o c o u l d be r e f l e c t i v e of the exp e r i e n c e s t h a t these p a r t i c u l a r c r i t i c a l care nurses have had with n u r s i n g q u a l i t y assurance programs. As can be seen i n the l i t e r a t u r e , many authors i d e n t i f y meeting a c c r e d i t a t i o n standards as the primary reason f o r i n i t i a t i n g these programs (Christensen, 1990; Coyne & K i l l i e n , 1987; H a r r i s , Kreger & Davis, 1989; K e r f o o t & Watson, 1985; O'Brian, 1988). Furthermore, the a c c r e d i t a t i o n standards demand t h a t h o s p i t a l s seeking a c c r e d i t a t i o n s t a n d i n g have a f u n c t i o n i n g q u a l i t y assurance program i n order t o r e c e i v e a p p r o v a l . One p a r t i c i p a n t i n the study, e l a b o r a t i n g on t h i s component noted, " I . . . t h i n k t h a t many times n u r s i n g a d m i n i s t r a t i o n may i n i t i a t e q u a l i t y assurance programs but not always f o r the r i g h t reasons, e.g., they 'have' to f o r a c c r e d i t a t i o n purposes." Another p a r t i c i p a n t added " [ n u r s i n g q u a l i t y assurance a c t i v i t i e s ] are merely used as a t o o l t o meet a c c r e d i t a t i o n requirements as they [nursing q u a l i t y assurance a c t i v i t i e s ] do not a c c u r a t e l y p o r t r a y the q u a l i t y of care p a t i e n t s get, t h i s i s a l l they [ n u r s i n g q u a l i t y assurance a c t i v i t i e s ] are good f o r . " With q u a l i t y assurance b e i n g a requirement f o r a c c r e d i t a t i o n and with many h o s p i t a l s e x p e r i e n c i n g a c c r e d i t a t i o n reviews every two years, the response r a t e t o t h i s item may not 48 be su r p r i s i n g . RESEARCH QUESTION THREE: WHAT IS THE INVOLVEMENT OF CRITICAL CARE NURSES IN NURSING QUALITY ASSURANCE ACTIVITIES? The re s u l t s on the involvement of the subjects i n nursing qu a l i t y assurance a c t i v i t i e s are found i n Table 9. The re s u l t s indicate that the involvement l e v e l for t h i s group of c r i t i c a l care nurses i n those a c t i v i t i e s they considered as components of a nursing qu a l i t y assurance program (Table 8), i s low for a number of the a c t i v i t i e s . In p a r t i c u l a r , there are low p a r t i c i p a t i o n l e v e l s i n serving on an audit committee (25.0%), incorporating findings of a qual i t y assurance study into actual practice (35.7%), developing nursing practice standards for measuring the quality of nursing care (35.7%), and conducting a nursing audit (37.5%). The above involvement rates are very s i m i l a r to those found for the same a c t i v i t i e s i n the Edwardson and Anderson (1983) study. The three i t e m s / a c t i v i t i e s i n Table 8, that were not i d e n t i f i e d as frequently as components of a nursing q u a l i t y assurance program also had s i m i l a r l y low involvement rates by the subjects. In p a r t i c u l a r , only 32.1% had u t i l i z e d a workload measurement system, 12.5% had performed audits on biomedical equipment, and 28.6% 49 had suggested topics for a nursing q u a l i t y assurance audit/study. The reasons for not being involved i n these a c t i v i t i e s were not s p e c i f i c a l l y elaborated on by the p a r t i c i p a n t s i n the study. However, i t i s reasonable to assume that the same reasons put fo r t h to explain the lower selection rates for these a c t i v i t i e s i n Table 8 could account for the low involvement by the part i c i p a n t s i n the a c t i v i t i e s . In addition, the wording change between question one and question two i n the component describing biomedical equipment may have been a contributing factor. The change from "checks and maintenance" to "audit" could have resulted i n a di f f e r e n t i nterpretation by the participants when they responded to the questions. Supplemental Findings The study also provided, through questions three and four on the questionnaire, information on the opinions and attitudes of t h i s group of c r i t i c a l care nurses to nursing quality assurance. Every participant (100%) i d e n t i f i e d that nursing q u a l i t y assurance a c t i v i t i e s involved them, and 87.5% further noted that these a c t i v i t i e s were part of t h e i r professional r e s p o n s i b i l i t i e s (Table 10). Furthermore, 91.1% of the participants f e l t that these a c t i v i t i e s involved a l l lev e l s of nursing personnel. The res u l t s 50 obtained from t h i s p a r t i c u l a r group of nurses suggests not only a p o s i t i v e attitude to quality assurance and qu a l i t y assurance programs but also a professional r e s p o n s i b i l i t y for t h i s concept. As noted by Beyers (1988) "...each nurse now has to learn an use qua l i t y assurance methodologies as an i n t e g r a l part of p r a c t i c e " (p.614). Therefore, the re s u l t s obtained i n t h i s survey may be an in d i c a t i o n that, although q u a l i t y assurance a c t i v i t i e s are perceived as a requirement by non-nursing personnel or outside agencies, they also are, i n fact, seen as an i n t e g r a l part of nursing p r a c t i c e . F i n a l l y , Table 11 presents those a c t i v i t i e s on which, given the opportunity, the part i c i p a n t s i n the study would choose to spend more time. The a c t i v i t i e s that received the highest response rate i n t h i s survey were those that were patient-oriented. In p a r t i c u l a r , 71.4% of the participants noted that they would l i k e to spend more time teaching patients and/or t h e i r families, and 69.9% would l i k e to involve patients i n planning t h e i r own care. These results are consistent with the Edwardson and Anderson (1983) study where " s t a f f nurses showed a clear preference for direct-care a c t i v i t i e s and ranked formal quality assurance a c t i v i t i e s and s o c i a l i n t e r a c t i o n low" (p.36). The a c t i v i t y which received the lowest response rate was 51 "to be an active member on a qual i t y assurance committee" (23.2%). This re s u l t , when considered i n l i g h t of the po s i t i v e responses towards q u a l i t y assurance, i s in t e r e s t i n g . Although these nurses have a po s i t i v e opinion of nursing quality assurance and i t s role i n providing quality nursing care, when given the opportunity less than one quarter want to p a r t i c i p a t e i n t h i s t y p i c a l quality assurance a c t i v i t y . It i s unclear from the results obtained i n t h i s survey why these nurses f e e l t h i s way. Limitations i n t h i s study There are several l i m i t a t i o n s i n t h i s study. F i r s t the population that was used worked i n a variety of hospitals, each with a unique nursing qua l i t y assurance program. Information was not sought from the subjects concerning the s p e c i f i c program i n t h e i r respective h o s p i t a l s . In addition, information was not sought regarding the subjects' s p e c i f i c experiences with nursing qu a l i t y assurance. Information from both these areas could have provided valuable insight into the analysis of the results obtained. Another l i m i t a t i o n i n the study may be the wording of the s p e c i f i c questions and choices of responses. The fact that the subjects were asked to i d e n t i f y components of a nursing quality assurance program using common t e r m i n o l o g y r a t h e r than t h e i r own, may have i n f l u e n c e d the r e s p o n s e s . As noted by Treece and Treece (1982) "the way a q u e s t i o n i s worded can i n f l u e n c e the r e s u l t s . . . [ i n a d d i t i o n ] peop le o f t e n t r y t o g i v e an answer t h a t enhances t h e i r image i n the eyes o f the r e s e a r c h e r . . . " (p .232 ) . F i n a l l y , the a c t u a l s t r u c t u r e and v i s u a l p r e s e n t a t i o n o f the q u e s t i o n s may have promoted a h i g h e r response r a t e to the v a r i o u s components o f the q u e s t i o n s , than would have o t h e r w i s e been o b s e r v e d . The s t r u c t u r e o f the q u e s t i o n s r e q u i r e d the s u b j e c t s t o check o f f t h e i r responses i n a column on one s i d e o f the page . The s u b j e c t s may have s i m p l y checked o f f the components wi thout g i v i n g s e r i o u s enough c o n s i d e r a t i o n t o t h e i r r e s p o n s e s . Summary R e s u l t s o f the i n f o r m a t i o n i n the r e t u r n e d q u e s t i o n n a i r e s were p r e s e n t e d i n t h i s c h a p t e r . The demographic d a t a were p r e s e n t e d f i r s t , f o l l o w e d by the r e s u l t s o f the f o u r q u a l i t y as surance q u e s t i o n s . The r e s u l t s were then d i s c u s s e d i n r e l a t i o n s h i p t o the t h r e e r e s e a r c h q u e s t i o n s , and then supp lementa l f i n d i n g s were d i s c u s s e d . F i n a l l y , l i m i t a t i o n s i n the s tudy were i d e n t i f i e d . 53 CHAPTER FIVE Summary, Conclusion, Implications and Recommendations A summary of the study findings and conclusions are presented i n t h i s chapter. Then, implications of the study are presented, with recommendations for future study. Summary The need to provide concrete evidence of qu a l i t y care i s a r e a l i t y , both within nursing and i n our present health care system. Lang and Clinton (1983) noted "objective and systematic evaluation or assessment of nursing care has been an urgent p r i o r i t y within the profession [of nursing] for several decades" (p.212). In addition, outside agencies such as the Hospital Accreditation Council, have, over the past decade, made quality assurance programs and a c t i v i t i e s a requirement i n the accreditation process (Acorn, Love & M i l l s , 1990; Finley-Cottone & Link, 1985; Harris, Kreger & Davis 1989; Maciorowski, Larson & Keane, 1985; O'Brian, 1988). However, the enthusiasm and 54 p a r t i c i p a t i o n l e v e l of many nurses has been at best, one of ambivalence and reluctant compliance with mandated nursing quality assurance programs. The purpose of t h i s study was to describe c r i t i c a l care nurses' perceptions of t h e i r experiences with nursing qu a l i t y assurance. Three research questions were used to guide t h i s study: 1. What do c r i t i c a l care nurses i d e n t i f y as components of a nursing quality assurance program? 2. What do c r i t i c a l care nurses i d e n t i f y as the purposes of nursing quality assurance a c t i v i t i e s ? 3. What i s the involvement of c r i t i c a l care nurses i n nursing quality assurance a c t i v i t i e s ? Using an exploratory, descriptive design, data were c o l l e c t e d i n a survey u t i l i z i n g a s e l f - administered questionnaire. The questionnaire developed by the researcher, contained questions modified from the Edwardson and Anderson (1983) study. A convenience sample of c r i t i c a l care nurses, who are members of the Canadian Association of C r i t i c a l Care Nurses, was used. C r i t i c a l care nurses were selected as the sample for t h i s study because nursing quality assurance a c t i v i t i e s have a high p r o f i l e i n these units due to the c r i t i c a l condition of the patients. The s t a t i s t i c a l techniques used to analyze the data were frequencies, percentages and means of the in d i v i d u a l items. 55 The r e s u l t s showed that, although t h i s p a r t i c u l a r group of c r i t i c a l care nurses appeared to know what comprised the components of a nursing q u a l i t y assurance program, t h e i r p a r t i c i p a t i o n l e v e l i n these a c t i v i t i e s was low. When asked what the purpose was of nursing q u a l i t y assurance a c t i v i t i e s the majority of the subjects i d e n t i f i e d that nursing quality assurance a c t i v i t i e s were required by a qua l i t y assurance director/coordinator and/or a quality assurance committee. In addition, more than 58.9% indicated that the primary purpose of nursing quality assurance a c t i v i t i e s was to meet the accreditation requirements of the h o s p i t a l . The findings also provide information on t h i s group of nurses attitudes and opinions concerning nursing q u a l i t y assurance. A l l of the subjects i d e n t i f i e d that nursing quality assurance a c t i v i t i e s involved them, with the majority i d e n t i f y i n g that these a c t i v i t i e s involve a l l le v e l s of nursing personnel and were part of t h e i r professional r e s p o n s i b i l i t i e s . However, very few i d e n t i f i e d that they would a c t i v e l y seek involvement i n t r a d i t i o n a l quality assurance a c t i v i t i e s such as serving on a quality assurance committee. The a c t i v i t i e s that were i d e n t i f i e d by the majority of the subjects, as those on which to spend more time, were those that involved d i r e c t patient 56 care, such as teaching patients and/or t h e i r families, and involving patients i n t h e i r own care. Conclusions The r e s u l t s of t h i s study suggest that t h i s group of c r i t i c a l care nurses have an understanding of what would be considered components of a nursing q u a l i t y assurance program. However, t h e i r p a r t i c i p a t i o n l e v e l i n these a c t i v i t i e s i s low. It was beyond the scope of t h i s study to explain p a r t i c i p a t i o n l e v e l s i n recognized nursing quality assurance programs. In the supplemental findings, the majority of the subjects i d e n t i f i e d nursing quality assurance a c t i v i t i e s as part of t h e i r professional r e s p o n s i b i l i t i e s . However, i n i d e n t i f y i n g the purpose for these a c t i v i t i e s the majority chose meeting the hospital's accreditation requirements. Although the r e s u l t s i d e n t i f i e d that these nurses valued nursing qu a l i t y assurance a c t i v i t i e s , i n the r e a l i t y of practice, they perceived t h e i r purpose i s for other than improving nursing care. In addition, the supplemental re s u l t s also i d e n t i f i e d that these nurses perceived nursing q u a l i t y assurance a c t i v i t i e s as involving a l l l e v e l s of nursing and as a way of improving patient care. However, i f 57 given the opportunity they were unwilling to p a r t i c i p a t e i n the a c t i v i t i e s that they i d e n t i f i e d as components of a nursing quality assurance program. The a c t i v i t i e s which they would seek involvement i n are those that involve d i r e c t patient contact. This r e s u l t i s consistent with the findings i n the Edwardson and Anderson (1983) study, i n which the respondents "agreed that involvement i n quality assurance was an important part of the professional nurses' role...[however] less than half of the staff-nurses respondents would choose to p a r t i c i p a t e i n these a c t i v i t i e s [quality assurance a c t i v i t i e s ] i f they had the opportunity" (p.37-38). Therefore, i t appears that the p a r t i c i p a n t s of t h i s study know and value nursing qu a l i t y assurance a c t i v i t i e s but they do not transform that knowledge and those values into d e f i n i t e nursing qu a l i t y assurance a c t i v i t i e s . Implications and Recommendations Although the study population was l i m i t e d to a s p e c i f i c group of nurses, thereby giving r i s e to problems of generalization, several implications for nursing practice, nursing education, nursing administration and nursing research can be derived from the r e s u l t s obtained. 58 Nursing Practice The r e s u l t s of t h i s study have a number of implications for nurses who are i n c l i n i c a l p r a c t i c e . The r e s u l t s show that the nurses who p a r t i c i p a t e d i n t h i s study f e l t that nursing quality assurance a c t i v i t i e s were for quality assurance coordinators/committees and were primarily used to meet hosp i t a l accreditation r e s p o n s i b i l i t i e s . These re s u l t s are very disturbing i n l i g h t of the current l i t e r a t u r e that i d e n t i f i e s nursing quality assurance a c t i v i t i e s as one method of defining nursing practice and the i n d i v i d u a l nurses' r e s p o n s i b i l i t y for that p r a c t i c e . In addition, the subjects perceived that, nursing q u a l i t y assurance a c t i v i t i e s involved a l l l e v e l s of nursing personnel and were part of t h e i r professional r e s p o n s i b i l i t i e s . However, when given the opportunity to p a r t i c i p a t e i n nursing q u a l i t y assurance a c t i v i t i e s , these nurses selected patient-oriented a c t i v i t i e s . Nurses who practice d i r e c t patient care have to develop an awareness that not a l l a c t i v i t i e s that concern professional practice involve d i r e c t patient contact. Nurses have to stop being passive p a r t i c i p a n t s i n the nursing quality assurance process and seek out an active role for themselves. This active role should include d i r e c t involvement i n the decisions involving t h e i r unit and the nursing quality assurance program 59 w i t h knowledge and u t i l i z a t i o n of the f i n d i n g s from the a c t i v i t i e s i n the program. In a d d i t i o n , nurses who accept appointments to n u r s i n g q u a l i t y assurance a c t i v i t i e s must request t h a t n u r s i n g a d m i n i s t r a t i o n p r o v i d e r e l e a s e time t o a t t e n d meetings, e n s u r i n g t h a t t h e r e i s no c o n f l i c t f o r these nurses between d i r e c t and i n d i r e c t p a t i e n t c a r e . N u r s i n g E d u c a t i o n The f i n d i n g s of t h i s study have i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n . These f i n d i n g s i n d i c a t e t h a t t h i s group of nurses has developed a value system w i t h i n t h e i r p r o f e s s i o n a l growth t h a t r e c o g n i z e s t h a t the assurance of q u a l i t y i n p r o f e s s i o n a l a c t i v i t y i s p a r t of t h e i r p r o f e s s i o n a l r e s p o n s i b i l i t y . However, what does not seem to have been a c q u i r e d i s how t o t r a n s l a t e these v a l u e s i n t o p r o f e s s i o n a l a c t i v i t i e s and p r a c t i c e . In a d d i t i o n , the r e s u l t s of the study i n d i c a t e t h a t , when g i v e n the o p p o r t u n i t y , t h i s p a r t i c u l a r group of nurses would choose to p a r t i c i p a t e i n those' a c t i v i t i e s which predominantly i n v o l v e d i r e c t p a t i e n t c o n t a c t . As a r e s u l t of these f i n d i n g s , i t would appear t h a t n u r s i n g e d u c a t i o n has a r o l e i n t e a c h i n g students and s t a f f how to t r a n s l a t e t h e i r v a l u e s f o r q u a l i t y care i n t o c o n c r e t e a c t i v i t i e s w i t h i n the c l i n i c a l environment. One method r e c e n t l y d i s c u s s e d i n the 60 l i t e r a t u r e was a l i a i s o n w i t h a p r a c t i c e i n s t i t u t i o n t o p r o v i d e a n u r s i n g p r a c t i c u m f o r s tudent s which would a c t i v e l y i n v o l v e the s tudent i n a n u r s i n g u n i t ' s q u a l i t y a s surance program. The b e n e f i t s as n o t e d by Smith and Power (1990), are t h a t "the l i n k between e d u c a t i o n and p r a c t i c e i s s t r e n g t h e n e d ; . . . a n d p r a c t i c a l s tudent e x p e r i e n c e s t h a t address t i m e l y p a t i e n t c a r e i s s u e s are p r o v i d e d " ( p . 3 0 ) . A n o t h e r p a r t o f n u r s i n g e d u c a t i o n t h a t s h o u l d p l a y an a c t i v e r o l e i s the c o n t i n u i n g e d u c a t i o n systems t h a t many n u r s i n g d i v i s i o n s o f f e r t h e i r s t a f f . These s t a f f e d u c a t i o n a l departments can p l a y a s i g n i f i c a n t r o l e i n the awareness l e v e l o f s t a f f i n n u r s i n g q u a l i t y a s s u r a n c e a c t i v i t i e s . T h e i r e d u c a t i o n a l programs s h o u l d i n c l u d e a b a s i c o r i e n t a t i o n to n u r s i n g q u a l i t y a s s u r a n c e as w e l l as e x p e r i e n c e s i n w r i t i n g s t a n d a r d s , c r e a t i o n o f a u d i t i n g t o o l s , and u t i l i z a t i o n o f r e s u l t s . In a d d i t i o n , g i v e n the i n c r e a s i n g emphasis on q u a l i t y i n the p r e s e n t h e a l t h c a r e env ironment , new developments i n n u r s i n g q u a l i t y a s surance s h o u l d be p r e s e n t e d r e g u l a r l y to a l l n u r s i n g s t a f f . N u r s i n g A d m i n i s t r a t i o n The r e s u l t s o f t h i s s tudy are v e r y i m p o r t a n t f o r the nurse a d m i n i s t r a t o r to c o n s i d e r because , as n o t e d by Devet (1986), "[nurse a d m i n i s t r a t o r s ] o f t e n p e r c e i v e Q.A. [quality assurance] as a function to delegate to a s t a f f support service rather than one to keep well integrated into t h e i r own leadership r o l e . . . " (p.52). Consequently, i n l i g h t of the findings of t h i s study, nurse administrators should involve themselves i n t h e i r department's nursing quality assurance program on a regular basis. This involvement could be accomplished i n a variety of ways. F i r s t , nursing quality assurance reports should be considered a regular component of a l l nursing s t a f f and nursing management meetings. This w i l l help refocus the perception that the nursing s t a f f have about who the nursing quality assurance a c t i v i t i e s are for and why nursing s t a f f should be involved i n these a c t i v i t i e s . Secondly, nursing s t a f f ' s involvement in nursing quality assurance a c t i v i t i e s has to be encouraged and supported by the nurse administrator. This should involve delegating r e s p o n s i b i l i t y for the process down to the nursing unit l e v e l and using the s t a f f ' s ideas and input into the type of nursing q u a l i t y assurance a c t i v i t i e s that are most suitable for t h e i r s p e c i f i c unit. As noted by O'Brian (1988) " [ s t a f f nurses] as d i r e c t care givers,... are i n the best p o s i t i o n to monitor nursing practice by i d e n t i f y i n g problems and implementing corrective actions which have the greatest impact on patient care" (p.33). Without 62 t h i s type of d i r e c t involvement by the n u r s i n g s t a f f , d e l e g a t e d by the nurse a d m i n i s t r a t o r , n u r s i n g q u a l i t y assurance programs w i l l continue t o be seen as e x e r c i s e s i n f u l f i l l i n g t h i r d p a r t y requirements. F i n a l l y , the s p e c i f i c r esources needed t o p r o p e r l y operate a n u r s i n g q u a l i t y assurance program should be a r e g u l a r p a r t of the n u r s i n g d i v i s i o n ' s budget. Resource a l l o c a t i o n i n c l u d e s p r o v i s i o n s f o r r e l i e f s t a f f t o f a c i l i t a t e the attendance and p a r t i c i p a t i o n of d e s i g n a t e d n u r s i n g s t a f f i n q u a l i t y assurance a c t i v i t i e s . F a i l u r e t o p r o v i d e t h i s type of r e l i e f w i l l r e s u l t i n a c o n f l i c t between d i r e c t and i n d i r e c t p a t i e n t care requirements, with the d i r e c t p a t i e n t care needs always t a k i n g precedence. The r e s u l t s of the study a l s o i n d i c a t e t h a t although the nurses knew the components of a n u r s i n g q u a l i t y assurance program, they i d e n t i f i e d t h e i r p a r t i c i p a t i o n l e v e l i n these a c t i v i t i e s as low. Edwardson and Anderson (1983) i n t h e i r study noted s i m i l a r l y low p a r t i c i p a t i o n l e v e l s f o r nurses i n formal q u a l i t y assurance a c t i v i t i e s and they recommended t h a t nurse a d m i n i s t r a t o r s i n v e s t i g a t e why s t a f f nurses were not more a c t i v e l y i n v o l v e d i n n u r s i n g q u a l i t y assurance a c t i v i t i e s . T h erefore, based on the p r e s e n t f i n d i n g s nurse a d m i n i s t r a t o r s should not only take an a c t i v e r o l e i n n u r s i n g q u a l i t y assurance a c t i v i t i e s , but 63 should also investigate why s t a f f nurses do not pa r t i c i p a t e more e n t h u s i a s t i c a l l y i n these a c t i v i t i e s . Nursing Research Based on the findings from t h i s study the following research a c t i v i t i e s are recommended: 1. A f i v e year, longitudinal study, surveying at yearly i n t e r v a l s a l l nurses i n a s p e c i f i c i n s t i t u t i o n , to determine i f the nursing quality assurance program and the related educational programs are having any e f f e c t . 2. Using the same nursing population, and the resu l t s obtained i n t h i s study as a foundation, use a q u a l i t a t i v e approach to explore the nurses' attitudes, perceptions and low p a r t i c i p a t i o n l e v e l s i n more depth. 3. survey a larger group of s t a f f nurses to investigate the s p e c i f i c causes of nurses' d i s s a t i s f a c t i o n with nursing quality assurance a c t i v i t i e s . 4. Revise the questionnaire used i n t h i s study, correcting the weaknesses that have been i d e n t i f i e d i n the wording and v i s u a l presentation. 64 BIBLIOGRAPHY Acorn, S., Love, S., & M i l l s , W. (1990). 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Young, L.C., & Hayne, A.N. (1988). N u r s i n g a d m i n i s t r a t i o n from concepts t o p r a c t i c e . P h i l a d e l p h i a : W.B. Saunders Company. 72 Appendix C 6 Nursing Q u a l i t y Assurance Survey Q u e s t i o n n a i r e D i r e c t i o n s 1. P l e a s e read each statement and the i n s t r u c t i o n s c a r e f u l l y . 2. I f you f e e l t h a t a statement i s d i f f i c u l t f o r you to answer, p l e a s e check the response t h a t you t h i n k i s c l o s e s t t o bei n g c o r r e c t . 3. P l e a s e do not s i g n the q u e s t i o n n a i r e . 1. I f e e l the i t e m s / a c t i v i t i e s l i s t e d below are components of a n u r s i n g q u a l i t y assurance program: (check as many as you t h i n k are a p p l i c a b l e ) _a. n u r s i n g care a u d i t s _b. r e g u l a r s t a f f performance a p p r a i s a l s _c. a u d i t or q u a l i t y assurance committees _d. i n c i d e n t r e p o r t s _e. u t i l i z a t i o n of q u a l i t y assurance f i n d i n g s _ f . r e g u l a r h o s p i t a l - b a s e d n u r s i n g i n s e r v i c e _g. r e g u l a r checks and maintenance of b i o m e d i c a l equipment _h. v e r i f i c a t i o n of c u r r e n t n u r s i n g r e g i s t r a t i o n _ i . n u r s i n g p r a c t i c e standards _ j . s u g g e s t i o n s by n u r s i n g s t a f f of t o p i c s f o r n u r s i n g q u a l i t y assurance a u d i t s / s t u d i e s _k. o r i e n t a t i o n programs f o r new s t a f f _1. n u r s i n g work l o a d management systems ( i e . GRASP) m. other (please s p e c i f y ) 73 2. In the p a s t year I have been i n v o l v e d i n the f o l l o w i n g a c t i v i t i e s : (check as many as you wish) _a. conducted a n u r s i n g a u d i t _b. r e c e i v e d a performance a p p r a i s a l about my work performance _c. served on an a u d i t or q u a l i t y assurance committee _d. i n i t i a t e d i n c i d e n t r e p o r t s _e. i n c o r p o r a t e d f i n d i n g s of q u a l i t y assurance s t u d i e s i n t o a c t u a l p r a c t i c e _ f . r e g u l a r l y attended h o s p i t a l - b a s e d n u r s i n g i n s e r v i c e s _g. performed a u d i t s of b i o m e d i c a l equipment _h. produced evidence of c u r r e n t n u r s i n g r e g i s t r a t i o n _ i . developed n u r s i n g p r a c t i c e standards f o r measuring the q u a l i t y of n u r s i n g care _ j . suggested t o p i c s f o r n u r s i n g q u a l i t y assurance a u d i t s / s t u d i e s _k. o r i e n t e d of new n u r s i n g s t a f f _1. u t i l i z e d a n u r s i n g workload management system ( i e . GRASP) m. other (please s p e c i f y ) 3. I f e e l n u r s i n g q u a l i t y assurance a c t i v i t i e s : (check as many as you f e e l are a p p l i c a b l e ) a. are r e q u i r e d by the q u a l i t y assurance d i r e c t o r / c o o r d i n a t o r b. are p r i m a r i l y used t o meet a c c r e d i t a t i o n requirements f o r the h o s p i t a l c. are r e q u i r e d by the q u a l i t y assurance committee j — _ - • _d. are r e q u i r e d by s u p e r v i s o r y - l e v e l nurses _e. do not i n v o l v e me _ f . are a waste of time _g. take up time t h a t should be spent on p a t i e n t care _h. i n v o l v e a l l l e v e l s of n u r s i n g p e r s o n n e l _ i . are a p a r t of my d a i l y a c t i v i t i e s _ j . improve n u r s i n g care _k. are p a r t of my p r o f e s s i o n a l r e s p o n s i b i l i t i e s _1. are a p r i o r i t y i n the n u r s i n g d i v i s i o n / u n i t m. other (please s p e c i f y ) _ 74 4. I f I could, I would: (check as many as you wish) a. spend more time p l a n n i n g p a t i e n t s ' care b. be an a c t i v e member on a q u a l i t y assurance committee c. spend more time t e a c h i n g p a t i e n t s and/or f a m i l i e s _d. i n v o l v e p a t i e n t s i n p l a n n i n g t h e i r care e. spend more time g e t t i n g t o know my f e l l o w workers f. w r i t e n u r s i n g care standards f o r s p e c i a l i t y area _g. p a r t i c i p a t e i n r e v i e w i n g the n u r s i n g care g i v e n by other r e g i s t e r e d nurses h. improve my s k i l l s i n performing n u r s i n g care procedures i . o t her (please s p e c i f y ) In the f o l l o w i n g q u e s t i o n s p l e a s e check or f i l l i n the data t h a t d e s c r i b e s you most adequately. 5. N u r s i n g e d u c a t i o n : (please check a l l t h a t apply) a. N u r s i n g diploma b. B a c c a l a u r e a t e degree c. Master's degree d. other (please s p e c i f y ) 6. Please i n d i c a t e the area of c r i t i c a l care t h a t you are c u r r e n t l y employed i n : a. i n t e n s i v e care u n i t b. coronary care u n i t e. s u r g i c a l i n t e n s i v e care u n i t f . post-open heart recovery u n i t e. p e d i a t r i c i n t e n s i v e care u n i t f . n e o n a t a l i n t e n s i v e care u n i t g. other (please s p e c i f y ) . ^

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