Quality Nursing Care

NURSING EXAMPLE A Summary of Proposed explore Program for Master of Philosophy Title The Delivery of Quality breast feeding C are A Grounded opening Study of the Nurses Perspective Abstract The purpose of this see is to explore and describe the slant of prime(a) breast feeding pull off from the perspective of practising nurses working in the subtle usual infirmary setting of Western Australia (WA). The show go forth examine the actions and interactions attributed to prime(a), and factors identified as enhancing or inhibiting the sales talk of prime(a) nurse wangle. A grounded supposition approach is proposed.The sample for the weigh result be drawn from nurses working in an discerning public hospital located in Perth, WA. Data give be collected using semi-structured interviews and some(prenominal) observation. It is estimated that somewhat 10-15 interviews leave be performed. Theoretical sampling forget guide the recognizeion of thespians. The significanc e of this inquiry impart be to increase understanding of this complex phenomenon and contribute to efforts aimed at improving and maintaining fiber direction for business within the current context of the WA health disturbance system.A substantive theory explaining the dish of tone of voice bearing, focussing on the nurses perspective, in an acute public hospital setting, go away be developed. Implications for utilize go out be discussed and directions for further query in this area exit be provided. Objectives The purpose of this adopt is to explore and describe the actors line of timberland negociate for care from the perspective of practising nurses, working in the acute public hospital setting of WA. The train will examine the actions and interactions attributed to whole tone, and factors identified as enhancing or inhibiting the saving of prize breast feeding care.The objectives guiding this proposed study are 1. To explore and describe nurses sensings of the implication of eccentric nursing care. 2. To describe nurses knowledges in the saving of nursing care give to forbearings in hospital and to compare these with their expectations of quality nursing care. 3. To explore factors identified by nurses as enhancing and as inhibiting quality nursing care. 4. To develop a substantive theory which explains the solve used to deliver quality nursing care in an acute public hospital setting, as perceived by nurses. BackgroundThe provision of quality patient care is a priority in all health care institutions (Erith-Toth & Spencer, 1991). Formal definitions of what constitutes quality are legion(predicate) (Ambler Peters, 1991), as are the approaches used to assess the quality of patient care (Harvey, 1991 MacGuire, 1991). Although much has been written nigh the phenomenon of quality care, significant variations exist in its interpretation and use, unaware or undeterred by the abstract confusion, quality care continues to be ass ured, controlled, evaluated and managed in the Health Service today (Attree, 1993, p. 55). Furthermore, definitions and assessment of quality wealthy person rarely considered the reality faced by nurses on a daily basis, in the radiation diagram and delivery of quality care. Quality nursing care has been studied from various perspectives using different methods. Much of the research reported in the literature has been quantitative in nature and under dole outn in countries other than Australia, particularly coupling the States.Some studies mode roll focussed on the measurement of quality nursing care (Gilloran, McGlew, McKee, Robertson & Wight, 1993 MacGuire, 1991 Pearson, Durant & Punton, 1989 Kitson, 1985), or the meaning of quality nursing care from either the nurses perspective (Janhonen, 1993 Forchuk Kirkpatrick, 1991 Whelan, 1988 Jenkins, 1988) or the patients perspective (Irurita, 1993 Erith-Toth & Spencer, 1991 Deeny & McCrea, 1991 Rempusheski, Chamberlain, Picard, Ruzan ski & Collier, 1988).Other studies have compared the perceptions of quality nursing care from the perspective of nurses and patients (Norman, Redfern, Tomalin & Oliver, 1992 Yonge, 1989 Varholak, 1989 Board, 1988). Of the studies that have explored nurses perceptions of quality care, two included some elements of the delivery of nursing care (Forchuk Kirkpatrick, 1991 Jenkins, 1988). Those studies differ from this proposed study in context, as both were carried out in North America and used health settings other than acute public hospitals.Forchuk Kirkpatrick (1991) used survey methods in their study of quality care in a psychiatrical facility where nurses indicated that the nursing care they 2 delivered was the best potential under unfavourable conditions (p8). Barriers to quality nursing care were identified as heavy workload and staffing issues (p8). However, the results of this study are limited by use of a convenience sample and administration of a questionnaire for which reli capability and rigor were not demonstrated. Jenkins studied quality nursing care in a small hospital in the United States and used a similar design to that proposed for this study.Using the grounded theory method, the characteristics of quality nursing care from the nurses perspective were found to be technical care, adequate time, assessment, observation, teaching, communication, and individualised care. Some enhancing and inhibiting factors were identified, as well as positive and negative outcomes in the status of the patients. This proposed study is justified in that although the methodology is similar, the study by Jenkins was under tugn in a small hospital, whilst this study will be undertaken in a large acute public hospital. Furthermore, the cultural aspects of this proposed study are different.Another study of quality nursing care was carried out within the context of an acute public hospital setting in WA (Irurita, 1993). This study used grounded theory to explore q uality nursing care from the patients perspective. Patients described different levels of care and suggested that high quality nursing care could not be expected due to intervening conditions much(prenominal) as lack of time, high patient turnover, competing demands on the nurse, lack of consistency and continuity in nurses charge to their care, ageism, shortage of staff, lack of co-ordination on ward, and communication problems between doctornurse- patients.These findings raise questions requiring further exploration, including the nurses perspective. A number of factors whitethorn determine the quality of care delivered by nurses to patients. A review of the literature by Fitzpatrick, While, and Roberts (1992) identified nursing competence, use of research, communication skills, care management and organisation of workload, provision of health education and health promotion, productive thinking and reflection as elements of high quality patient care.A number of research studie s have equated the quality of nursing with the ability of the nurse to exhibit pity behaviours towards their patients. Some of these studies have explored the behaviours identified by nurses (From, 1992 Clarke & Wheeler, 1992 Mangold, 1991 Chipman, 1991 Schaefer & Lucke, 1990 Morrison, 1990 Forrest, 1989 Larson, 1986), while others the behaviours identified by patients (Fosbinder, 1991 Cronin & Harrison, 1988 Brown, 1986 Rieman, 1986 Larson, 1984).Some of the research has compared the views of nurses and patients (Appleton, 1993 Smit & Spoelstra, 1991 Lapsley, 1989 Larson, 1987 Mayer, 1986). Whereas fondness has been described as an important fortune of quality nursing care, exploratory research is lacking in the study of factors which may influence the nurses ability to exhibit caring behaviours under varying conditions, and what special factors may be involved in the delivery of quality nursing care.There is evidence in the literature to suggest that although nurses may be sur e-footed of providing quality care and know what constitutes quality care, their performance in practice may be touch by factors such as decreased numbers and the resulting reduction in available time, which can rule out the delivery of quality nursing care (Forchuk Kirkpatrick, 1991 Hendrickson, Doddato Kovner, 1990). A recent survey of 2,488 Australian nurses (Millis Tattam, 1994) found that budgetary cuts and management restructuring were having a negative impact on nurses work environment.Increased workload, reduced standards of care (particularly in the public sector), and a lack of improvement in patient care were also said to be apparent. In WA, hundreds of nurses protested at a rally organised by the Australian Nursing Federation to put forward concerns about(predicate) the personal effects of economic cut backwardss in the WA health environment. Specifically, the dismantling of the WA Nurses Career complex body part and the reduction of nursing positions were said t o be having a negative effect on the delivery of quality nursing care (Bartley, 1994).Nursing staff in the hospital environment of WA are shortly challenged to maintain and improve the quality of care in the face of changing work patterns and moves to promote former discharge of hospitalised patients resulting from increasing economic restrictions (Health Observer, 1994). The indication that problems exist in the delivery of quality nursing care in WA warrants closer examination, to discover how nurses deliver quality care and factors which nurses perceive to affect the delivery of quality nursing care in the resent context of acute public hospitals in WA. more and more it is recognised that gaps exist between theory and practice (Chine Jacobs, 1987 Riley Oermann, 1992), an understanding may exist among nurses as to what constitutes quality nursing care, but what actually occurs in practice, under varying conditions, may differ from the recognised standard. bread and butter of strategies used by nurses to maintain quality when conditions are adverse are 3 bsent in the literature, as is cultivation indicating what circumstances are favourable to quality care provision and what constitutes the highest quality of nursing care. The tip that the delivery of quality nursing care within the public hospital context of WA may be subject to variation and be influenced by different conditions requires further investigation. As stated previous in this proposal, some research has been performed in other countries on this phenomenon, but few studies have explored quality nursing care from the perspective of practising nurses.The use of the grounded theory method to research the phenomenon of quality nursing care allows exploration in terms of the current time, place and culture and can give new insights into a topic central to the practice of nursing (Chenitz Swanson, 1986). Furthermore, the gap between theory and practice may be reduced by a substantive theory dev eloped in this way. Significance The significance of this research will be to increase our understanding of this complex phenomenon and contribute to efforts aimed at improving and maintaining quality nursing care, within the context of the WA health care system.A substantive theory explaining the process of quality nursing care, focussing on the nurses perspective, in an acute public hospital setting will be developed. Implications for practice will be discussed and directions for further research in this area will be provided. look for Method A qualitative research method is proposed for this study, using the grounded theory approach (Glaser & Strauss, 1967). This method, which has its roots in Symbolic Interactionism, will reveal the reality of the quality ursing for nurses by interpreting selective information using a systematic set of procedures to develop a theory of the phenomenon, grounded in the findings (Strauss & Corbin, 1990). Sample Selection The sample for the study w ill be drawn from nurses working in one area of an acute public hospital located in Perth, WA. Initially, a purposive sampling technique will be used to select nurses for interview. Only Registered Nurses with a minimum of six months post registration nursing experience (of which at least lead must have been worked in the study area) will be approached.Participants will need to be able to reflect on and be willing to share detailed experiential information about the phenomenon. Volunteers will be sought initially at staff meetings and a mop up number will be left on the notice board in each of the ward areas. Further participants will be approached using a theoretical sampling technique where initial summary of information guides the police detective to subsequent specific information sources (Glaser & Strauss, 1967). When this technique is used, sampling continues until theoretical saturation occurs.This is recognised by the establishment and minginess of identified categor ies as well as an absence of new concepts in the data (Strauss & Corbin, 1990). It is estimated that approximately 10-15 participants will be selected for interview, the final number beingness determined by theoretical saturation. Procedure Data will be collected from nurses through tape- save interviews guided by questions reflecting the objectives of the study (Appendix A). A semi-structured interviews technique will be used where, use of the interview guide is not rigidly adhered to by the interviewer (Chenitz & Swanson, 1986, p. 67).In this technique the researcher explores different aspects of the topic in detail using probes such as how, what, where and when. Interviews will take place in mutually agreeable private venues where the risk of interruptions is perceived to be minimal. Basic demographic information will be gathered from participants before the interview commences (Appendix B). The primary source of data will be the write down interviews, however, published litera ture and some observation will be used as additional data sources. The observations will be performed by the researcher (who is regularly assigned to clinical areas) and recorded by field notes.The main objective of these observations will be to verify data obtained by interview. Furthermore, additional aspects may be noted to be included in subsequent interviews. Data Analysis The ceaseless comparative method of data analysis will be used, whereby data are simultaneously collected, coded and analysed, in a way that allows the creativity necessary for the generation of a theory (Glaser & Strauss, 1967). Interviews will be write down verbatim on a word processor and organised for 4 analysis using the Ethnograph information processing system software (Seidel, 1988).This package numbers each line of the interview transcript and allows for segments of the interview to be coded and selected as required. Firstly, interview transcripts will be coded line by line, sentence by sentence, b y a process of open coding, to identify and label common themes and categories by asking questions about the content (Strauss & Corbin, 1990). This will be done by extensively reading the data and listening to the tapes. Categories and subcategories will be developed from this, minify and mapped onto the numbered interview transcript through the Ethnograph.Coded segments from the interviews will be accessed from the computer for Axial Coding. This involves putting the data back together again in new ways by making connections between the coded categories and subcategories. Memos and diagrams will be used throughout the process of analysis. Selective coding in which the core category is identified, relationships validated and sub-categories expanded, will take place before a conditional matrix is constructed and a substantive theory developed (Strauss & Corbin, 1990). Reliability and asperity A number of strategies will be employed throughout this study to ensure that he data colle ction and interpretation accurately reflects the phenomenon. Guba (1981) and LeCompte and Goetz (1982) discuss a number of ways in which reliability and validity issues of qualitative research can be addressed. This study has been designed to incorporate measures to address these issues as follows To forfend bias in the data collection and analysis, the researcher (who possesses current personal experience of nursing in a hospital setting) will raise awareness of own preconceptions and bias to the topic by being interviewed by another researcher, using the proposed interview guide.The researcher will avoid imposing these preconceptions on the data collection and analysis. Furthermore, interview transcripts will be reviewed by an independent person to detect the presence of whatever such bias. A personal diary will also be kept. Interviews will be transcribed verbatim and transcripts will be checked for accuracy by listening to the tape recording. The process of data collection and analysis will be cl beforehand(predicate) described. During the coding of the data, other researchers will be asked to independently code segments of the transcripts to confirm the categories identified by the researcher. Once the description of the phenomenon is complete, a sample of participants will be approached and asked to validate the description by reading it and seeing if it makes sense in terms of their own experience. honest Issues The proposed research will be submitted through the Human Research Ethical Committee at Curtin University of Technology. The study has already been approved for implementation by the Nursing Research and Ethical Review Committee at Sir Charles Gairdner Hospital. Each participant will be informed of the purpose of the study.Participants personal contribution together with their valet de chambre objurgates will be explained and the opportunity to ask questions about the study will be provided. Once the participant is satisfied with the re quirements of the study, a consent form will be signed. The consent outlines the purpose of the study, its voluntary nature, the right to withdraw at any time without penalty, as well as providing an assurance that all information provided will be treated in a non-identifiable, confidential manner (Appendix C). The consent form will be signed by the participant and the researcher, and a copy will be kept by each.Participants will be identified on the interview transcript by a numerical number. The individualism of the participants will be known only to the researcher who will keep names and workplace lucubrate in a secure place, separate to the transcripts (this information will be required if further contact is necessary). In keeping with the requirements of the University, the transcribed interviews and field notes will be kept for a period of quin years. Facilities and Resources The majority of expenses related to this project have already been funded by the Nursing Division o f Sir Charles Gairdner Hospital.Additional expenses are estimated as follows Photocopying and paper 5 reams $8 $440 5 Inter-Library Loans $200 Audio tapes 5 tapes $3 $15 Batteries 6 batteries $1 $6 Travel $100 Micro cassette recorder $400 Total $1 161 Data Storage Data collected will be qualitative in nature and will be stored on a computer while analyses using Ethnograph computer software are completed. The data files will be maintained for five years by and by which they will be destroyed. Timeline June-August Year 1 Proposal submitted to University Ethics Committee August Year 1-January Year 2 Data collection and analysisFebruary-June Year 2 Writing of final report 6 References Ambler Peters, D. (1991). Measuring quality management of opportunity. Holistic Nurse Practitioner, 5(3), 1-7. Appleton, C. (1993). 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Strauss, A. , & Corbin, J. (1990). Basics of qualitative research. Graounded theory procedures and techniques. Sage California. Varholak, D. M. (1989). Experiencing quality nursing care in a long term setting A patient-nurse perspective. Unpublished manuscript.Columbia University Teachers College. Whelan, J. (1988). Ward sisters management styles and their effects on nurses perceptions of quality care. Journal of Advanced Nursing, 13, 125-138. Yonge, O. J. ( 1 989). Nurses and patients perceptions of constant care in an acute care psychiatric facility A descriptive qualitative study. Unpublished PhD Thesis, University of Alberta, Canada. 8 APPENDIX A Interview exit What does quality nursing care mean to you? How does one ensure that quality nursing care is given? Give examples, in your experience, where you think high quality nursing care was given. Describe an incident). What are some of the most important aspects to consider in the delivery of quality nursing care? Can these be prioritised? What factors (if any) prevent you from achieving the delivery of quality nursing care to your patients (or patients generally)? What factors enable or help in the delivery of quality nursing care? Give examples of where improvements in nursing care delivery could have been made. How would you rate the quality of care given to patients in your area of work? 9 APPENDIX B demographic Information 1. Length of time employed at this hospital____________ _ 2.Length of time employed as a nurse_____________ 3. Length of time employed on present ward___________ 4. Level New graduate______ Level 1_____ Level 2______ 5. Part-time______ Full-time______ 6. Initial nursing education Hospital_________ College/University__________ 7. Year completed__________ 8. Post basic educational achievements ____________________________________________________ ____________________________________________________ 9. ongoing studies ____________________________________________________ ____________________________________________________ 10. Male_______ Female________ 11. Age_________