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Critical care nurses' perceptions of their experience with nursing quality assurance Perry, Mary Barbara 1990-12-31

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CRITICAL CARE NURSES' PERCEPTIONS OF THEIR EXPERIENCE WITH NURSING QUALITY ASSURANCE by MARY BARBARA PERRY B.N. Dalhousie U n i v e r s i t y , 1984  THESIS SUBMITTED IN PARTIAL FULFILLMENT THE  REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING  in THE  FACULTY OF GRADUATE STUDIES School o f Nursing  We accept t h i s t h e s i s as conforming to t h e r e q u i r e d  THE  standard  UNIVERSITY OF BRITISH COLUMBIA August 1990 Mary Barbara Perry, 1990  In  presenting this  degree at the  thesis  in  University of  partial  fulfilment  of  of  department  this thesis for or  by  his  or  requirements  British Columbia, I agree that the  freely available for reference and study. I further copying  the  representatives.  an advanced  Library shall make it  agree that permission for extensive  scholarly purposes may be her  for  It  is  granted  by the  understood  that  head of copying  my 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 o f t h i s study was t o d e s c r i b e  critical  care nurses' p e r c e p t i o n s o f t h e i r e x p e r i e n c e s w i t h 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 . Using an e x p l o r a t o r y , d e s c r i p t i v e 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 - a d m i n i s t e r e d  questionnaire.  A convenience sample of c r i t i c a l care nurses, who are members of the Canadian A s s o c i a t i o n o f C r i t i c a l  Care  Nurses, was used. The r e s u l t s showed t h a t these p a r t i c u l a r nurses knew what comprised the components of a n u r s i n g 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 i n these a c t i v i t i e s was low. In a d d i t i o n , the m a j o r i t y i d e n t i f i e d t h a t the primary purpose 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 was t o meet the a c c r e d i t a t i o n requirements o f the h o s p i t a l . the r e s u l t s a l s o i d e n t i f i e d t h a t a l l of t h i s group o f nurses f e l t t h a t n u r s i n g q u a l i t y  Finally, particular  assurance  a c t i v i t i e s i n v o l v e d them, and the m a j o r i t y f e l t these a c t i v i t i e s were p a r t o f t h e i r responsibilities.  professional  that  iii TABLE OF CONTENTS Abstract Table o f Contents L i s t o f Tables L i s t of Figures Acknowledgements  Page i i i i i v vi v i i  Chapter One - I n t r o d u c t i o n Background t o t h e Problem Purpose o f t h e Study Conceptual Base Research Questions Definitions Assumptions Limitations Delimitations . . . Significance Overview o f T h e s i s Content  1 4 4 7 7 9 9 10 10 10  Chapter Two - Review o f the L i t e r a t u r e N u r s i n g Q u a l i t y Assurance Q u a l i t y Assurance i n C r i t i c a l Care D i r e c t i o n s and Trends i n N u r s i n g Q u a l i t y Assurance 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 N u r s i n g Q u a l i t y Assurance Summary o f L i t e r a t u r e Review  12 13 14 15 18  Chapter Three - Methods and Procedures Design Sample S e l e c t i o n Instrument V a l i d i t y Testing E t h i c a l Considerations A d m i n i s t r a t i o n of Q u e s t i o n n a i r e Data A n a l y s i s Chapter Four - F i n d i n g s and D i s c u s s i o n Demographic C h a r a c t e r i s t i c of t h e Sample Findings Discussion Response Rate.. Research Question One Research Question Two Research Question Three Supplemental F i n d i n g s L i m i t a t i o n s i n t h i s Study Summary .  19 20 20 21 22 23 24 26 32 41 42 46 48 49 51 52  iv Chapter  Five  - 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 Conclusions Implications: Nursing Practice Nursing Education Nursing Administration Nursing Research  53 56  Bibliography  64  Appendices: A p p e n d i x A. A p p e n d i x B. A p p e n d i x C. A p p e n d i x D.  A g e n c y C o n s e n t Form Letter of Introduction Questionnaire Letter of Permission  58 59 60 63  70 71 72 76  V  LIST OF TABLES Page Table 1. Q u e s t i o n n a i r e Response Rate  24  Table 2. Age  27  Distribution  Table 3. Time i n Present P o s i t i o n  27  Table 4. Employment Status  28  Table 5. E d u c a t i o n a l L e v e l  29  Table 6. Current Nursing P o s i t i o n  30  Table 7. Areas of C r i t i c a l Care Employment  31  Table 8. Components of a Nursing Assurance Program  34  Quality  Table 9. Involvement i n Q u a l i t y Assurance Activities  36  Table 10. Purpose of Nursing Assurance A c t i v i t i e s  38  Quality  Table 11. P r e f e r r e d C l i n i c a l A c t i v i t i e s  40  vi  LIST OF FIGURES Page F i g u r e 1. I n t e r r e l a t e d n e s s of the nurse a d m i n i s t r a t o r , s t a f f nurse, and 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  6  vii  Acknowledgements  I would l i k e t o acknowledge the a s s i s t a n c e and d i r e c t i o n p r o v i d e d by the members of my t h e s i s committee, Dr. Sonia Acorn and Dr. A l i c e Jope. T h e i r p a t i e n c e , 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 s p e c i a l thankyou c l o s e f r i e n d s , who, throughout the ready t o l i s t e n and o f f e r words of support. In p a r t i c u l a r , B e r n i e and  t o my f a m i l y and process were always encouragement and Lynda, Thanks!  I would a l s o l i k e t o express my g r a t i t u d e t o the Department of N a t i o n a l Defence, and i n p a r t i c u l a r the N u r s i n g Core, f o r p r o v i d i n g me with t h i s o p p o r t u n i t y t o grow i n my p r o f e s s i o n a l knowledge and e x p e r i e n c e . F i n a l l y , t o T i f f a n y and Sam, whose d e v o t i o n and acceptance throughout t h i s long process has kept me r e a l i t y o r i e n t a t e d , Thanks!  1  CHAPTER ONE  Background t o the Problem  Inherent  i n the p r a c t i c e of h e a l t h care i s the  f a c t t h a t h e a l t h care p r o v i d e r s 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 o f determining  what c o n s t i t u t e s  q u a l i t y c a r e . T h i s p r i v i l e g e has been granted by s o c i e t y t o p r o f e s s i o n a l groups with the e x p e c t a t i o n t h a t they w i l l honour t h e i r o b l i g a t i o n t o p r o v i d e a h i g h standard  o f care through s e l f - r e g u l a t i o n . The  p r o v i s i o n o f q u a l i t y care, and the standards  that  determine t h a t care, have concerned the n u r s i n g p r o f e s s i o n s i n c e F l o r e n c e N i g h t i n g a l e d e s c r i b e d her experiences Clinton,  d u r i n g the Crimean War  (Baker, 1983; Lang &  1983) .  However, over the past s e v e r a l decades, an i n c r e a s e i n the need f o r c o s t a c c o u n t a b i l i t y of h e a l t h care and an i n c r e a s e i n p r o f e s s i o n a l i s m has r e s u l t e d i n a demand f o r e m p i r i c a l evidence  that q u a l i t y health  care i s b e i n g p r o v i d e d . As noted by Wilson new standards  for hospital accreditation  (1987), the "demand t h a t  q u a l i t y and i t s p u r s u i t come out of the c l o s e t "  (p.4).  In other words, q u a l i t y assurance programs t h a t  provide  e m p i r i c a l evidence  of the q u a l i t y o f care  being  2 d e l i v e r e d are now  a n e c e s s i t y t o the p r a c t i c e of  care p r o f e s s i o n a l s and t o the i n s t i t u t i o n s t h a t  health provide  care. More r e c e n t l y , t h e r e has been, w i t h i n the profession,  an i n c r e a s e d emphasis on d e f i n i n g what  c o n s t i t u t e s n u r s i n g p r a c t i c e and  an i n d i v i d u a l ' s  a c c o u n t a b i l i t y f o r that p r a c t i c e . Several i d e n t i f i e d nursing  addresses these two 1985;  authors have  q u a l i t y assurance a c t i v i t i e s as a  mechanism t h a t can p r o v i d e  Sliefert,  nursing  areas  e x p l i c i t evidence t h a t (Blake,  1981;  Schmadl,  Smeltzer, 1983) . However, the  1979;  general  a t t i t u d e of s t a f f nurses about the performance of q u a l i t y assurance a c t i v i t i e s ,  as noted i n a  study by Edwardson and Anderson are  recent  (1983), i s t h a t  they  " o f t e n l i t t l e more than an e x e r c i s e i n  compliance..."  (p.39). This i n v e s t i g a t o r has  i n v o l v e d with v a r i o u s n u r s i n g a c t i v i t i e s s i n c e 1983  and  been  q u a l i t y assurance  can a t t e s t to the  l a c k 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 Anderson  f u r t h e r noted by Edwardson  (1983), "a d i s c o u r a g i n g  reality  f o r nurses  and who  h o l d q u a l i t y assurance p o s i t i o n s i n h o s p i t a l s i s the c o n c l u s i o n t h a t t h e i r nurse c o l l e a g u e s about the q u a l i t y assurance p r o c e s s " One  area t h a t has  are  ambivalent  (p.33).  a h i g h 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 u n i t . N u r s i n g q u a l i t y  3 assurance  a c t i v i t i e s become h i g h p r o f i l e i n t h i s  because of the c r i t i c a l  area  c o n d i t i o n s of the p a t i e n t s and  the heavy r e l i a n c e on s p e c i a l i z e d n u r s i n g knowledge, combined with advanced medical technology. As noted Kieller  (1985),  "today,  critical  c o n f r o n t e d with mind-boggling, technology-overloaded,  care nurses  by  are  resource-demanding,  moral-confronting  c h a l l e n g e s . . . [and t h a t ] QA  [quality  assurance  programs]...have been expanded t o cover every aspect of every department..." q u a l i t y assurance  (p.20). T h i s i n c r e a s e d emphasis i n  r e l i e s on the c o o p e r a t i o n of the  nurse t o ensure t h a t s a f e , e f f e c t i v e care i s p r o v i d e d and documented. There are numerous a r t i c l e s on the reasons q u a l i t y assurance programs are necessary and  why  how  i n d i v i d u a l agencies have e s t a b l i s h e d t h e i r programs. In a d d i t i o n , many a r t i c l e s o f f e r suggestions and p l a n s of a c t i o n t o nurse a d m i n i s t r a t o r s on how  to obtain nursing  s t a f f s ' c o o p e r a t i o n and compliance  with  assurance  Lowe-Serge, M a r c i l l i  & O'Brian,  activities 1988;  (Kelly,  T a y l o r & Haussman, 1988). However,', i n  a review of over 1,000  a r t i c l e s and books w r i t t e n on  n u r s i n g q u a l i t y assurance, t h e r e appeared  1984;  quality  (Lang & C l i n t o n ,  1983),  t o be l i m i t e d r e s e a r c h i n the area of  nurses' a t t i t u d e s and/or p e r c e p t i o n s of n u r s i n g q u a l i t y assurance. With t h i s l a c k of r e s e a r c h and an i n c r e a s e  4 i n the need t o demonstrate t h a t q u a l i t y care i s b e i n g p r o v i d e d , a study t h a t d e a l s with q u a l i t y assurance i s timely. Information gathered from t h i s type o f study c o u l d h e l p the nurse a d m i n i s t r a t o r prepare and implement n u r s i n g q u a l i t y assurance programs t h a t 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 t o monitor  their  n u r s i n g care and the n u r s i n g care o f o t h e r s , and thereby meet the requirements  f o r assuring that quality  care i s b e i n g p r o v i d e d t o p a t i e n t s .  Purpose o f the Study  The purpose of t h i s study was t o d e s c r i b e c r i t i c a l care nurses' p e r c e p t i o n s of t h e i r experiences n u r s i n g q u a l i t y assurance was sought  a c t i v i t i e s . This information  f o r the purpose o f enhancing  base o f n u r s i n g q u a l i t y assurance l e v e l of q u a l i t y assurance  with  the knowledge  and improving the  programs.  Conceptual  T h i s study was conducted  Base  w i t h i n a c o n c e p t u a l base  t h a t d i r e c t s the nurse a d m i n i s t r a t o r t o seek out and understand  s t a f f nurses' p e r c e p t i o n s o f t h e i r  experiences with n u r s i n g q u a l i t y assurance. The  5  components, and key f a c t o r s i n v o l v e d i n the r e l a t i o n s h i p s of these components, are shown i n F i g u r e 1. N u r s i n g q u a l i t y assurance  activities  are  r e q u i r e d by the nurse a d m i n i s t r a t o r i n order 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 g i v e n . Information i s compiled by the s t a f f nurse, who charged with m o n i t o r i n g h i s / h e r own  is  n u r s i n g care  and  the care p r o v i d e d by peers, u s i n g n u r s i n g q u a l i t y assurance  c r i t e r i a . In order t o ensure p o s i t i v e  outcomes f o r p a t i e n t s , n u r s i n g s t a f f s ,  and the  nurse  a d m i n i s t r a t o r , t h e r e should be a measure of agreement and cohesiveness  concerning n u r s i n g q u a l i t y  a c t i v i t i e s between the s t a f f nurse and the  assurance nurse  a d m i n i s t r a t o r . Therefore, the need e x i s t s t o seek out and e x p l o r e the p e r c e p t i o n s , a t t i t u d e s ,  and  potential  motives of the s t a f f nurse i n r e l a t i o n t o n u r s i n g quality  assurance.  Furthermore, i t i s g e n e r a l l y accepted t h a t t h e r e are s e v e r a l components t h a t c o n s t i t u t e n u r s i n g q u a l i t y assurance programs. These components c o n s i s t of the e s t a b l i s h m e n t of a c c e p t a b l e standards of care, methods of d e t e r m i n i n g compliance  with these  a n a l y s i s of the data c o l l e c t e d , results  obtained.  standards,  and the u t i l i z a t i o n  of  E x p l o r a t i o n of a t t i t u d e s , i n t e r e s t s , p o t e n t i a l motives, and needs.  Nurse Administrator  Positive Perceptions Nursing Q u a l i t y Assurance  Posxtive Outcome Nursing Q u a l i t y Assurance  F i g u r e 1: I n t e r r e l a t e d n e s s of the nurse s t a f f nurse,  administrator  and n u r s i n g q u a l i t y assurance  activities  7 Research  1. What do c r i t i c a l components  care nurses  of a nursing quality  2. What do c r i t i c a l purposes  Questions  nursing quality  assurance  as  program?  identify  assurance  3. What i s t h e i n v o l v e m e n t in  assurance  care nurses  of nursing quality  identify  as t h e  activities?  of c r i t i c a l  care  nurses  activities?  Definitions  1. N u r s i n g assurance  quality  assurance:  nursing  i n v o l v e s a s s u r i n g t h e consumer o f a  degree of [nursing] e x c e l l e n c e through measurement  nursing process,  alteration  norms,  components,  a n d / o r consumer  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 available  specific  continuous  and e v a l u a t i o n o f s t r u c t u r a l  goal-directed  and  quality  and  a  outcome,  standards  and f o l l o w e d by a p p r o p r i a t e  w i t h t h e p u r p o s e o f improvement  (Schmadl,  1979, p . 4 6 5 ) . 2. N u r s i n g  quality  formal monitoring defines given,  assurance  (composed o f components)  and e v a l u a t e s t h e q u a l i t y and t a k e s  p r o g r a m : a method o f  a c t i o n t o ensure  r e m a i n s a t an optimum  level  1983;  1990).  S m i t h & Powers,  which  of nursing care  being  that the quality  (Campbell,  1982; C o n l i n e ,  8 3. N u r s i n g q u a l i t y assurance  activities:  those  d e s i g n a t e d a c t i v i t i e s t h a t are the components of a n u r s i n g q u a l i t y assurance program. F o r example, n u r s i n g a u d i t s , performance a p p r a i s a l s ,  credentialing,  c o n t i n u i n g education, and u t i l i z a t i o n o f q u a l i t y assurance  findings.  4. General duty nurse: a r e g i s t e r e d nurse whose primary  r e s p o n s i b i l i t y i s d i r e c t e d t o p a t i e n t care and  the a c t i v i t i e s t h a t are i n v o l v e d i n the p r o v i s i o n of that care. 5. Nurse a d m i n i s t r a t o r : a nurse who i s employed i n a management p o s i t i o n w i t h i n a h e a l t h care  institution  or agency and whose primary r e s p o n s i b i l i t i e s are t o supervise , d i r e c t ,  and counsel other nurses i n the  performance o f d i r e c t p a t i e n t care 1983;  E p s t e i n , 1982; G i l l i e s ,  (Douglas  & Bevis,  1989).  6. C r i t i c a l c a r e : r e f e r s t o the care o f c r i t i c a l l y ill  p a t i e n t s i n s p e c i f i c s p e c i a l i z e d areas of a  h o s p i t a l t h a t are s t r u c t u r e d t o d e a l with  life-  t h r e a t e n i n g p h y s i o l o g i c a l c r i s e s . These i n c l u d e i n t e n s i v e care u n i t s , coronary care u n i t s , i n t e n s i v e care u n i t s , post-open  surgical  heart recovery u n i t s ,  p a e d i a t r i c care u n i t s and neonatal i n t e n s i v e care units. 7. E x p e r i e n c e s : d i r e c t p e r s o n a l p a r t i c i p a t i o n or o b s e r v a t i o n , a c t u a l knowledge or c o n t a c t . . . (Hanks,  1986,  p.536). 8. P e r c e p t i o n s : t h e p r o c e s s  detects  and i n t e r p r e t s  by w h i c h an  i n f o r m a t i o n from  w o r l d b y means o f s e n s o r y  organism  the external  r e c e p t o r s . . . (Hanks, 1986,  p.1139) .  Assumptions  1. critical care  Q u a l i t y assurance  care t o provide evidence  i s being 2.  Nurses working i n c r i t i c a l  that quality  Nursing  consumer  care areas  with nursing q u a l i t y quality  assurance  n u r s i n g p r o f e s s i o n t o ensure the  are used i n nursing  provided.  some e x p e r i e n c e 3.  activities  have had  assurance.  i s essential  a high quality  to the  of care t o  (patient).  Limitations  and D e l i m i t a t i o n s  Limitations Since the p a r t i c i p a n t s convenience applicable study and  sample,  i n the study  the results  only t o those  are a  of the study a r e  individuals  i n v o l v e d . The  was l i m i t e d by t h e q u e s t i o n n a i r e i n s t r u m e n t  the extent  variable  t o w h i c h i t was a measure o f t h e  studied.  used  10 Delimitations The study was  d e l i m i t e d t o 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 are  members of the l o c a l chapter of the  A s s o c i a t i o n of C r i t i c a l Care  who  Canadian  Nurses.  Significance  The study w i l l p r o v i d e i n f o r m a t i o n on the p r o c e s s of  q u a l i t y assurance and i t s r e l a t i o n s h i p t o n u r s i n g .  By i d e n t i f y i n g nurses' p e r c e p t i o n s of t h e i r e x p e r i e n c e s with q u a l i t y assurance the nurse a d m i n i s t r a t o r can develop an understanding of the knowledge and e x p e c t a t i o n s nurses have of the q u a l i t y  assurance  p r o c e s s . I t i s hoped t h a t t h i s understanding w i l l  allow  the development and/or enhancement of those programs t h a t w i l l be b e n e f i c i a l t o the c l i e n t s by a s s u r i n g a s p e c i f i c standard of q u a l i t y care, and w i l l b e n e f i t the i n d i v i d u a l nurse and the p r o f e s s i o n of n u r s i n g .  Overview of the T h e s i s Content  T h i s t h e s i s i s comprised of f i v e c h a p t e r s . In Chapter One,  the background  c o n c e p t u a l base, assumptions,  t o the problem,  purpose,  research questions, d e f i n i t i o n s ,  and s i g n i f i c a n c e of the study are  outlined.  In Chapter  literature in  Two,  on q u a l i t y  a review of  assurance a c t i v i t i e s  n u r s i n g , i s presented. Chapter  r e s e a r c h methods u s e d ,  Three  data c o l l e c t i o n  considerations,  statistical  analysis. sample, the  In C h a p t e r F o u r ,  a report  results  are  and  programs  addresses  procedures  of the f i n d i n g s  Five.  and  the  used  ethical i n data  of the  a discussion  summary,  recommendations  presented i n Chapter  instrument,  the d e s c r i p t i o n  a r e p r e s e n t e d . The  implications,  and  i n c l u d i n g the research design,  sampling procedure, and  selected  of  conclusions,  for future research  12  CHAPTER  TWO  L i t e r a t u r e Review  A s e l e c t i v e l i t e r a t u r e review was p r o v i d e the scope of what i s c u r r e n t l y  conducted t o available  c o n c e r n i n g n u r s i n g q u a l i t y assurance. Four areas were reviewed: the l i t e r a t u r e c o n c e r n i n g the need f o r and e s t a b l i s h m e n t of n u r s i n g q u a l i t y assurance programs, n u r s i n g q u a l i t y assurance i n c r i t i c a l care, d i r e c t i o n s and t r e n d s i n n u r s i n g q u a l i t y assurance, and c o n c e r n i n g n u r s i n g and n u r s i n g q u a l i t y  Nursing Quality  studies  assurance.  Assurance  There i s a l a r g e body of l i t e r a t u r e t h a t  addresses  n u r s i n g q u a l i t y assurance. Many of the authors, a d d r e s s i n g the need f o r n u r s i n g q u a l i t y programs, e x p l a i n how  after  assurance  their particular institutions  are  meeting q u a l i t y assurance requirements. Some authors d e f i n e q u a l i t y assurance programs as a management p r o c e s s t h a t i s e s t a b l i s h e d t o d e f i n e and e v a l u a t e the q u a l i t y of care p r o v i d e d t o the consumer (Campbell,  1982;  Coyne & K i l l i e n ,  K e r f o o t & Watson, 1985;  1987;  Maciorowski,  [patient] Conline,  1983;  Larson & Keane,  1985). Components of the q u a l i t y assurance p r o c e s s are  i d e n t i f i e d as the e s t a b l i s h i n g of standards o f care, implementing  and m o n i t o r i n g those standards, and  e v a l u a t i n g the r e s u l t s of the m o n i t o r i n g 1983;  Campbell,  Migleozzi, Thurston  (Billings,  1982; G i o v a n n e t t i , 1979; Marker, 1987;  1990; Smeltzer, Feltman,  & Best,  & R a j k i , 1983;  1990). In a d d i t i o n , the mechanisms  used f o r the formation, o r i e n t a t i o n ,  and f u n c t i o n o f  committees t h a t c o o r d i n a t e q u a l i t y assurance are d e s c r i b e d ( H a r r i s , Kreger 1982;  O'Brian,  activities  & Davis, 1989; Judkins,  1988). For the most p a r t , the l i t e r a t u r e  r e g a r d i n g n u r s i n g q u a l i t y assurance d e f i n i n g q u a l i t y assurance  i n v o l v e s authors  and o f f e r i n g a d v i c e on what  s p e c i f i c a l l y has worked f o r them i n the e s t a b l i s h m e n t of t h e i r programs.  Q u a l i t y Assurance  i n C r i t i c a l Care N u r s i n g  In a review of the l i m i t e d a r t i c l e s on q u a l i t y assurance  i n c r i t i c a l care n u r s i n g , the i n f o r m a t i o n  c e n t r e d mainly on the components o f the q u a l i t y assurance process i n c r i t i c a l  care and mechanisms t h a t  have been s u c c e s s f u l i n e s t a b l i s h i n g q u a l i t y programs 1989;  assurance  ( F i n l e y - C o t t o n e & Link, 1985; H i r t h & Lauzon,  Kaplow & Bendo, 1989; McGee, 1988; Mudd, 1988). In a survey on the s t a t e o f the a r t i n c r i t i c a l  care n u r s i n g standards, conducted Scherer  by Kidd, Whitely, and  (1987) f o r the Canadian A s s o c i a t i o n o f 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 e s t a b l i s h i n g standards t o assess the q u a l i t y of n u r s i n g care d e l i v e r e d i n critical  care  (p.12). Using a q u e s t i o n n a i r e designed by  the authors, 217 h o s p i t a l s , with  intensive  c a r e / c r i t i c a l care u n i t s , were surveyed w i t h a response r a t e of 147. A c t i v i t i e s such as equipment and environment a u d i t s , p a t i e n t c l a s s i f i c a t i o n systems, p a t i e n t s a t i s f a c t i o n surveys, c o n t i n u i n g e d u c a t i o n programs, and t r a n s f e r of f u n c t i o n d e s c r i p t i o n s were i d e n t i f i e d as mechanisms f o r e s t a b l i s h i n g standards of care t o assure q u a l i t y i n n u r s i n g care  (p.12). In  a d d i t i o n , n u r s i n g a u d i t s and performance a p p r a i s a l s were i d e n t i f i e d as methods t o e v a l u a t e the q u a l i t y of n u r s i n g c a r e . Other than the above survey, no other s t u d i e s were found on q u a l i t y assurance  in critical  care n u r s i n g .  D i r e c t i o n s and Trends i n N u r s i n g Q u a l i t y Assurance S e v e r a l authors address the need t o implement q u a l i t y assurance programs as a method t o m a i n t a i n a c c o u n t a b i l i t y and autonomy i n n u r s i n g p r a c t i c e & Simpson, 1985; Devet, 1986; K e l l y , 1990; O'Brian, Smeltzer,  (Curtis  1984; M i g l i o z z i ,  1988; O t t , 1987; S l i e f e r t , 1985;  1983). The authors emphasize t h a t  q u a l i t y assurance  through  and peer review a c t i v i t i e s , n u r s i n g  care  i srefined  and t h e p r o v i s i o n o f q u a l i t y  enhanced. Furthermore,  Finley-Cottone  and L i n k s  emphasised t h a t , with  r e g u l a r involvement  assurance  theability  activities,  incorporate daily  quality  assurance  (p.49).  practice  exists  principles  (1988)  Beyers  care  (1985)  i n quality f o r nurses t o into  expanded  their this  f u r t h e r by n o t i n g t h a t t h e p r a c t i c e h a b i t s o f nurses are being  i n f l u e n c e d and changed by t h e q u a l i t y  assurance  movement. No l o n g e r  i s i t focused  specific  n e e d s o f management, b u t g r e a t e r  emphasis  i s placed  nurse.  Beyers  on t h e i n d i v i d u a l  (1988)  on t h e  and g r e a t e r  p r a c t i c e o f each  e m p h a s i z e s t h a t we a r e m o v i n g  away  f r o m t h e e v a l u a t i o n o f t h e p r a c t i c e o f a l l n u r s e s on one  unit,  and s t a r t i n g  activities  t o focus  a s an i n t e g r a l  Studies  Concerning  Nursing  Q u a l i t y Assurance  Little literature  evidence  of their  of individual  a t t i t u d e s toward  experiences  with  staffs'  cooperation  involving  staffs'  nursing  and/or quality  i n d i s c u s s i n g t h e mechanisms  used t o e s t a b l i s h nursing q u a l i t y nursing  practice.  i savailable i n the nursing  Many a u t h o r s ,  address  assurance  Nurses' A t t i t u d e s and P e r c e p t i o n s o f  regarding nurses'  perceptions assurance.  part  on q u a l i t y  assurance  programs,  a t t i t u d e s by s u g g e s t i n g  and compliance  that  c a n be o b t a i n e d b y  them i n t h e c r e a t i o n a n d o r g a n i z a t i o n o f t h e  programs 1988;  (Kelly,  1984;  Lowe-Serge, M a r v u l l i  & O'Brian,  T a y l o r & Haussmann, 1988). I n 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  involvement  emphasise t h e c r e a t i o n o f u n i t assurance programs  usually  specific  (Acorn, Love & M i l l s ,  B e y e r m a n , 1987; F i n l e y - C o t t o n e & L i n k , Lauzon,  1989; K i e l l e r ,  Maibusch  & Anderson,  with unit  quality 1990;  1985;  1985; McGee, 1988;  Hirth &  Schroder,  1982). T h e s e a u t h o r s n o t e  s p e c i f i c q u a l i t y assurance programs,  and c o n c e r n s u n i q u e t o t h e u n i t a r e a d d r e s s e d . makes t h e p a r t i c i p a t i o n of  quality  i n and u t i l i z a t i o n  assurance a c t i v i t i e s  that issues This  of results  more m e a n i n g f u l t o  general nursing staff. A s t u d y by Edwardson and Anderson  (1983)  to  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  is  a v i t a l part of their nursing role,  demonstrate  attempted assurance  do n o t  t h i s b e l i e f by s e e k i n g o u t and  participating  i n q u a l i t y assurance 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 h a d experience with quality  assurance would  show a p o s i t i v e  a t t i t u d e toward q u a l i t y assurance, would assurance a c t i v i t i e s , such a c t i v i t i e s  value  quality  a n d w o u l d be more l i k e l y t o v i e w  as p a r t o f t h e n u r s e ' s r o l e .  Using  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 f r o m  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 a n d St.  P a u l a r e a . The f i n d i n g s s u g g e s t t h a t ,  although  s t a f f nurses thought a c t i v i t i e s was  involvement  in quality  assurance  an important p a r t of the p r o f e s s i o n a l  r o l e and a r e s p o n s i b i l i t y of a l l nurses, i n a r a n k i n g of nurses' d u t i e s and a c t i v i t i e s ,  i t consistently  fell  f a r below p a t i e n t care a c t i v i t i e s . A p p a r e n t l y , these nurses v a l u e d p a t i e n t care 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 o l e and r e s p o n s i b i l i t y , but d i d not v a l u e m o n i t o r i n g the q u a l i t y of these a c t i v i t i e s .  In  a d d i t i o n , l e s s than h a l f the s t a f f nurses who would choose t o p a r t i c i p a t e i n q u a l i t y  responded  assurance  a c t i v i t i e s i f they had the o p p o r t u n i t y . In d i s c u s s i n g the i m p l i c a t i o n s of t h e i r f i n d i n g s , the authors suggest t h a t 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 the causes of nurses' d i s s a t i s f a c t i o n with q u a l i t y assurance a c t i v i t i e s t h a t t h e i r a t t i t u d e s toward q u a l i t y assurance  and  be  a s s e s s e d i n order t o e f f e c t a commitment t o t h i s aspect of the nurse's r o l e  (Edwardson & Anderson,  1983).  Although the 10 h o s p i t a l s used i n the survey have q u a l i t y assurance a c t i v i t i e s , by v i r t u e of b e i n g r e p r e s e n t e d on the M e t r o p o l i t a n Nurses Assurance  i n Quality  (MNQA) group, no d e s c r i p t i o n was  given  r e g a r d i n g the types of q u a l i t y assurance programs at each i n s t i t u t i o n . Since q u a l i t y assurance i s a concept s u b j e c t t o v a r i o u s i n t e r p r e t a t i o n s , d i f f e r e n c e s between the programs might have accounted f o r some of the r e s u l t s . In a d d i t i o n , the q u e s t i o n n a i r e used  was  18 c r e a t e d by findings  t h e MNQA g r o u p and,  are only g e n e r a l i z a b l e to the  personnel  who  study,  other  no  specifically of t h e i r  participated literature  with nurses'  experiences  Quality important  particular  quality  of q u a l i t y  assurance of the  ultimately  assurance for the  assurance.  have become  from  assurance  over  the  to date  and  a management b e e n on  activities  development  nursing quality  and  the  p r o g r a m s and  is vital  nurses.  assurance  of t h e i r  past  discusses  to the  on  the  It i s this  area  information i n nurses'  experiences will  group  assurance.  who  utilizing  their  with nursing  o f p r o g r a m s and  of a  and  attitudes  provide useful  that  success  program i s the p e r c e p t i o n staff  an  w h i c h have b e e n s u c c e s s f u l f o r  Knowledge o f t h e s e  perceptions  this  dealt  a r e r e s p o n s i b l e f o r o b t a i n i n g and  nursing quality practice.  that  n u r s i n g d e p a r t m e n t s . However., one  been a d d r e s s e d  attitudes  Beyond  and/or p e r c e p t i o n s  literature  activities  many methods a v a i l a b l e  not  attitudes  p o i n t o f v i e w . E m p h a s i s has  establishment  has  found  for nursing practice  the need f o r these  nursing  study.  activities  d e c a d e s . Much o f t h e  clients'  was  t e s t e d , the  Review  assurance  concern  i n the  with q u a l i t y  Summary o f L i t e r a t u r e  two  though p i l o t  and quality  information  activities  in  19  CHAPTER THREE  Methods and Procedures  T h i s chapter i n c l u d e s a review of the methods used i n t h i s study. The r e s e a r c h design, sample s e l e c t i o n , 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 ,  ethical  c o n s i d e r a t i o n s which guided the design, procedure f o r data c o l l e c t i o n ,  and the data a n a l y s i s methods are  presented.  Design  An e x p l o r a t o r y , d e s c r i p t i v e d e s i g n was used as a r e s e a r c h approach Groves  f o r t h i s study. As noted by Burns and  (1987) , "the purpose  of exploratory research i s  the e x p l o r a t i o n and d e s c r i p t i o n of phenomena. T h i s approach  i s used t o generate new knowledge  concepts on t o p i c s about which l i t t l e  about  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 s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e . A survey, as f u r t h e r e x p l a i n e d by Burns and Groves (1987) , " i s used t o d e s c r i b e a technique o f data c o l l e c t i o n i n which q u e s t i o n n a i r e s ( c o l l e c t e d by m a i l or i n p e r s o n ) . . . are used t o gather data about an  20 i d e n t i f i e d population"  (p.250).  Sample S e l e c t i o n  A convenience  sample of c r i t i c a l  used f o r t h i s study. P e r m i s s i o n was  care nurses  o b t a i n e d from the  l o c a l chapter of the Canadian A s s o c i a t i o n of Care Nurses  was  Critical  (CACCN) f o r access t o t h e i r m a i l i n g l i s t  approximately 78 c u r r e n t members  (Appendix  A).  of  Critical  care nurses were s e l e c t e d f o r t h i s study because q u a l i t y assurance a c t i v i t i e s w i t h i n these u n i t s have a h i g h p r o f i l e due t o the c r i t i c a l c o n d i t i o n s of the p a t i e n t s and the heavy r e l i a n c e on s p e c i a l i z e d n u r s i n g knowledge combined with medical Furthermore,  technology.  l i m i t i n g the study t o c r i t i c a l  care nurses  p r o v i d e d a r e a l i s t i c e x p e c t a t i o n i n the type and amount of data c o l l e c t e d . T h i s l i m i t a t i o n a l s o  facilitates  e a s i e r 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  results.  Instrument  The  instrument  administered,  (Appendix  C) used was  a self-  s t r u c t u r e d q u e s t i o n n a i r e developed by the  i n v e s t i g a t o r . The q u e s t i o n n a i r e c o n t a i n e d m o d i f i e d q u e s t i o n s used with the p e r m i s s i o n  (Appendix  authors of the Edwardson and Anderson  D) of the  (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 following that  types  critical  of  data.  First,  care nurses  the  Then,  quality  their  assurance  Question three attitudes and,  have o f t h e  level,  activities  4).  given the  choice,  The i n i t i a l were  currently  age,  assurance were of for  nurses  (question  2).  and activities  activities  s p e n d more t i m e  of the  completion,  covering l e t t e r  five  Science  U n i v e r s i t y of B r i t i s h  had had e x p e r i e n c e  and t h e  v a l i d i t y by  e n r o l l e d i n the Master of the  was  Testing  in  Columbia.  in nursing quality  i n p r e v i o u s e m p l o y m e n t . Comments  regarding c l a r i t y  instructions,  employment,  10).  reviewed f o r content  activities  sought  (question  a n d employment s t a t u s  5 through  draft  N u r s i n g program at five  to  length of  Validity  All  sought  on w h i c h  choose  employment,  (question  instrument  a  Demographic d a t a , i n c l u d i n g . e d u c a t i o n  position,  requested  nurses  was  addressed t h e i r perceptions  area of  present  sought  of  of p a r t i c i p a t i o n i n n u r s i n g  would these nurses  (question  level  components  towards n u r s i n g q u a l i t y assurance  finally,  listed  level  the  knowledge  n u r s i n g q u a l i t y a s s u r a n c e p r o g r a m was 1).  collect  of meaning,  overall presentation, and r e l e v a n c e  of  effectiveness  time  items t o  required  the  research  22 questions.  Construct  v a l i d i t y was e s t a b l i s h e d by  s e l e c t i n g items t h a t corresponded with t h e t h e o r e t i c a l constructs  o f q u a l i t y assurance a c t i v i t i e s and  programs. Furthermore, i t was e s t i m a t e d t h a t i t would take approximately 20 minutes t o complete t h e questionnaire.  A revised questionnaire  was then  produced i n c o r p o r a t i n g t h e suggestions o f t h e reviewers.  Ethical  Burns and Groves research  Considerations  (1987) noted t h a t  "conducting  e t h i c a l l y r e q u i r e s t h a t r e s e a r c h e r s and  reviewers o f r e s e a r c h of human r e s e a r c h  recognize  subjects"  and p r o t e c t t h e r i g h t s  (p.74). The f o l l o w i n g  measures were taken t o ensure the p r o t e c t i o n o f the r i g h t s o f t h e i n d i v i d u a l s who p a r t i c i p a t e d i n t h i s study. First,  t h e study p r o p o s a l  U.B.C. B e h a v i o u r i a l  Sciences  was approved by t h e  Screening  Committee t o  ensure t h a t t h e study complied with t h e g u i d e l i n e s e s t a b l i s h e d by t h e U n i v e r s i t y f o r t h e p r o t e c t i o n of human r i g h t s . The p a r t i c i p a n t s were r e c r u i t e d from a chapter o f t h e Canadian A s s o c i a t i o n o f C r i t i c a l  Care  Nurses r a t h e r than from an agency so t h a t t h e d e c i s i o n regarding  p a r t i c i p a t i o n i n the study was not i n f l u e n c e d  by t h e i r  employment. I t was  f e l t that recruitment  p a r t i c i p a n t s i n t h i s manner allowed  of  for increased  w i l l i n g n e s s to p a r t i c i p a t e s i n c e t h e r e would be no  link  between the r e s e a r c h e r 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 s u b j e c t r e c e i v e d a l e t t e r of explanation (Appendix C)  (Appendix B), along with the i n the m a i l . The  each q u e s t i o n n a i r e was  l e t t e r explained that  i d e n t i f i e d with a code number i n  order t o f a c i l i t a t e follow-up q u e s t i o n n a i r e s . The  questionnaire,  efforts  in retrieval  i d e n t i f i c a t i o n number  of  was  c o n t r o l l e d by and known only to the r e s e a r c h e r .  The  c o v e r i n g l e t t e r a l s o s t a t e d t h a t the responses g i v e n would not be  i d e n t i f i e d with the s u b j e c t s and  t h e i r names would not appear i n any  A d m i n i s t r a t i o n of  On February 1,  1990  document or r e p o r t .  Questionnaire  each of the 78 persons whose  names appeared on the c u r r e n t m a i l i n g l i s t chapter  of the CACCN, was  package. A two  mailed  week p e r i o d was  the q u e s t i o n n a i r e s . During  out and useable.  Two  of the  local  a questionnaire  allowed  f o r r e t u r n of  t h i s time, 38 of the  q u e s t i o n n a i r e s were returned, filled  that  36  (4 6.2%)  of which were  were r e t u r n e d to  the  i n v e s t i g a t o r because the i n d i v i d u a l s had moved with  no  24 forwarding  address.  At t h i s time a reminder p o s t c a r d was m a i l e d t o those  i n d i v i d u a l s on the m a i l i n g l i s t  who had not  r e t u r n e d the q u e s t i o n n a i r e . T h i s r e s u l t e d i n an a d d i t i o n a l 21 q u e s t i o n n a i r e s b e i n g returned, 20  of which  (25.6%) were useable. One q u e s t i o n n a i r e was  unanswered because the i n d i v i d u a l , of the chapter,  returned  an a s s o c i a t e member  was not a r e g i s t e r e d nurse. A summary  of t h e q u e s t i o n n a i r e s r e t u r n e d i s i n Table  1.  Table 1: Q u e s t i o n n a i r e Response Rate Number Useable q u e s t i o n n a i r e s r e t u r n e d Non-useable q u e s t i o n n a i r e s r e t u r n e d Questionnaires  not r e t u r n e d Total  Percentage  56  71.8%  3  3.8%  19  24.4%  78  100.0%  Data A n a l y s i s  Data were analyzed u s i n g the S t a t i s t i c a l Package f o r the S o c i a l Sciences a v a i l a b l e through the computer c e n t r e at the U n i v e r s i t y 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 t h e r e f o r e , the s t a t i s t i c a l techniques  t h a t were  a p p r o p r i a t e f o r the type of data c o l l e c t e d i n t h i s r e s e a r c h design, were f r e q u e n c i e s , percentages,  and  means o f  individual  items.  26  CHAPTER FOUR  F i n d i n g s and D i s c u s s i o n  In t h i s chapter, the study f i n d i n g s and a d i s c u s s i o n of those f i n d i n g s w i l l be p r e s e n t e d .  The  f i r s t p a r t of the chapter w i l l present the demographic d a t a . Next, the f i n d i n g s from the f i r s t  four questions,  of the q u e s t i o n n a i r e , w i l l be presented.  Then, these  f i n d i n g s w i l l be d i s c u s s e d i n r e l a t i o n t o each of the r e s e a r c h q u e s t i o n s . Supplemental f i n d i n g s w i l l then d i s c u s s e d and,  finally,  l i m i t a t i o n s of the  be  study  identified.  Demographic C h a r a c t e r i s t i c s of the Sample  Demographic i n f o r m a t i o n c o l l e c t e d i n c l u d e d , c h a r a c t e r i s t i c s of the sample, time spent  age  i n present  p o s i t i o n , employment s t a t u s , e d u c a t i o n a l l e v e l , n u r s i n g p o s i t i o n h e l d , and area of c r i t i c a l  current  care i n  which the p a r t i c i p a n t s were employed. The presented  age  c h a r a c t e r i s t i c s of the sample are  i n Table 2. The most frequent age  r e p r e s e n t e d was  the 31-35  r e p r e s e n t a t i o n of 32.1%  group  year group, with a  of the p a r t i c i p a n t s . The  lowest  27 representation group  (1.8%),  Table  2: Age  f o r age g r o u p s was i n t h e 20-25 a n d t h e 46 + y e a r  group  year  (12.5%).  Distribution Number  Percentaqe  20-25 y e a r s  1  26-30 y e a r s  11  19.6%  31-35 y e a r s  18  32.1%  36-40 y e a r s  10  17.9%  41-45 y e a r s  9  16.1%  46 +  7  12.5%  years Total  Table spent,  3 presents the data  by t h e s u b j e c t s ,  56  1.8%  100.0%  collected  i n t h e i r present  on t h e t i m e nursing  position.  Table  3: Time i n P r e s e n t  Nursing  Position Number  Percentaqe  0-1 y e a r  17  30.3%  2-3 y e a r s  14  25.0%  4-5 y e a r s  10  17. 9%  6 + years  15  2 6.8%  56  100.0%  Total  28 The  l a r g e s t number, 17  (30.3%), have been i n  t h e i r present p o s i t i o n f o r l e s s than one year. The h i g h e s t c a t e g o r i e s , 2-3  years and  s i m i l a r number of s u b j e c t s with 14 (26.8%) r e s p e c t i v e l y . The the 4-5  next  6 + years, have a (25.0%) and  15  lowest category i n Table 3 i s  year category with 10  (17.9%).  Table 4 p r e s e n t s the data c o l l e c t e d on the s u b j e c t s ' c u r r e n t n u r s i n g employment s t a t u s . The q u e s t i o n i d e n t i f i e d t h r e e s p e c i f i c employment  classes:  f u l l - t i m e , p a r t - t i m e , and c a s u a l . Table 4: Employment  Status Number  Percentage  Full-time  46  82.1%  Part-time  6  10.7%  Casual  4  7.1%  Other  0  0 . 0%  Total  Of the nurses who c l a s s i f i e d themselves  56  100.0%  responded, the m a j o r i t y , 82.1%, as b e i n g i n f u l l - t i m e  employment.  However, of t h i s group, two p a r t i c i p a n t s i n d i c a t e d t h a t they would be changing t o c a s u a l employment s t a t u s w i t h i n a month of f i l l i n g  i n the q u e s t i o n n a i r e . In  a d d i t i o n , another p a r t i c i p a n t wrote, t h a t , i n order "to  m a i n t a i n my  broad knowledge base and s k i l l s  c a s u a l at other i n s t i t u t i o n s as" w e l l as f u l l  I work  time...".  The f o l l o w i n g of  the  table,  data c o l l e c t e d  on t h e  subjects.  Although, a l l  the  categories  three  elaborated "other"  Table  T a b l e 5,  the  listed,  presents  educational participants a number o f  on a d d i t i o n a l e d u c a t i o n a l  a summary  level  of  the  were i n one them  experiences  in  Educational Level Number  Percentage  Nursing Diploma  30  53.6%  Baccalaureate  22  39.3%  _4  7 .1%  .56  100.0%  Master's  Degree  Degree Total  Under t h e  basic that  the  category.  5:  noted,  of  that,  "other"  in addition,  c r i t i c a l care they  nursing.  they  course.  32.1%  of  the  In a d d i t i o n ,  the  paediatric  there  i n d i c a t i n g other effective  subjects  had a l s o t a k e n  Further,  10.7%  were w o r k i n g on a b a c c a l a u r e a t e  responses, s u c h as  category,  head nurse  course,  n u r s i n g and p a e d i a t r i c  post-  indicated degree  were a v a r i e t y educational  a  of  in  single  experiences diploma  education  courses,  a n d 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 subjects  are d i s p l a y e d i n Table  6.  o c c u p i e d by  the  30 Table 6: Current Nursing  Position Number  Percentage  22  39.3%  A s s i s t a n t Head Nurse  4  7.1%  Head Nurse  7  12 .5%  16 2 1  28.6% 3.6% 1.8%  4  7.1%  56  100.0%  S t a f f Nurse  Other: I n s t r u c t o r Industry D i r e c t o r of Nursing C N S / C l i n i c a l resource/ Nurse C l i n i c i a n Total As can be seen i n Table 6, 22 participants identified,  are f i l l i n g  (39.7%) of the a staff  nurse's  p o s i t i o n . The next h i g h e s t number appears i n the "other" category, where 16  (28.6%) of the s u b j e c t s  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  instructor. Finally, in c r i t i c a l  demographic data were c o l l e c t e d on where,  care, the s u b j e c t s were employed. The  q u e s t i o n n a i r e o f f e r e d s i x d e f i n i t e c h o i c e s , with a seventh b e i n g the "other" category. T h i r t y s i x (64.3%) of  the s u b j e c t s i d e n t i f i e d t h a t they were employed i n  one area of c r i t i c a l  care  (Table 7-A). The remaining  (35.7%) l i s t e d two or more c r i t i c a l employment  areas  (Table 7-B).  care areas as  20  31 Table 7: Areas of C r i t i c a l Care Employment A: S i n q l e areas o f C r i t i c a l  Care Employment Number Percentage  I n t e n s i v e Care U n i t Coronary Care U n i t  8 6  14 • 3 % 10 .7%  S u r g i c a l I n t e n s i v e Care U n i t  1  1• 8 %  Post-open Heart Recovery  6  10 .7%  P a e d i a t r i c I n t e n s i v e Care U n i t  4  7 .1%  Neonatal I n t e n s i v e Care Unit  0  0%  Other: C r i t i c a l Care Areas Recovery Room Education Emergency Baro M e d i c a l  3 2 2 1  5• 3 % 3• 5 % 3• D ^ 1• 8 %  Other: None C r i t i c a l Care Areas Head Nurse Med/Surg Area P r i v a t e Industry Not P r e s e n t l y Employed  1 1 1  1.8% 1.8 % 1.8 %  Unit  B: M u l t i p l e Areas o f C r i t i c a l Care Employment Number Percentaqe I n t e n s i v e care/Coronary Care  16  28 . 6%  I n t e n s i v e care/Coronary Care/ S u r g i c a l care/Post-open Heart Recovery U n i t  2  3 • D 15  I n t e n s i v e care/Coronary Care/ S u r g i c a l I n t e n s i v e Care U n i t  1  1.8 %  Coronary C a r e / S u r g i c a l Care  1  1.8%  Intensive Total  56  100 .0%  32  The next s e c t i o n of the chapter w i l l p r e s e n t f i n d i n g s from the f i r s t  the  f o u r q u e s t i o n s of the  questionnaire.  Findings  Information c o l l e c t e d on the s u b j e c t s ' p e r c e p t i o n s , a t t i t u d e s , knowledge, and l e v e l i n n u r s i n g q u a l i t y assurance  participation  are p r e s e n t e d i n the  following tables. The  first  q u e s t i o n requested t h a t the s u b j e c t s  identify items/activities,  on the l i s t  provided, that  they c o n s i d e r e d components of a n u r s i n g q u a l i t y assurance program. The r e s u l t s are p r e s e n t e d 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 p a r t i c i p a n t s as a component of a n u r s i n g q u a l i t y assurance program. remaining t h r e e : r e g u l a r checks  The  and maintenance of  b i o m e d i c a l equipment, suggestions 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 n u r s i n g workload  activities,  and a  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 p a r t i c i p a n t s added, i n the "other" category, a d d i t i o n a l i t e m s / a c t i v i t i e s which they c o n s i d e r e d as components of a n u r s i n g q u a l i t y assurance program. A summary of the l i s t i n c l u d e s ,  education  b a s e d on a u d i t r e s u l t s ,  r o u t i n e updates t o n u r s i n g and  procedures,  work e x p e r i e n c e , budget  s t a f f regarding  mandatory c r i t i c a l nursing  self-auditing,  research,  policies  care t r a i n i n g skills  a n a l y s i s a c t i v i t i e s , and minimum  p a t i e n t s per nurse per s h i f t .  new  and  assessment,  number o f  34 Table  8:  Components Program  of  a Nursing Quality  Assurance  Q u e s t i o n 1: I f e e l t h e i t e m s / a c t i v i t i e s l i s t e d b e l o w a r e 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 p r o g r a m : (check as many as you t h i n k a r e a p p l i c a b l e ) (N = 56) Number checked a.  Nursing care  b.  Regular s t a f f appraisals  c.  audits  Percentage  55  98 .2%  51  91.1%  55  98 .2%  51  91.1%  performance  A u d i t or q u a l i t y committee  assurance  d.  Incident  e.  U t i l i z a t i o n of q u a l i t y assurance findings  55  98.2%  Regular hospital-based inservice  49  87.5%  R e g u l a r c h e c k s and m a i n t e n a n c e of b i o m e d i c a l equipment  43  76.8%  V e r i f i c a t i o n of current nursing registration  47  83. 9%  i.  Nursing practice  52  92.9%  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 for nursing q u a l i t y assurance a u d i t s / s t u d i e s  44  78. 6%  O r i e n t a t i o n programs staff  52  92. 9%  42  75.0%  f. g. h.  k. 1.  reports  standards  for  new  N u r s i n g w o r k l o a d management s y s t e m s (eg.GRASP)  Responses t o the second q u e s t i o n p r o v i d e d i n f o r m a t i o n on how  many of the i t e m s / a c t i v i t i e s  listed  i n q u e s t i o n one the s u b j e c t s had been i n v o l v e d i n over the p a s t year. The data c o l l e c t e d are p r e s e n t e d i n Table 9. The h i g h e s t responses of c u r r e n t r e g i s t r a t i o n staff  (85.7%). The  were: p r o d u c i n g  evidence  (87.5%) and o r i e n t a t i o n of  lowest response  new  r a t e were:  p e r f o r m i n g a u d i t s on b i o m e d i c a l equipment s e r v i n g on an a u d i t or q u a l i t y assurance  (12.5%) and committee  (25.0%). S e v e r a l of the remaining  items/activities  been p a r t i c i p a t e d i n by approximately  had  one t h i r d of the  s u b j e c t s over the past year. These i t e m s / a c t i v i t i e s i n c l u d e d : conducting a n u r s i n g a u d i t  (37.5%),  i n c o r p o r a t i n g f i n d i n g s of q u a l i t y assurance into practice standards  studies  (35.7%), d e v e l o p i n g n u r s i n g p r a c t i c e  f o r measuring the q u a l i t y of n u r s i n g care  (35.7%), and s u g g e s t i n g 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 (28.6%).  A number of s u b j e c t s noted,  i n the  "other"  category, a d d i t i o n a l a c t i v i t i e s t h a t they c o n s i d e r e d as 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 . These i n c l u d e :  p r e s e n t i n g evidence of currency i n BCLS (basic c a r d i a c life  s u p p o r t ) , s u c c e s s f u l l y completing the ACLS  (advanced c a r d i a c l i f e  support)  course,  and  p a r t i c i p a t i n g i n the s e l e c t i o n of a n u r s i n g model.  36 Table 9; Involvement i n Q u a l i t y Assurance A c t i v i t i e s Question 2: In the past 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) (N = 56) Activities Identified  Percentage  a. Conduct a n u r s i n g a u d i t  21  37.5%  b. Received a performance a p p r a i s a l about my work  37  66.1%  c. Served on an a u d i t or q u a l i t y assurance committee  14  25.0%  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  30  53.6%  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 into practice  20  35.7%  f . R e g u l a r l y attended h o s p i t a l based n u r s i n g i n s e r v i c e  44  78.6%  7  12.5%  49  87.5%  20  35.7%  q u a l i t y assurance a u d i t s / s t u d i e s 16  28.6%  g. Performed a u d i t s on b i o m e d i c a l equipment h. Produced evidence of c u r r e n t nursing r e g i s t r a t i o n i.  j.  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 o f n u r s i n g care Suggested t o p i c s f o r n u r s i n g  k. O r i e n t e d new s t a f f  48  86.7%  1. U t i l i z e d a n u r s i n g workload measurement system ( i . e . , GRASP) 18  32.1%  37 The  third  subjects  question  regarding  10.  I n i d e n t i f y i n g who  should  be i n v o l v e d i n  q u a l i t y assurance a c t i v i t i e s ,  nursing  q u a l i t y assurance a c t i v i t i e s of nursing  personnel.  (100.0%),  identified  activities  involved  activities  as p a r t  responsibilities  that  them, w i t h of t h e i r  (Table  of t h e i r  responded t o t h i s nursing the  assurance  i d e n t i f y i n g these  when  responding  q u a l i t y assurance activities,  and o n l y  only  42.9%  activities •  62.5%  indicated  were a p r i o r i t y  a l s o c o l l e c t e d on who  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  activities  by t h e h o s p i t a l q u a l i t y  are required  69.6%  assurance d i r e c t o r / c o o r d i n a t o r , required felt  felt  activities.  10,  35.7%  on  required the  As c a n be s e e n i n T a b l e  are  that  unit.  I n f o r m a t i o n was data  involve a l l  professional  q u a l i t y assurance a c t i v i t i e s  nursing  that  subjects,  quality  87.5%  felt  should  10). However,  daily item,  91.1%  A l l of the  nursing  t o whether or not n u r s i n g were p a r t  quality  The r e s u l t s a r e s u m m a r i z e d i n  nursing  levels  of the  the purposes of nursing  assurance a c t i v i t i e s . Table  sought t h e o p i n i o n s  60.7%  that  felt  these  that  by t h e q u a l i t y a s s u r a n c e c o m m i t t e e ,  that  they  are required 58.9%  assurance  a r e u s e d p r i m a r i l y t o meet  accreditation  requirements  that  and  supervisory-level  nurses. Furthermore, activities  felt  by  they  nursing  f o r the h o s p i t a l .  quality  38 Table  10;  Purpose of N u r s i n g Q u a l i t y Assurance Activities  Q u e s t i o n 3: activities: applicable)  I f e e l nursing q u a l i t y assurance (check as many as you f e e l a r e (N = 56) Items Checked  a. b.  c. d.  a r e r e q u i r e d by t h e 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  39  69.6%  a r e p r i m a r i l y u s e d t o meet a c c r e d i t a t i o n requirements the h o s p i t a l  33  58.9%  34  60.7%  20  35.7%  me  0  0.0%  time  2  3.6%  4  7.1%  51  91.1%  35  62.5%  48  85.7%  49  87.5%  24  42 . 9%  a r e r e q u i r e d by t h e a s s u r a n c e committee a r e r e q u i r e d by l e v e l nurses involve  supervisory-  do n o t  f.  are  g.  t a k e up t i m e t h a t s h o u l d be s p e n t on p a t i e n t c a r e  a waste o f  involve  all  for  quality  e.  h.  levels  of  nursing personnel i.  are p a r t  j.  improve n u r s i n g care  k.  a r e p a r t o f my p r o f e s s i o n a l responsibilities are a p r i o r i t y i n the n u r s i n g division/unit  1.  Percentage  if  my d a i l y  activities  39 Question f o u r asked the s u b j e c t s , i f they  had  the c h o i c e , 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 m a j o r i t y of the  p a r t i c i p a n t s as one  i n which they would l i k e t o spend  more time. However, t h e r e were t h r e e a c t i v i t i e s  that  d i d r e c e i v e a h i g h e r response than the o t h e r s . The most f r e q u e n t l y i d e n t i f i e d a c t i v i t y was  spending more time  t e a c h i n g p a t i e n t s and/or t h e i r f a m i l i e s next was  (71.4%)  The  i n v o l v i n g p a t i e n t s i n p l a n n i n g t h e i r own  with a 69.6%  response,  care,  f o l l o w e d by the w r i t i n g of  n u r s i n g care standards f o r s p e c i a l i t y area w i t h a  64.3%  response. Three a c t i v i t i e s :  improving my  p e r f o r m i n g n u r s i n g care procedures,  skills in spending more time  p l a n n i n g p a t i e n t care, and r e v i e w i n g the care g i v e n by other r e g i s t e r e d nurses, were i d e n t i f i e d by approximately 50% of the p a r t i c i p a n t s , as ones t h a t they would spend more time on g i v e n the o p p o r t u n i t y . A c t i v i t i e s l e a s t f r e q u e n t l y i d e n t i f i e d were g e t t i n g t o know my  f e l l o w workers  (23.2%), and b e i n g an  member on a q u a l i t y assurance committee  active  (23.2%).  40 Table 11: P r e f e r r e d C l i n i c a l Question  Activities  4: I f I could, I would: wish) (N = 56)  (check as many as you Number Identified  a. Spend more time p a t i e n t care  Percentage  planning 30  53.6^  b. Be an a c t i v e member on a q u a l i t y assurance committee  13  23.2^  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  40  71. 4  d. Involve p a t i e n t s i n p l a n n i n g t h e i r care  39  69.6^  e. Spend more time g e t t i n g t o know my f e l l o w workers  13  23. 2  f . Write n u r s i n g care standards f o r s p e c i a l i t y area  36  64 .3%  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  29  51. 8  h. Improve my s k i l l s i n performing n u r s i n g care procedures  30  53. 6%  !  s  !  A d d i t i o n a l a c t i v i t i e s t h a t the s u b j e c t s 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 f u r t h e r education, t e a c h i n g nurses the importance o f m a i n t a i n i n g standards  o f care, i n c o r p o r a t i n g peer  performance a p p r a i s a l s , and i n v o l v i n g f e l l o w workers i n q u a l i t y assurance f u n c t i o n s .  41 The next s e c t i o n of the chapter w i l l p r e s e n t a d i s c u s s i o n on the study  findings.  Discussion  The  response  r a t e t o the q u e s t i o n n a i r e w i l l  be  d i s c u s s e d f i r s t . F o l l o w i n g t h i s , the r e s u l t s of the study w i l l be 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 each of the three research questions. F i n a l l y , d i s c u s s i o n on the supplemental  t h e r e w i l l be a  f i n d i n g s and the  l i m i t a t i o n s of the study.  Response Rate Table 1 (p.23) p r e s e n t s the r e s u l t s of the response for  r a t e t o the survey. The response  useable q u e s t i o n n a i r e s was  r a t e of  71.8%  h i g h e r than what i s  g e n e r a l l y e x p e r i e n c e d by r e s e a r c h e r s u t i l i z i n g  this  method of data c o l l e c t i o n . As noted by Burns & Groves (1987),  "the response r a t e f o r m a i l e d q u e s t i o n n a i r e s i s  u s u a l l y small response  (25 t o 30 p e r c e n t ) . . . " (p.314). T h i s h i g h  suggests t h a t n u r s i n g q u a l i t y assurance  t o p i c t h a t i s meaningful  and important t o 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.  is a  RESEARCH QUESTION ONE: WHAT DO CRITICAL CARE NURSES IDENTIFY AS COMPONENTS OF A NURSING QUALITY ASSURANCE PROGRAM? The  r e s u l t s t h a t t h i s p a r t i c u l a r group o f c r i t i c a l  care nurses  c o n s i d e r e d t o be components o f a n u r s i n g  q u a l i t y assurance  program are found  i n Table  8. A l l but  t h r e e o f 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% o f the p a r t i c i p a n t s as components o f a n u r s i n g  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 h i g h response t o 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 o f a n u r s i n g q u a l i t y assurance encouraging  f o r nurses  program, i s  and n u r s i n g d i v i s i o n s who are  e s t a b l i s h i n g and managing n u r s i n g q u a l i t y programs. There c o u l d be s e v e r a l reasons  assurance why t h e r e was  such a h i g h response r a t e t o the i t e m s / a c t i v i t i e s l i s t e d . The h i g h r a t e o f i d e n t i f i c a t i o n c o u l d be a r e f l e c t i o n o f s p e c i f i c a c t i v i t i e s / p r o g r a m s i n which the p a r t i c i p a n t s have been i n v o l v e d , and which they b e l i e v e t o be components of a n u r s i n g q u a l i t y  assurance  program. Another e x p l a n a t i o n f o r t h i s response r a t e may i n v o l v e the q u e s t i o n and i t s wording, i n t h a t , s e v e r a l of the c h o i c e s o f f e r e d u t i l i z e d the phrase assurance."  "quality  The use of the same wording i n the c h o i c e s  may have p r o v i d e d the p a r t i c i p a n t s with  information  t h a t helped them answer the q u e s t i o n . F i n a l l y , the  43 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  may  have i n f l u e n c e d the p a r t i c i p a n t s t o 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 t h a t was s e l e c t e d the l e a s t , by 75%,  was t h e n u r s i n g workload management system. In the Kidd, Whiteley  and Scherer  c l a s s i f i c a t i o n system  (1987) survey,  a patient  (workload management system) was  one method, s p e c i f i e d under q u a l i t y assurance, f o r e s t a b l i s h i n g standards authors  of c a r e . F u r t h e r ,  several  have noted t h a t workload measurement systems  are an e f f e c t i v e t o o l t h a t p r o v i d e s monitoring  the n u r s e / p a t i e n t  a method f o r  r a t i o t o ensure t h a t  e q u i t a b l e safe workloads are assigned t o n u r s i n g (Billings,  staff  1983; G i o v a n n e t t i , 1979: Marker, 1987).  S e v e r a l p o s s i b l e reasons e x i s t f o r the low response r a t e t o a n u r s i n g workload measurement system as a component of a n u r s i n g q u a l i t y assurance program. First,  not a l l h o s p i t a l s c u r r e n t l y u t i l i z e  measurement system t o determine s t a f f i n g  a workload  levels  r e q u i r e d on t h e i r n u r s i n g u n i t s . In a d d i t i o n , r a p i d l y changing p a t i e n t a c u i t y l e v 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 h o s p i t a l not t o extend t h e i r system'to i n c l u d e c r i t i c a l Finally,  i f the i n f o r m a t i o n gathered  care  areas.  u t i l i z i n g such a  t o o l i s not used t o a d j u s t s t a f f i n g l e v e l s t o workload demands when r e q u i r e d , then, i t can not be c o n s i d e r e d as a component of a n u r s i n g q u a l i t y assurance  program.  T h i s f i n a l reason was noted by one s u b j e c t who s t a t e d , "[a n u r s i n g workload  management system] would be a  u s e f u l t o o l i f i t would be f o l l o w e d up on. Our h o s p i t a l i g n o r e s i t i f the p o i n t s are t o o h i g h showing a need f o r e x t r a s t a f f . I f i t i s ignored, then i t i s a waste of v a l u a b l e n u r s i n g time when you're The  a l r e a d y busy."  i t e m / a c t i v i t y with the next lowest r a t e o f  response,  r e g u l a r checks  and maintenance o f b i o m e d i c a l  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 nurses as a n u r s i n g q u a l i t y assurance  activity.  a c t i v i t y was i d e n t i f i e d as a q u a l i t y assurance for c r i t i c a l Scherer  care  This standard  care n u r s i n g i n the Kidd, Whiteley and  (1987) survey. The f a c t t h a t t h i s a c t i v i t y was  i d e n t i f i e d l e s s f r e q u e n t l y than the others l i s t e d was unexpected  f o r t h i s p a r t i c u l a r group o f nurses. In  c r i t i c a l care n u r s i n g , the r e l i a n c e on b i o m e d i c a l equipment t o a s s i s t i n the assessment and m o n i t o r i n g o f the p h y s i o l o g i c a l s t a t u s o f the p a t i e n t s i s a v i t a l component o f the nurses' r o u t i n e . One p o s s i b l e e x p l a n a t i o n was noted by one s u b j e c t , who s t a t e d " . . . [ b i o m e d i c a l equipment] i f other p e r s o n n e l do [ i t ] then no, otherwise yes". Therefore, i t would appear t h a t a u d i t i n g and m o n i t o r i n g b i o m e d i c a l 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 nurse. H o s p i t a l s may  have s p e c i a l t e c h n i c i a n s who  r e s p o n s i b l e f o r p r o v i d i n g r o u t i n e maintenance a u d i t s of t h i s equipment. However, another low response  are  and  reason f o r a  r a t e with t h i s a c t i v i t y c o u l d be i n the  wording of the q u e s t i o n , which may  have been  i n t e r p r e t e d d i f f e r e n t l y by the p a r t i c i p a n t s , on t h e i r  care  depending  experiences.  The t h i r d lowest i t e m / a c t i v i t y ,  suggestions  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 a u d i t s / s t u d i e s , was  i d e n t i f i e d by 78.6%  p a r t i c i p a n t s . The reasons why  by  assurance  of the  t h i s a c t i v i t y was  not  s e l e c t e d as f r e q u e n t l y as other a c t i v i t i e s are not c l e a r . However, as noted by C h r i s t e n s e n i s of utmost importance  was  (p.50). The  l a c k of  i n the complete q u a l i t y assurance  commented on by one nurse, who  bedside n u r s e s . . . understand assurance]  choosing  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" involvement  "...it  t h a t s t a f f nurses be i n v o l v e d  i n s e t t i n g standards, or at l e a s t them...active  (1990),  process  s t a t e d , "not enough  i t [nursing q u a l i t y  or the a c t i v i t i e s have not d i r e c t l y i n v o l v e d  them! They have been a u d i t e d ( p a s s i v e ) , not i n c l u d e d ( a c t i v e ) ! " . Consequently, i n the t o t a l process may  a f a i l u r e t o i n c l u d e nurses e x p l a i n why  this activity  not s e l e c t e d as f r e q u e n t l y as the others  listed.  was  RESEARCH QUESTION TWO:  WHAT DO CRITICAL CARE NURSES  IDENTIFY AS THE PURPOSE OF NURSING QUALITY ASSURANCE ACTIVITIES? The r e s u l t s of the survey t h a t address  this  r e s e a r c h q u e s t i o n can be found i n Table 10. Over 69% of the s u b j e c t s 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 a c t i v i t i e s are r e q u i r e d by a q u a l i t y d i r e c t o r / c o o r d i n a t o r , with 60.7%  assurance  assurance  i d e n t i f y i n g 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 a q u a l i t y  assurance  committee. Although the survey d i d not seek  specific  i n f o r m a t i o n on the s t r u c t u r e of the q u a l i t y  assurance  programs with which they have been i n v o l v e d ,  the  responses t o t h i s q u e s t i o n c o u l d be r e f l e c t i v e of what the s u b j e c t s have e x p e r i e n c e d . Many of the q u a l i t y assurance programs d e s c r i b e d i n the l i t e r a t u r e d e a l with e s t a b l i s h i n g programs where the a c t i v i t i e s o r g a n i z e d and c o o r d i n a t e d by e i t h e r a q u a l i t y  are  assurance  committee or c o o r d i n a t o r ( H a r r i s , Kreger, & Davis, 1989;  Judkins, 1982;  these c r i t i c a l  O'Brian,  1988). T h e r e f o r e , what  care nurses i d e n t i f y as the purpose  n u r s i n g q u a l i t y assurance programs may how  of  be r e f l e c t i v e of  the program has been e s t a b l i s h e d and i s f u n c t i o n i n g  i n t h e i r present employment. Another purpose activities, was  for nursing quality  i d e n t i f i e d by 58.9%  assurance  of the p a r t i c i p a n t s ,  t o meet the a c c r e d i t a t i o n requirements of the  hospital  ( T a b l e 1 0 ) . The h i g h r e s p o n s e  activity  also  that  c o u l d be r e f l e c t i v e  these p a r t i c u l a r  with nursing q u a l i t y in the literature, accreditation initiating Killien, Watson,  critical  rate  for this  of the experiences  c a r e n u r s e s have h a d  a s s u r a n c e p r o g r a m s . As c a n be  many a u t h o r s  standards  identify  as t h e p r i m a r y  t h e s e programs  meeting  reason f o r  ( C h r i s t e n s e n , 1990; Coyne &  1987; H a r r i s ,  Kreger  & Davis,  1985; O ' B r i a n ,  1988).  Furthermore, t h e  1989; K e r f o o t &  accreditation  s t a n d a r d s demand t h a t  accreditation  s t a n d i n g have a f u n c t i o n i n g  hospitals  seeking  quality  assurance program i n o r d e r t o r e c e i v e  a p p r o v a l . One  participant  on t h i s  noted,  i n t h e study,  "I...think  that  elaborating  to  n o t always  quality  f o r the right  merely  "[nursing quality used  as a t o o l  requirements activities]  as t h e y  care patients  get, t h i s  activities]  assurance  being a requirement  w i t h many h o s p i t a l s  participant  accreditation assurance  portray the quality of  i s a l l they  assurance  [nursing  a r e good f o r . " With  quality  quality  f o r a c c r e d i t a t i o n and  experiencing accreditation  e v e r y two y e a r s , t h e r e s p o n s e  'have'  a c t i v i t i e s ] are  [nursing q u a l i t y  do n o t a c c u r a t e l y  programs  e.g., t h e y  Another  assurance  t o meet  assurance  reasons,  f o r a c c r e d i t a t i o n purposes."  added  component  many t i m e s 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 but  seen  rate to t h i s  reviews  i t e m may n o t  48 be  surprising.  RESEARCH QUESTION THREE: WHAT IS THE INVOLVEMENT OF CRITICAL CARE NURSES IN NURSING QUALITY ASSURANCE ACTIVITIES? The  r e s u l t s on the involvement  n u r s i n g q u a l i t y assurance  o f the s u b j e c t s i n  a c t i v i t i e s are found i n Table  9. The r e s u l t s i n d i c a t e t h a t the involvement t h i s group o f c r i t i c a l  care nurses i n those  level for activities  they c o n s i d e r e d as components of a n u r s i n g q u a l i t y assurance program activities.  (Table 8), i s low f o r a number o f the  In p a r t i c u l a r , t h e r e are low p a r t i c i p a t i o n  l e v e l s i n s e r v i n g on an a u d i t committee  (25.0%),  i n c o r p o r a t i n g f i n d i n g s o f a q u a l i t y assurance into actual practice p r a c t i c e standards care  study  (35.7%), d e v e l o p i n g n u r s i n g  f o r measuring the q u a l i t y o f n u r s i n g  (35.7%), and conducting a n u r s i n g a u d i t  The above involvement  (37.5%).  r a t e s are very s i m i l a r t o those  found f o r the same a c t i v i t i e s i n the Edwardson and Anderson  (1983) study.  The t h r e e i t e m s / a c t i v i t i e s i n Table 8, t h a t were not i d e n t i f i e d as f r e q u e n t l y as components o f a n u r s i n g q u a l i t y assurance program a l s o had s i m i l a r l y low involvement 32.1%  r a t e s by the s u b j e c t s . In p a r t i c u l a r ,  had u t i l i z e d a workload  had performed  only  measurement system, 12.5%  a u d i t s on b i o m e d i c a l equipment, and 28.6%  49 had  suggested t o p i c s f o r a n u r s i n g q u a l i t y assurance  audit/study. these  The reasons f o r not b e i n g i n v o l v e d i n  a c t i v i t i e s were not s p e c i f i c a l l y e l a b o r a t e d 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  t o assume t h a t the same reasons put f o r t h t o  e x p l a i n t h e lower s e l e c t i o n r a t e s f o r these i n Table  activities  8 c o u l d account f o r the low involvement by the  p a r t i c i p a n t s i n the a c t i v i t i e s .  In a d d i t i o n , the  wording change between q u e s t i o n one and q u e s t i o n two i n the component d e s c r i b i n g b i o m e d i c a l  equipment may have  been a c o n t r i b u t i n g f a c t o r . The change from "checks and maintenance" t o " a u d i t " c o u l d have r e s u l t e d i n a different  i n t e r p r e t a t i o n by the p a r t i c i p a n t s when they  responded t o the q u e s t i o n s .  Supplemental F i n d i n g s The and  study  a l s o provided,  f o u r on the q u e s t i o n n a i r e ,  through q u e s t i o n s i n f o r m a t i o n on t h e  o p i n i o n s and a t t i t u d e s o f t h i s group of c r i t i c a l nurses t o n u r s i n g q u a l i t y  three  care  assurance.  Every p a r t i c i p a n t (100%) i d e n t i f i e d t h a t  nursing  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, and 87.5% f u r t h e r noted t h a t these  a c t i v i t i e s were p a r t o f t h e i r  professional responsibilities 91.1%  (Table 10). Furthermore,  o f the p a r t i c i p a n t s f e l t t h a t these  involved a l l l e v e l s of nursing personnel.  activities The r e s u l t s  50 o b t a i n e d from t h i s p a r t i c u l a r group of nurses  suggests  not o n l y a p o s i t i v e a t t i t u d e t o q u a l i t y assurance  and  q u a l i t y assurance programs but a l s o a 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 f o r t h i s concept. As noted by (1988) "...each nurse now assurance methodologies practice"  Beyers  has t o l e a r n an use  quality  as an i n t e g r a l p a r t of  (p.614). Therefore, the r e s u l t s o b t a i n e d i n  t h i s survey may  be an i n d i c a t i o n t h a t , although q u a l i t y  assurance a c t i v i t i e s are p e r c e i v e d as a requirement  by  non-nursing p e r s o n n e l or o u t s i d e agencies, they a l s o are, i n f a c t ,  seen as an i n t e g r a l p a r t of n u r s i n g  practice. Finally, which,  Table 11 p r e s e n t s those a c t i v i t i e s  on  g i v e n the o p p o r t u n i t y , the p a r t i c i p a n t s i n the  study would choose t o spend more time. The  activities  t h a t r e c e i v e d the h i g h e s t response r a t e i n t h i s  survey  were those t h a t were p a t i e n t - o r i e n t e d . In p a r t i c u l a r , 71.4%  of the p a r t i c i p a n t s noted t h a t they would  t o 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 , and 69.9% p l a n n i n g t h e i r own  like  their  would l i k e t o i n v o l v e p a t i e n t s i n c a r e . These r e s u l t s are c o n s i s t e n t  with the Edwardson and Anderson  (1983) study where  " s t a f f nurses showed a c l e a r p r e f e r e n c e f o r d i r e c t - c a r e a c t i v i t i e s and ranked formal q u a l i t y  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 r e c e i v e d the lowest response r a t e  was  51 "to be an a c t i v e member on a q u a l i t y committee"  assurance  (23.2%). T h i s r e s u l t , when c o n s i d e r e d i n  l i g h t o f the p o s i t i v e responses towards q u a l i t y assurance, i s i n t e r e s t i n g . Although these nurses have a p o s i t i v e o p i n i o n o f n u r s i n g q u a l i t y assurance and i t s r o l e i n p r o v i d i n g q u a l i t y n u r s i n g care, when g i v e n t h e o p p o r t u n i t y l e s s than one q u a r t e r want t o p a r t i c i p a t e i n t h i s t y p i c a l q u a l i t y assurance a c t i v i t y .  It i s  u n c l e a r from t h e r e s u l t s o b t a i n e d i n t h i s survey why these nurses f e e l t h i s way.  L i m i t a t i o n s i n t h i s study There are s e v e r a l l i m i t a t i o n s i n t h i s study. F i r s t the p o p u l a t i o n t h a t was used worked i n a v a r i e t y o f hospitals,  each with a unique n u r s i n g q u a l i t y  program. Information was not sought  from t h e s u b j e c t s  c o n c e r n i n g t h e s p e c i f i c program i n t h e i r hospitals.  In a d d i t i o n ,  assurance  respective  i n f o r m a t i o n was not sought  r e g a r d i n g the s u b j e c t s ' s p e c i f i c e x p e r i e n c e s with n u r s i n g q u a l i t y assurance. Information from both these areas c o u l d have p r o v i d e d v a l u a b l e i n s i g h t analysis  i n t o the  of t h e r e s u l t s o b t a i n e d .  Another  l i m i t a t i o n i n t h e study may be t h e wording  of t h e s p e c i f i c q u e s t i o n s and c h o i c e s of responses. The f a c t t h a t t h e s u b j e c t s were asked t o i d e n t i f y components o f a n u r s i n g q u a l i t y assurance program u s i n g  common t e r m i n o l o g y influenced (1982)  the  "the  responses.  that  addition]  and v i s u a l  is  (p.232).  presentation  of  the  components  questions,  been the  observed. subjects  on one  side  checked o f f enough  of  check the  the  off  page.  to  actual  to  the  of  the  the  various otherwise  questions  required  i n a column  The s u b j e c t s may h a v e  their  an  may h a v e  responses  without  the  structure  t h a n w o u l d have  their  components  consideration  the  give  eyes of  questions  rate  The s t r u c t u r e  to  t r y to  i n the  Finally,  response  the  often  image  promoted a h i g h e r of  may h a v e  worded c a n i n f l u e n c e  people  enhances t h e i r  researcher..."  own,  As n o t e d by T r e e c e and T r e e c e  way a q u e s t i o n  results...[in answer  rather than t h e i r  giving  simply  serious  responses.  Summary  Results questionnaires  of  the  information i n the  were p r e s e n t e d  in this  d e m o g r a p h i c d a t a were p r e s e n t e d results  of  results  were t h e n  three  four q u a l i t y discussed  research questions,  findings study  the  were d i s c u s s e d .  were  identified.  first,  assurance  returned  chapter. followed  Finally,  by  questions.  in relationship  and t h e n  The  to  the  The the  supplemental limitations  in  the  53  CHAPTER FIVE  Summary, C o n c l u s i o n , I m p l i c a t i o n s and Recommendations  A summary o f the study f i n d i n g s and c o n c l u s i o n s are p r e s e n t e d i n t h i s chapter. Then, i m p l i c a t i o n s o f the study are presented, with recommendations f o r future  study.  Summary  The need t o p r o v i d e concrete evidence o f q u a l i t y care i s a r e a l i t y ,  both w i t h i n n u r s i n g and i n our  present h e a l t h care system.  Lang and C l i n t o n  (1983)  noted " o b j e c t i v e and s y s t e m a t i c e v a l u a t i o n or assessment o f n u r s i n g care has been an urgent w i t h i n the p r o f e s s i o n [of nursing] f o r s e v e r a l  priority decades"  (p.212). In a d d i t i o n , o u t s i d e agencies such as the H o s p i t a l A c c r e d i t a t i o n C o u n c i l , have, over the past decade, made q u a l i t y assurance programs and a c t i v i t i e s a requirement & Mills,  i n the a c c r e d i t a t i o n process  1990; F i n l e y - C o t t o n e & Link, 1985; H a r r i s ,  Kreger & Davis 1989; Maciorowski, O'Brian,  (Acorn, Love  Larson & Keane, 1985;  1988). However, the enthusiasm and  54  p a r t i c i p a t i o n l e v e l o f many nurses has been at best, one o f ambivalence  and r e l u c t a n t compliance  mandated n u r s i n g q u a l i t y assurance  with  programs.  The purpose o f t h i s study was t o d e s c r i b e care nurses' p e r c e p t i o n s o f t h e i r experiences n u r s i n g q u a l i t y assurance. were used t o guide t h i s 1. What do c r i t i c a l  purposes  with  Three r e s e a r c h q u e s t i o n s  study: care nurses i d e n t i f y as  components o f a n u r s i n g q u a l i t y assurance 2. What do c r i t i c a l  critical  program?  care nurses i d e n t i f y as the  o f n u r s i n g q u a l i t y assurance  3. What i s the involvement i n n u r s i n g q u a l i t y assurance  activities?  of c r i t i c a l  care  nurses  activities?  Using an e x p l o r a t o r y , d e s c r i p t i v e design, were c o l l e c t e d i n a survey u t i l i z i n g  data  a self-  a d m i n i s t e r e d q u e s t i o n n a i r e . The q u e s t i o n n a i r e developed by t h e r e s e a r c h e r , c o n t a i n e d q u e s t i o n s m o d i f i e d the Edwardson and Anderson sample o f c r i t i c a l  (1983) study. A  convenience  care nurses, who are members o f the  Canadian A s s o c i a t i o n of C r i t i c a l Critical  from  Care Nurses,  was used.  care nurses were s e l e c t e d as the sample f o r  t h i s study because n u r s i n g q u a l i t y assurance  activities  have a h i g h p r o f i l e i n these u n i t s due t o the c r i t i c a l c o n d i t i o n o f the p a t i e n t s . The s t a t i s t i c a l  techniques  used t o analyze the data were f r e q u e n c i e s ,  percentages  and means o f the i n d i v i d u a l  items.  55 The r e s u l t s showed t h a t , 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 t o know what  comprised the components of a n u r s i n g  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  activities  was low. When asked what the purpose was 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 m a j o r i t y subjects  i d e n t i f i e d that nursing  of the  q u a l i t y assurance  a c t i v i t i e s were r e q u i r e d by a 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 and/or  a q u a l i t y assurance  committee. In a d d i t i o n , more than 58.9% i n d i c a t e d t h a t the primary purpose  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 was t o meet the a c c r e d i t a t i o n requirements of the h o s p i t a l . The f i n d i n g s a l s o p r o v i d e i n f o r m a t i o n group of nurses a t t i t u d e s and o p i n i o n s nursing  on t h i s  concerning  q u a l i t y assurance. A l l of the s u b j e c t s  i d e n t i f i e d that nursing  q u a l i t y assurance  i n v o l v e d them, with the m a j o r i t y  activities  i d e n t i f y i n g t h a t these  a c t i v i t i e s 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 and were p a r t of t h e i r p r o f e s s i o n a l  responsibilities.  However, very few i d e n t i f i e d t h a t 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 q u a l i t y assurance  a c t i v i t i e s such as s e r v i n g on a q u a l i t y assurance committee. The a c t i v i t i e s t h a t were i d e n t i f i e d by the majority  of the s u b j e c t s ,  as those on which t o spend  more time, were those t h a t i n v o l v e d d i r e c t p a t i e n t  56 care, such as t e a c h i n g p a t i e n t s and/or t h e i r and i n v o l v i n g p a t i e n t s i n t h e i r own  families,  care.  Conclusions  The r e s u l t s of t h i s study suggest t h a t t h i s group of c r i t i c a l  care nurses have an understanding of what  would be c o n s i d e r e d components of a n u r s i n g 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 i n these a c t i v i t i e s i s low. I t was  level  beyond the scope of  t h i s study t o e x p l a i n p a r t i c i p a t i o n l e v e l s i n r e c o g n i z e d n u r s i n g q u a l i t y assurance programs. In the supplemental f i n d i n g s , the m a j o r i t y 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 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 . However, i n i d e n t i f y i n g the  purpose  f o r these a c t i v i t i e s the m a j o r i t y chose meeting  the  h o s p i t a l ' s a c c r e d i t a t i o n requirements. Although the r e s u l t s i d e n t i f i e d t h a t these nurses v a l u e d 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 the r e a l i t y of  p r a c t i c e , they p e r c e i v e d t h e i r purpose  i s f o r other  than improving n u r s i n g c a r e . In a d d i t i o n , the supplemental r e s u l t s  also  i d e n t i f i e d t h a t these nurses p e r c e i v e d 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 i n v o l v i n g a l l l e v e l s of n u r s i n g and as a way  of improving p a t i e n t c a r e . However, i f  57 g i v e n the o p p o r t u n i t y they were u n w i l l i n g t o p a r t i c i p a t e i n the a c t i v i t i e s t h a t they i d e n t i f i e d  as  components of a n u r s i n g q u a l i t y assurance program. The a c t i v i t i e s which they would seek involvement  i n are  those t h a t 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 . T h i s r e s u l t i s c o n s i s t e n t with the f i n d i n g s i n the Edwardson and Anderson  (1983) study, i n which the  "agreed t h a t involvement  respondents  i n q u a l i t y assurance was  an  important p a r t of the p r o f e s s i o n a l nurses' role...[however]  l e s s than h a l f of the  staff-nurses  respondents would choose t o p a r t i c i p a t e i n these activities  [ q u a l i t y assurance a c t i v i t i e s ]  i f they had  the o p p o r t u n i t y " (p.37-38). T h e r e f o r e , 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 v a l u e 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 they do not t r a n s f o r m t h a t knowledge and those v a l u e s i n t o d e f i n i t e n u r s i n g q u a l i t y assurance  activities.  I m p l i c a t i o n s and Recommendations  Although the study p o p u l a t i o n was  l i m i t e d to a  s p e c i f i c group of nurses, thereby g i v i n g r i s e t o problems of g e n e r a l i z a t i o n ,  several implications f o r  n u r s i n g p r a c t i c e , n u r s i n g education, n u r s i n g a d m i n i s t r a t i o n and n u r s i n g r e s e a r c h can be d e r i v e d from the r e s u l t s o b t a i n e d .  58  Nursing  Practice  The  r e s u l t s of t h i s study have a number of  implications The  f o r nurses who  are  in c l i n i c a l  r e s u l t s show t h a t the nurses who  t h i s study f e l t t h a t n u r s i n g  practice.  participated in  q u a l i t y assurance  a c t i v i t i e s were f o r q u a l i t y assurance coordinators/committees and  were p r i m a r i l y used t o meet  h o s p i t a l a c c r e d i t a t i o n r e s p o n s i b i l i t i e s . These r e s u l t s are very d i s t u r b i n g i n l i g h t of the that one  i d e n t i f i e s nursing  current l i t e r a t u r e  q u a l i t y assurance a c t i v i t i e s  method of d e f i n i n g n u r s i n g  p r a c t i c e 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 f o r t h a t p r a c t i c e . addition,  the  subjects  perceived  assurance a c t i v i t i e s i n v o l v e d p e r s o n n e l and  were p a r t  that,  nursing  a l l l e v e l s of  In  quality  nursing  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 . However, when given the to p a r t i c i p a t e i n nursing  opportunity  q u a l i t y assurance  these nurses s e l e c t e d p a t i e n t - o r i e n t e d Nurses who  as  activities.  practice direct patient  develop an awareness t h a t not  activities,  care have to  a l l activities  that  concern p r o f e s s i o n a l p r a c t i c e i n v o l v e d i r e c t p a t i e n t contact. i n the  Nurses have t o stop b e i n g p a s s i v e  nursing  participants  q u a l i t y assurance process and  seek  out  an a c t i v e r o l e f o r themselves. This a c t i v e r o l e should include  d i r e c t involvement i n the d e c i s i o n s  t h e i r u n i t and  the n u r s i n g  involving  q u a l i t y assurance program  59 w i t h k n o w l e d g e and activities accept  i n the  provide  and  p r o g r a m . In  appointments to  activities  there  utilization  i s no  time to  conflict  findings  attend  who  assurance administration  meetings,  ensuring  that  direct  care.  o f t h i s s t u d y have i m p l i c a t i o n s  e d u c a t i o n . These f i n d i n g s  g r o u p o f n u r s e s has their  nursing  nurses  the  Education  The nursing  quality  from  f o r t h e s e n u r s e s between  indirect patient  Nursing  that  findings  addition,  nursing  must r e q u e s t  release  of the  professional  assurance of  developed a value growth t h a t  quality  seem t o  have b e e n a c q u i r e d  into professional  In  the  when g i v e n t h e  activity  activities  r e s u l t s of the  opportunity,  i s how  study  this  within the is  r e s p o n s i b i l i t y . However,  these values addition,  system  recognizes that  in professional  of t h e i r p r o f e s s i o n a l does not  indicate that  for  part  what  to  translate  and  practice.  indicate  that,  t h i s p a r t i c u l a r group  of  n u r s e s would choose t o 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 As that and care  a r e s u l t of  nursing staff  how  involve  these findings,  e d u c a t i o n has to  translate  into concrete  e n v i r o n m e n t . One  direct patient  a role  i t would  within  method r e c e n t l y  appear  in teaching  t h e i r values  activities  contact.  for  the  discussed  students  quality  clinical in  the  60 literature provide  was  a liaison  a nursing practicum for  actively quality  involve  the  assurance  S m i t h and Power  student  (1990),  and p r a c t i c e  practical  student  patient  care  issues  role  is  the  include  creation  as of  In a d d i t i o n , i n the  developments  as  staff Their  address  timely  (p.30).  their  that  the  health  should  play  systems  that  These  to  nursing  all  in  should  quality  in writing  and u t i l i z a t i o n  environment,  standards, of on  results. quality  new  assurance  nursing  role  programs  i n c r e a s i n g emphasis care  staff  quality  educational  in nursing quality  r e g u l a r l y to  staff.  in nursing  experiences  auditing tools, given  ...and  can p l a y a s i g n i f i c a n t  orientation  well  present  presented  of  activities.  a basic  assurance  offer  by  between  continuing education  departments  awareness l e v e l  assurance  that  noted  link  nursing education  many n u r s i n g d i v i s i o n s educational  "the  are provided"  of  to  unit's  as  strengthened;  experiences  Another part an a c t i v e  in a nursing  are that is  institution  students which would  p r o g r a m . The b e n e f i t s  education  the  with a p r a c t i c e  should  be  staff.  Nursing Administration The r e s u l t s the  nurse  by D e v e t  of  this  study  a d m i n i s t r a t o r to (1986),  "[nurse  are very  consider  important  because,  administrators]  as  often  for  noted perceive  Q.A.  [ q u a l i t y assurance] as a f u n c t i o n to d e l e g a t e  s t a f f support  s e r v i c e r a t h e r than one  i n t e g r a t e d i n t o t h e i r own  to a  t o keep w e l l  leadership r o l e . . . "  (p.52).  Consequently, i n l i g h t of the f i n d i n g s of t h i s  study,  nurse a d m i n i s t r a t o r s should i n v o l v e themselves i n t h e i r department's n u r s i n g q u a l i t y assurance program on a regular basis. T h i s involvement c o u l d be accomplished i n a v a r i e t y of ways. F i r s t ,  n u r s i n g q u a l i t y assurance  r e p o r t s should be c o n s i d e r e d  a r e g u l a r component of a l l  n u r s i n g s t a f f and n u r s i n g management meetings. T h i s w i l l h e l p r e f o c u s the p e r c e p t i o n t h a t the n u r s i n g have about who are f o r and why these  the n u r s i n g q u a l i t y assurance n u r s i n g s t a f f should be  activities.  activities  involved i n  Secondly, n u r s i n g s t a f f ' s  involvement  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 has to encouraged and  supported  staff  be  by the nurse a d m i n i s t r a t o r .  T h i s should i n v o l v e d e l e g a t i n g r e s p o n s i b i l i t y f o r the process  down t o the n u r s i n g u n i t l e v e l and u s i n g  s t a f f ' s ideas and  the  input i n t o the type 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 t h a t are most s u i t a b l e f o r t h e i r s p e c i f i c u n i t . As noted by O'Brian  (1988)  nurses] as d i r e c t care g i v e r s , . . . are i n the p o s i t i o n t o monitor n u r s i n g p r a c t i c e by problems and  "[staff  best  identifying  implementing c o r r e c t i v e a c t i o n s which have  the g r e a t e s t impact on p a t i e n t c a r e "  (p.33).  Without  62 this  type  of d i r e c t  d e l e g a t e d by  involvement  the nurse  by  the n u r s i n g s t a f f ,  administrator, nursing  a s s u r a n c e programs w i l l  c o n t i n u e t o be  exercises  t h i r d party  Finally,  in fulfilling the  specific  of the n u r s i n g d i v i s i o n ' s  includes provisions  facilitate  the attendance  designated nursing s t a f f  result  Failure  The  results  quality  level  similarly quality  study a l s o  activities.  will  indirect patient  indicate  identified  care  that  their  i n t h e s e a c t i v i t i e s as (1983) i n t h e i r levels  a c t i v i t i e s and  administrators investigate  n o t more a c t i v e l y  and  of r e l i e f  knew t h e components o f a n u r s i n g  low p a r t i c i p a t i o n  assurance  of  precedence.  E d w a r d s o n and A n d e r s o n  role  type  with the d i r e c t  a s s u r a n c e program, t h e y  participation  to  assurance  to provide this  of the  although the nurses  nurse  in quality  a  Resource  staff  and p a r t i c i p a t i o n  care requirements,  needs always t a k i n g  s h o u l d be  budget.  for relief  i n a c o n f l i c t between d i r e c t  patient  nurse  requirements.  assurance program  allocation  activities.  as  r e s o u r c e s needed t o p r o p e r l y  operate a nursing q u a l i t y regular part  seen  quality  involved  study  noted  f o r nurses  that  why  were  s t a f f nurses  on t h e p r e s e n t  a d m i n i s t r a t o r s s h o u l d not  only take  assurance  i n formal  t h e y recommended  in nursing quality  Therefore, based  i n nursing quality  low.  an  assurance  findings active  a c t i v i t i e s , but  63 should a l s o  investigate  participate  more e n t h u s i a s t i c a l l y  Nursing  why s t a f f nurses  i n these a c t i v i t i e s .  Research  Based on the f i n d i n g s following  from t h i s study the  r e s e a r c h a c t i v i t i e s are recommended:  1. A f i v e year, yearly  do not  longitudinal  i n t e r v a l s a l l nurses  study,  s u r v e y i n g at  in a specific institution,  to determine i f the n u r s i n g q u a l i t y  assurance  program  and the r e l a t e d e d u c a t i o n a l programs are having any effect. 2. Using the same n u r s i n g p o p u l a t i o n , and the r e s u l t s o b t a i n e d i n t h i s study as a foundation, qualitative  approach t o e x p l o r e the nurses'  p e r c e p t i o n s and low p a r t i c i p a t i o n 3. survey investigate  use a  attitudes,  l e v e l s i n more depth.  a l a r g e r group of s t a f f nurses t o  the s p e c i f i c causes o f nurses'  d i s s a t i s f a c t i o n with n u r s i n g q u a l i t y  assurance  activities. 4. 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The b e n e f i t s o f s t a f f nurse involvement i n m o n i t o r i n g the q u a l i t y of p a t i e n t c a r e . J o u r n a l of N u r s i n g Q u a l i t y Assurance, 1(3) , 1-7. Smith, T.C. & Powers, B.A. (1990). An i n t e g r a l approach t o q u a l i t y assurance. N u r s i n g Management, 21(6), 28-30. T a y l o r , A.G., & Haussmann, G.M. (1988). Meaning and measurement of q u a l i t y n u r s i n g c a r e . A p p l i e d N u r s i n g Research, 1 ( 2 ) , 84-88.  69 T h u r s t o n , N., & B e s t , M. (1990). C l i n i c a l n u r s i n g r e s e a r c h and q u a l i t y a s s u r a n c e : I n t e g r a t i o n f o r improved p a t i e n t c a r e . Canadian J o u r n a l of N u r s i n g A d m i n i s t r a t i o n , 3.(1), 19-23. T r e e c e , W.T. & T r e e c e , J.W. (1982). Elements i n r e s e a r c h i n n u r s i n g . S t . L o u i s : The C.V. Mosby Company. W i l s o n , C.R.M. (1987). H o s p i t a l wide q u a l i t y a s s u r a n c e models f o r i m p l e m e n t a t i o n and d e v e l o p m e n t . T o r o n t o , O n t a r i o : W.B. Saunders. W o l f f , E.M. ( 1 9 8 6 ) . Systems management: E v a l u a t i n g n u r s i n g d e p a r t m e n t s as w h o l e . N u r s i n g Management, 1/7 ( 2 ) , 40-43. 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. S a u n d e r s 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  Directions 1. P l e a s e carefully. 2. I f y o u answer, p l e a s e being c o r r e c t . 3. P l e a s e  read  each statement  and t h e i n s t r u c t i o n s  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 t o check t h e response t h a t you t h i n k i s c l o s e s t t o do n o t s i g n t h e q u e s t i o n n a i r e .  1. I f e e l t h e i t e m s / a c t i v i t i e s l i s t e d b e l o w a r e 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 p r o g r a m : (check as many a s y o u t h i n k are a p p l i c a b l e ) _a. _b. _c. _d. _e. _f. _g. _h. _i. _j.  nursing care audits r e g u l a r s t a f f performance a p p r a i s a l s a u d i t o r q u a l i t y assurance committees incident reports 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 regular hospital-based nursing inservice r e g u l a r c h e c k s and m a i n t e n a n c e o f b i o m e d i c a l e q u i p m e n t v e r i f i c a t i o n of current nursing r e g i s t r a t i o n nursing p r a c t i c e standards s u g g e s t i o n s 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 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 p r o g r a m s f o r new s t a f f _1. n u r s i n g work l o a d management s y s t e m s ( i e . GRASP) m. o t h e r ( p l e a s e s p e c i f y )  73  2. I n t h e p a s t y e a r I have b e e n i n v o l v e d a c t i v i t i e s : ( c h e c k as many as you wish)  i n the  following  _a. _b.  conducted a nursing audit r e c e i v e d a p e r f o r m a n c e a p p r a i s a l a b o u t my work performance _ c . s e r v e d on an a u d i t o r q u a l i t y a s s u r a n c e c o m m i t t e e _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 o f q u a l i t y a s s u r a n c e s t u d i e s into actual practice _f. r e g u l a r l y attended hospital-based nursing i n s e r v i c e s _g. p e r f o r m e d a u d i t s o f b i o m e d i c a l e q u i p m e n t _h. p r o d u c e d e v i d e n c e 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 _ i . developed nursing p r a c t i c e standards f o r measuring the q u a l i t y of nursing care _ j . suggested t o p i c s f o r nursing q u a l i t y assurance audits/ studies _k. o r i e n t e d o f 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 w o r k l o a d management s y s t e m ( i e . GRASP) m. o t h e r ( p l e a s e 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 a s s u r a n c e a c t i v i t i e s : you f e e l a r e a p p l i c a b l e ) a. b. c. _d. _e. _f. _g. _h. _i. _j. _k. _1. m. j  ( c h e c k as  many  a r e r e q u i r e d by t h e q u a l i t y a s s u r a n c e director/coordinator a r e p r i m a r i l y u s e d t o meet a c c r e d i t a t i o n r e q u i r e m e n t s the h o s p i t a l a r e r e q u i r e d by t h e q u a l i t y a s s u r a n c e c o m m i t t e e a r e 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 r s e s do n o t i n v o l v e me are a waste o f t i m e t a k e up t i m e t h a t s h o u l d be s p e n t on p a t i e n t c a r e 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 r e a p a r t o f my d a i l y a c t i v i t i e s improve n u r s i n g c a r e a r e 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 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 other (please s p e c i f y ) _ —  _  -  •  as  for  74 4. I f I c o u l d ,  I would:  (check  as many as y o u w i s h )  a. b. c. _d. e. f. _g.  s p e n d more t i m e p l a n n i n g p a t i e n t s ' c a r e be an a c t i v e member on a q u a l i t y a s s u r a n c e c o m m i t t e e s p e n d more t i m e t e a c h i n g p a t i e n t s a n d / o r f a m i l i e s involve p a t i e n t s i n planning t h e i r care s p e n d more t i m e g e t t i n g t o know my f e l l o w w o r k e r s w r i t e nursing care standards f o r s p e c i a l i t y area p a r t i c i p a t e i n r e v i e w i n g t h e n u r s i n g c a r e g i v e n by other r e g i s t e r e d nurses h. i m p r o v e my s k i l l s i n p e r f o r m i n g n u r s i n g c a r e p r o c e d u r e s i . other (please s p e c i f y )  In t h e f o l l o w i n g q u e s t i o n s p l e a s e d e s c r i b e s y o u most a d e q u a t e l y .  5.  Nursing  education:  check o r f i l l  (please check a l l t h a t  i n the data  apply)  a. N u r s i n g d i p l o m a b. B a c c a l a u r e a t e d e g r e e c. M a s t e r ' s degree d. o t h e r ( p l e a s e s p e c i f y )  6. P l e a s e currently  i n d i c a t e the area employed i n :  of c r i t i c a l  a. i n t e n s i v e c a r e u n i t b. c o r o n a r y c a r e u n i t e. s u r g i c a l i n t e n s i v e c a r e u n i t f. post-open heart recovery unit e. p e d i a t r i c i n t e n s i v e c a r e u n i t f. neonatal i n t e n s i v e care unit g. o t h e r ( p l e a s e s p e c i f y ) . ^  c a r e t h a t you a r e  that  

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