ABSTRACT
Background
Nurses have a professional obligation to provide safe, quality practice responsive to the needs of people they care for. The Healthcare Quality Framework designed to describe nurses’ responsibilities in healthcare quality, was utilised to explore nurses’ perceptions of quality care to improve patients’ experience.
Methods
Qualitative exploratory descriptive design conducted in two stages, in a South Australian metropolitan health service. First stage involved eight focus groups attended by 41 participants, comprising enrolled and registered nurses delivering direct patient care. Discussions recorded digitally, transcribed and thematically analysed. Second stage involved mapping and synthesis of focus group data against 61 elements located across seven domains of the Healthcare Quality Framework.
Findings
First stage: Eleven themes identified that described nurses’ skills and responsibilities to deliver quality nursing care. Most frequently reported were effective communication, delivering basic elements of care, team work, supportive environment and compassionate, respectful, dignified care. Second stage: Out of 61 elements of the Healthcare Quality Framework, twenty-four gaps were identified related to domains: Management of the Environment; Promotion of Safety; Clinical Leadership and Governance.
Discussion and Conclusion
Nurses’ narratives focused on delivery of quality care within their unit/ward. Participants did not identify how they may influence the healthcare team and health service to improve care. The Healthcare Quality Framework enabled a broader reflection on nurses’ responsibilities for quality care, identifying improvement initiatives. One initiative could be a specifically designed and evaluated mentorship program, based on the Healthcare Quality Framework that is accessible to all nurses after their transition year.
Keywords
Summary of relevance
Problem or Issue
Nurses have a substantial impact on patients' experiences of the quality of care and consequently patients' satisfaction with care delivery.
What is already known
Patient satisfaction data is one of the most frequent approaches used by health services for monitoring quality of care, which can be attained and reported through patients’ surveys, compliments, or complaints
What this paper adds
Discussion of the application of a new Australian framework that can be applied by nurse leaders/managers to assess organisational and professional elements of the nurses’ full scope of responsibilities in delivering quality nursing services.
1. Introduction
Within the nursing literature quality of care is frequently discussed, though as
Burhans and Alligood, 2010
and Peršolja, 2021
identified quality nursing care is not a definitive concept, rather it is defined depending on who is evaluating that care; the nurse, patient/family or nurse manager. However, intrinsic aspects of quality care have been identified, which include empathy, respect, advocacy, caring and intentionality (Burhans and Alligood, 2010
). These intrinsic aspects have also been discussed as attributes of professionalism (Cusack, Drioli-Phillips, Brown and Hunter, 2019
) linked with professional commitment, quality of patient care, and nursing staff retention and satisfaction (Garcia-Moyano, Altisent and Pellicer-Garcia, 2019
). Within Australia practice standards, codes and guidelines, are developed by the nursing profession's regulation body that establishes nurses’ responsibilities and accountability to deliver safe quality care. The regulator's documents also guide consumers of health services about the standards expected of nurses to ensure safe and effective quality nursing care (Nursing and Midwifery Board of Australia 2018
).Patients can also contribute their understandings of the quality of nursing care through patient satisfaction, measured by patient values, experiences, expectations and requirements. Patient satisfaction data is one of the most frequent approaches used by health services for monitoring quality of care, which can be attained and reported through patient surveys, compliments, or complaints (
Australian Commission on Safety and Quality in Health Care 2010
). The Australian Safety and Quality Framework for Health Care (Australian Commission on Safety and Quality in Health Care 2010
) reports that patient complaint data is integral to the identification of initiatives to improve safe patient care, experience and treatment outcomes.Kol et al., 2018
noted patients’ satisfaction in their journeys within the health service is most strongly influenced by their perceptions of nurses and the nursing care they receive. Nurses have the most significant amount of one-to-one contact with patients across twenty-four hours, every day of the week while delivering patient care, compared to any other health professional and therefore have a substantial impact on the patient's experience within a health service (Aiken et al., 2017
; - Aiken LH.
- Sloane D.
- Ball J.
- Bruyneel L.
- Rafferty AM.
- Griffiths P.
Patient satisfaction with hospital care and nurses in England: an observational study.
Nursing Research. 2017; https://doi.org/10.1136/bmjopen-2017-019189
Kol et al., 2018
).This article discusses nurses’ perceptions of their responsibilities in delivering quality nursing care in the context of a complex and busy health service environment. The Healthcare Quality Framework, which is designed to describe nurses’ responsibilities in healthcare quality (
Oldland, Botti, Hutchinson and Redley, 2020
) was applied to explore and understand the nurse participants' perspectives on delivering quality nursing care. The members of the project team included a clinical nurse, Nursing Director and an external research academic. No member of the project team had any direct clinical or managerial relationship with the nurse participants.2. Methods
The study used a qualitative explorative descriptive approach to answer the following questions:
- Question 1. What core clinical skills are required for nurses to deliver quality care?
- Question 2. What are the nursing staff perceptions of their professional responsibilities to deliver quality care?
The project was conducted in two stages at a major metropolitan health service in South Australia. The first stage comprised a series of focus groups with nurses delivering direct patient care in an inpatient setting. Focus groups were chosen over surveys, because this method provides richly descriptive reports of individuals’ perceptions, attitudes, beliefs and the meanings and interpretations (
Hakim, 2012
) that would enable a deeper understanding of delivering quality care. The second stage involved mapping and synthesis of focus group findings with the 61 elements located across seven domains of the Healthcare Quality Framework (Oldland, Botti, Hutchinson and Redley, 2020
). The Healthcare Quality Framework's seven domains are Management of the Environment; Promotion of Safety; Evidence Based Practice; Medical and Technical Competence; Person Centred Care; Positive Interpersonal Behaviours; and Clinical Leadership and Governance (Oldland, Botti, Hutchinson and Redley, 2020
).In discussion with the health service's Human Research Ethics Committee and Research Governance Office, the project was determined to be a quality improvement project (Health Service's Quality Improvement Register Number 3582). However, publication approval of the project was sought and granted by the relevant Human Research Ethics Committee and Research Governance Office. Issues concerning informed and free consent, and confidentiality are addressed in the relevant sections of this article. The SQUIRE guidelines for quality improvement reporting excellence were applied to guide recording of this study (
Ogrinc et al., 2015
).2.1 First stage
Participants included enrolled and registered nurses with direct patient care as their primary role, all of whom were nominated, with their permission, to attend a focus group by their unit managers. In preparation the nominated staff were provided with the focus group questions and encouraged to discuss these with their colleagues. Though it is unusual to have staff nominated by managers for focus groups this process enabled readily accessible and willing participants who were supported to attend (
Schneider, Whitehead, LoBiondo-Wood and Haber, 2013
). Many participants came prepared with comments following discussion with colleagues on their wards, which reduced the likelihood of bias.2.1.1 First stage: Data collection
Eight focus groups were conducted in November/December 2020. Two members of the study team who had no line management responsibilities conducted the focus groups. This was to promote open discussion of questions by participants. Focus groups went for no longer than one hour. A separate focus group was organised for enrolled nurses to ensure that they felt comfortable to express their views about quality care without registered nurses being present. With written consent of the participants, focus group discussions were digitally recorded to ensure data was confirmable (
East, Neville and Galvin, 2008
).2.1.2 First stage: Data analysis
Transcribed recordings had identifiers removed and replaced with numbers (FG1 - Focus Group 1) to preserve participants’ confidentiality and anonymity. Transcripts were analysed using
Braun and Clarke, 2006
approach to identify, analyse and report the main findings. The researchers focused on the content of the transcripts, then identified common themes and subthemes that related to the specific questions asked. This involved grouping of concepts, supported with quotes from the focus group interviews. The transcripts were also reviewed and themed by a second member of the team to build in a trustworthiness measure. Paper copies of transcripts and consent forms are stored securely in lead team members locked filing cabinet and, on a password protected health service computer drive.2.1.3 First stage: Results
Forty-one participants attended across eight focus groups. Focus groups consisted of six to eight participants per group. Data saturation was determined to be met following the final focus group with no new views emerging. Four themes and 13 subthemes were identified for question one: What are the core clinical skills for all nurses to deliver quality care? Seven themes with 19 subthemes were identified for question two: What are the nursing staff perceptions of their responsibilities to deliver quality care? (Table 1)
Table 1Summary of focus group themes.
| Question 1. What core clinical skills are required for nurses to deliver quality care? | |
|---|---|
| Theme | Sub-themes |
| 1.1 Effective communication: captures communication as a core clinical skill, in a number of forms, with patients/ families and colleagues. | 1.1.1 Taking time and listening to patients and family needs, concerns and responding (explaining, informing, reassuring, advocating). 1.1.2 Communicating effectively within nursing team, multidisciplinary team and outside agencies. 1.1.3 Asking for feedback and help impacts positively on delivering direct care. 1.1.4 Managing conflict and having good negotiation skills impacts direct care delivery. 1.1.5 Deliver on timely and comprehensive documentation. |
| 1.2 Delivering the basic elements of care: indicates importance of applying a holistic (bio-psychosocial) assessment and approach to practice. | 1.2.1 Provides holistic care. 1.2.2 Observing for physical and emotional changes. 1.2.3 Comprehensive assessment includes checking vital signs and understanding what they mean. 1.2.4 Delivers elements of fundamental care (i.e. Hygiene; shaved; toileted; mouth care; hydration). |
| 1.3 Ability to prioritise: highlights skills to plan and prioritise workload. | 1.3.1 Timely care. 1.3.2 Time management 1.3.3 Plans and prioritises care. |
| 1.4 Safe medication management: emphasises the importance of safe medication management. | 1.4.1 Applies pharmacological knowledge and safe and appropriate medication management. |
| Question 2. What are the nursing staff perceptions of their professional responsibilities to deliver quality care? | |
| Theme | Sub-themes |
| 2.1 Compassionate and kind care: demonstrating compassion and kindness is critical for delivering quality care. | 2.1.1 Showing compassion in practice. 2.1.2 Treating patients as we want to be treated. 2.1.3 Providing small comforts for patient care. |
| 2.2 Respectful and dignified: emphasises quality nursing care maintains a patient's dignity and is respectful of their life's journey. | 2.2.1 Respectful care. 2.2.2 Care with dignity. |
| 2.3 Context-specific knowledge: nurses have to be knowledgeable and accountable for their care and decision making. | 2.3.1 Being accountable for your practice. 2.3.2 Having contemporary clinical knowledge. 2.3.3 Objective critical decision making. |
| 2.4 Time with patients: increased workload reduces the time with patients and negatively impacts on good quality care. | 2.4.1 Taking time with patients/families. |
| 2.5 Providing patients/families with effective health education: health education and literacy is an important component of quality care. | 2.5.1 Assessing patients’ level of health literacy. 2.5.2 Providing appropriate level of health education to patients/families. |
| 2.6 Having a supportive work environment: the right environment; equipment; supportive leadership and teamwork enable quality care. Includes staff caring for and helping each other. | 2.8.1 Having the right staffing levels and skill mix. 2.8.2 Supportive team leader/unit manager. 2.8.3 Having good role models/leaders to enforce expected standard of care. 2.8.4 Looking after yourself and your colleagues. 2.8.5 Working in a supportive multidisciplinary team. 2.8.6 Having the right equipment available and working. |
| 2.7 Applying evidence-based care: safe care is based on evidence integrated into policy/guidelines | 2.9.1 Applying hospital policies and procedures. 2.9.2 Regularly accessing Health service policies / guidelines |
Question One: The participants consistently identified a number of core skills required to deliver quality nursing care.
Theme one captured communication as a core clinical skill, in a number of forms, by listening, explaining, informing, reassuring and advocating, with patients/ families and colleagues as these participants explained:
“Listening to patients and getting family involved.” FG3
“Communicating with patients and the multidisciplinary team.” FG6
“…collaborate with others, e.g. social work, doctors etc. and knowing when it is most appropriate to do that.” FG8
Theme two focused on delivering the basic elements of care that incorporated the essential elements such as hygiene, nutrition and elimination management:
“… start the routine for the day brushing teeth, toileting, showering and sitting out of bed.” FG6
“Have they had their meal, or has it just been put down in front of them and out of their reach?” FG7
Themes also incorporated assessment, problem solving, prioritising and decision-making for the patients’ comfort and safety:
“Knowing what deterioration looks like is a core skill to have regardless of where you work and knowing how to escalate that, knowing your own scope and skills, and getting other people involved when you are concerned.” FG5
The participants highlighted skills to provide holistic care:
“See the patient beyond the condition they have come in with.” FG1
“Meeting the physical, emotional and spiritual needs of the patient.” FG2
Theme three incorporated the ability to prioritise workload, which required skills in planning and time management:
“Prioritised the important things, take the time where and when it is needed.” FG3
“Planning work tasks” FG7T
Theme four was safe medication management. Participants discussed the importance of being competent in their knowledge of medications and medication management:
Pharmacological “knowledge of medication, when to review, when to hold off or escalate.” FG3
Question Two: What are the nursing staff perceptions of their professional responsibilities to deliver quality care?
Question Two, theme one mentioned by participants as defining quality was providing compassionate and kind care, as these participants commented:
“Compassionate and partnered” FG5
“Compassionate, caring”FG1
Theme two emphasised quality nursing care maintains patient's dignity and is respectful of their life's journey:
“… respectful of patient choices” FG4
“Treating the patient with dignity and respect.” FG3.
Theme three highlighted that nurses must have contemporary clinical knowledge, be accountable for their care and have the ability for critical decision making.
“Clinical skills require continued education and contemporary best practice.” FG5
“Recognising changes and responding to deterioration” FG1
Theme four acknowledged the challenges of increased workloads that reduced time with patients, and getting the right staff mix. Both challenges negatively impacted on good quality care:
“Staffing levels, acuity of patients and skill levels.” FG6
Theme five brought in the importance of providing patients/families with effective health education and literacy skills:
“Understanding health literacy to provide information to the patient” FG3
“Educating our patients” FG5
Theme six highlighted the need for supportive leadership and teamwork:
“Quality of support, Team leaders/nurse unit managers makes a difference to being able to deliver quality nursing care.” FG2
“Respecting each other” FG7
Theme seven focused on evidence being integrated into organisational and professional policy/guidelines:
“Following policies and procedures” FG7
2.2 Second stage: Methods—Mapping and synthesis
The second stage involved mapping the focus groups themed data (Themes and sub-themes) against the 61 elements located across seven domains of the Healthcare Quality Framework. This process also enabled the research team to explore the usefulness of the framework to identify gaps related to nurses’ responsibilities for delivering quality healthcare which may then lead to targeted quality improvement initiatives.
To ensure inter rater reliability in the mapping process the team members met and discussed the Healthcare Quality Framework domains and elements definitions provided by
Oldland, Botti, Hutchinson and Redley, 2020
to enable consistency in the interpretation of the terms. Two team members independently mapped, compared and contrasted the information before coming together with the team to review the final synthesis (Table 2). The research team discussed any discrepancies and overlapping elements to gain consensus. This process provided a reliable and comprehensive exploration of the relationships between the quality healthcare frameworks validated domains/elements and focus group themes/sub-themes.Table 2Focus group themes mapped against the Healthcare Quality Framework domains.
| Domains | Focus group themes |
|---|---|
| 1. Management of the environment Definition: Encapsulates nurses’ responsibilities to maintain an appropriate, healing physical space in which a health care service is delivered. | Compassionate and kind care |
| 2. Promotion of safety Definition: Refers to nurses’ responsibility to provide care that minimises risks and harm to themselves and service users. It avoids injuries to patients from the care that is intended to help them. | Safe medication management |
| 3. Evidence-based practice Definition: Involves giving consideration to the best available evidence; the context in which the care is delivered; client preference; and the professional judgement of the health professional. | Applying evidence-based care |
| 4. [Medical and] technical competence Definition: Refers to the discipline and context specific knowledge and psychomotor skills registered nurses need to provide quality healthcare. | Ability to prioritise Context specific knowledge |
| 5. Person-centred care Definition: Nursing care that takes into account the preferences and cultures of individual service users and their communities. Nurses have a responsibility to respect and respond to individual needs. | Respectful and dignified Delivering the basic elements of care Providing patient/ family with effective health education Applying person-centred care |
| 6. Positive interpersonal behaviours Definition: Refers to the communication skills, team behaviours and personal attributes that promote safe and quality healthcare. | Effective communication Having a supportive work environment Time with patients |
| 7. Clinical leadership and governance Definition: Refers to registered nurses’ behaviours that provide direction and support to clients and the healthcare team in the delivery of patient care. Nurses share accountability to patients and the community for assuring the delivery of health services that are safe, effective, high quality and continuously improving. |
Oldland, Botti, Hutchinson and Redley, 2020
.All but two of the focus groups’ sub-themes were able to be matched against the 61 elements under the seven domains. The two sub-themes that were unable to be matched to specific elements were: having the right equipment at the right time and; regularly accessing health service policies and procedures.
Domain four, (Medical and Technical Competence) (
Oldland, Botti, Hutchinson and Redley, 2020
, p.155), lacked clarity for the authors as it was considered to be too close to the Australian Medical Boards term ‘medical practice’ when discussing expectations of doctors. In response, the authors considered ‘technical competence’ only. The authors also had some difficulty in deciding where to place core nursing skills (i.e. mouth care, pressure injury prevention) as they were considered technical skills, but they also were important for person-centred care. It was considered that these core skills were best captured within the Healthcare Quality Framework's ‘Person-centred care domain’ (Oldland, Botti, Hutchinson and Redley, 2020
, p.156). The focus group themes were often interconnected across the domains, however, the definitions and elements under each of the domains were useful to guide the mapping within this framework, though the term ‘medical’ remained problematic.The domains most widely reflected in the focus group discussions were Person-centred Care and Positive Interpersonal Behaviours (
Oldland, Botti, Hutchinson and Redley, 2020
, p.156). ‘Compassionate and kind care’ was a main theme of all the focus group discussions and was eventually mapped to the domain Management of the Environment (Oldland, Botti, Hutchinson and Redley, 2020
, p.155), that included the element of patient and family comfort. The domain: Promotion of Safety (Oldland, Botti, Hutchinson and Redley, 2020
, p.155) had surprisingly only one component of the focus group discussions mapped to it, which was ‘safe medication management’. This was the same for the domain: Evidence-based Practice (Oldland, Botti, Hutchinson and Redley, 2020
, pg. 155) with only one focus group theme aligned: ‘applying evidence-based care’. Personal Interpersonal Behaviours had three themes located ‘effective communication’, ‘having a supportive work environment’ and ‘time with patients’.The final domain: Clinical Leadership and Governance (
Oldland, Botti, Hutchinson and Redley, 2020
p.157) had no themes matched against the specific elements, though mentorship and unit-based leadership was mentioned and had been coded within the ‘having a supportive work environment theme’.3. Discussion
The focus group data demonstrated that nurses perceived that quality care was focused predominantly on their responsibility and core skills to deliver person-centred care within their unit/ward. The current literature reflects the nurse participants’ perceptions on responsibilities related to effective communication (
Matinolli, Mieronkoski and Salantera, 2020
; Pentecost et al., 2020
; van Belle et al., 2020
), objective critical decision making (Feo, Donnelly, Athlin and Jangland, 2019
; Meehan, Timmins and Burke, 2018
), medication safety (Matinolli, Mieronkoski and Salantera, 2020
; van Belle et al., 2020
), and providing basic elements (fundamental aspects) of care for patient comfort (Pentecost et al., 2020
; Parr, Bell and Koziol-McLain, 2018
; van Belle et al., 2020
).The professional responsibilities identified by the nurses that met all of the elements in the Positive Interpersonal Behaviours domain of
Oldland, Botti, Hutchinson and Redley, 2020
Healthcare Quality Framework, are attributes identified in the Practice Standards and codes of the Nursing and Midwifery Board of Australia 2016
, the health care quality, safety (Feo, Donnelly, Athlin and Jangland, 2019
; Jangland et al., 2018
; Pentecost et al., 2020
) and professionalism (Cusack, Drioli-Phillips, Brown and Hunter, 2019
) literature, in particular dignity, respect, compassion and the capacity for self-reflection. However, to enable these responsibilities for quality care to be met nurses identified that they required: sufficient staffing based on acuity and not numbers (Kowalski et al., 2020
), supportive clinical leadership (Pentecost et al., 2020
; Richards and Borglin, 2019
) and access to ongoing education. These findings are consistent with the work of Cusack et al., 2016
where a number of environmental and relational factors were identified that support nurses’ resilience and ability to deliver safe, patient-centred care. The environmental factors include patient allocation, staffing levels, access to policies and equipment and opportunities for continual practice development (Cusack et al., 2016
).Of note, there was very little mentioned by focus group participants of their wider responsibilities to influence change within the health care system. These responsibilities include initiating wider health system quality improvement strategies, understanding and incorporating research, risk identification and management. The identification of and participation in initiatives that improve quality of nursing care, including research, are elements mentioned within the regulators registered nurse Practice Standards (
Nursing and Midwifery Board of Australia 2016
). It was interesting to note that managing environmental factors such as noise, lighting and ensuring clean and tidy wards/units were not mentioned by participants as affecting patients’ quality healthcare. The focus on quality healthcare within a unit/ward suggests that the workplace structures and processes may not enable nurses to have the time to be proactive, or the organisational knowledge to drive system change.This study has implications from an organisational perspective in considering how nurses are supported in their broader development as professionals to create the capacity to see the bigger organisational picture, and influence the health system to enable the delivery of nursing quality patient-centred care. Nurses new to the profession or to a health service environment initially focus their responsibility on the core skills and knowledge required to deliver quality care to their patients. However, once nurses have orientated themselves to their ward/unit environment, the healthcare service could consider what organisational and professional structures and processes are in place to develop nurses’ understanding of their broader health system responsibilities that ultimately improves quality care, enhances patients’ experiences and satisfaction with care.
The Healthcare Quality Framework (
Oldland, Botti, Hutchinson and Redley, 2020
) offers a useful tool to provide a broader reflection on nurses’ responsibilities for quality care and areas for improvement initiatives. Due to the interconnectedness of the focus groups’ themes it was at times unclear which domain best reflected the intent of the nurses’ views. This is where the elements were useful in assisting with the interpretation. It is noted that since this quality improvement project commenced further work has been published by Oldland et al., 2021
to “develop and psychometrically test a comprehensive instrument, the Nurses’ Responsibilities in Healthcare Quality Questionnaire (N-RiHQQ), to measure nurses' perceptions of their roles and responsibilities related to healthcare quality” (Oldland et al., 2021
, p.525).A limitation of this study is that the health service where the project was undertaken has its own workplace culture, which may affect the generalisability of the findings. However, the gap analysis using the Healthcare Quality Framework provided a useful process and point for discussion that can be considered in a range of health care settings within Australia and internationally, relevant to the different workplace cultures.
4. Conclusion
The outcome of mapping the focus groups’ main themes and subthemes against the domains and elements of
Oldland, Botti, Hutchinson and Redley, 2020
Healthcare Quality Framework highlighted that the nurses were very focused on their delivery of quality care to patients/families within their unit/ward, but did not identify how they can have a broader impact on the health service system for the delivery of quality care. This raises the suggestion for a quality improvement initiative that fosters organisational support to mentor nurses through their understanding of their broader responsibilities across all of Oldland, Botti, Hutchinson and Redley, 2020
domains of the Healthcare Quality Framework. This is consistent with nurses’ professional obligations in a regulated profession. A specifically designed initiative could be developed, embedded and evaluated within a sustainable mentorship or clinical leadership program, accessible to all nurses after their transition year.Authorship contribution statement
Study design: Cusack L; Thornton K; Brytan J.
Data collection Cusack L; Brytan J.; Thornton K
Data analysis: Cusack L; Brytan J.; Thornton K
Manuscript writing: Cusack L; Thornton K; Brytan J.
Ethical statement
This is a quality practice improvement project: Health Service's Quality Improvement Register (Number 3582) and Letter for Publication Approval, Central Adelaide Local Health Network Human Research Ethics Committee; Approved- December 20th 2021; Reference 15873. Issues concerning informed and free consent and confidentiality are addressed in the paper.
Conflict of interest
None.
Acknowledgements
The authors acknowledge the contribution of nurses who took the time to participate in this study and the Nurse Unit Managers who supported staff to attend the focus groups. The authors also acknowledge Dr Elizabeth Oldland for permission to use the Healthcare Quality Framework in this study.
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Article info
Publication history
Published online: July 22, 2022
Accepted:
July 9,
2022
Received in revised form:
April 18,
2022
Received:
January 11,
2022
Identification
Copyright
© 2022 Australian College of Nursing Ltd. Published by Elsevier Ltd.
