Patients Perception of Care Under Primary and Team Nursing

Knowledge, practice and faith on Total Quality Management principles among workers in the Health Care System: evidence from an Italian investigation

BACKGROUND

The implementation of Total Quality Management (TQM) principles in the sanitary field, in order to be effective, requires a radical change in management practice as well as the organizational culture and its philosophy. The need to monitor such a transformation emerges too.

OBJECTIVES

This study surveys how well TQM principles are known and understood by health care professionals from the employees' point of view and the factors affecting it.

RESEARCH DESIGN AND SUBJECTS

The Health Care System in Trieste was surveyed.

MEASURES

The Total Quality Test was used, a novel and quick instrument aimed at routine assessment of the penetration and interiorization of TQM principles within the health care structure.

RESULTS

Direct exposure to public, job role and time spent working within the same structure have been proved related to the penetration of TQM principles, whereas previous formative intervention did not prove to be associated with the penetration of TQM principles.

CONCLUSIONS

The implementation of a quick and simple instrument to monitor the TQM implementation highlighted several critical areas for intervention.

Including the provider in the assessment of quality care: development and testing of the Nurses' Assessment of Quality Scale - acute care version

This study was designed to develop a psychometrically sound measure of nurses' evaluation of patient care delivered. The Nurses' Assessment of Quality Scale-Acute Care Version (NAQS-ACV), derived from the qualitative interviews of acute care nurses, was initially 138 items formatted as a Likert-type scale and administered to 1272 nurses from 7 acute care hospitals. After analysis, the scale was reduced to 77 items contained in 8 factors. Reliability estimates for the factors ranged from 74 to 94.

Effects of resident-oriented care on quality of care, wellbeing and satisfaction with care

In a resident-oriented care model applied in nursing homes, the residents are assigned to primary nurses. These primary nurses are responsible for the total care of the residents assigned to them. The purpose of the present study, using a pretest, post-test and control group quasi-experimental design, was to evaluate the effects of the implementation of resident-oriented care on the following aspects of quality of care: coordination of care, instrumental aspects, expressive aspects, resident wellbeing and satisfaction with care, and family satisfaction with care. The study was carried out on somatic and psycho-geriatric wards in three nursing homes in the Netherlands. Data were collected by questionnaires, interviews and observations. The results of the study showed that the intervention was partly successful in the experimental group. Some aspects of the resident-oriented care model were not clearly evident. Moreover, the effects on quality-of-care aspects were limited. The results revealed that the 'coordination of care' increased on half of the experimental wards. Furthermore, there was an indication that 'expressive aspects' changed in favour of the experimental wards. The implementation of resident-oriented care had no effect on resident wellbeing and satisfaction or on family satisfaction. Finally, the results are discussed in the light of some methodological limitations that often go together with intervention studies in the real world.

Perceptions and experiences of primary nursing in an ICU: a combined methods approach

With the introduction of the Patient's Charter, greater emphasis has been placed on 'named nursing' (Department of Health 1991). While there is much literature extolling the benefits of this method of delivering care to patients (Reed 1988; Manley 1989; Macguire 1991); there is a dearth of empirical studies exploring primary nursing in an adult intensive care unit (ICU). In addition, little is known about how nurses feel about being a 'primary nurse'. The aim of this study was to determine qualified nurses' perceptions and experiences of the effect of primary nursing on patient care in an intensive care environment (ICU) and to explore nurses' experiences of being a primary nurse. This study was carried out in an ICU in Northern Ireland. Primary team nursing was the system of organizing care within this unit. This system consisted of teams of 'primary' and 'associate' nurses. A total of 65 qualified nurses were surveyed. Sixteen nurses took part in focus group interviews. A combined methods approach comprising a questionnaire and focus group interviews was employed for the study. Part one of the questionnaire provided data on professional and demographic details. Part two facilitated nurses to elaborate on their feelings and perceptions of the concept of primary nursing. The focus groups facilitated in-depth exploration of the respondents' personal feelings and experiences about their role as a primary nurse. The data obtained from the two-part questionnaire were analysed using descriptive statistic and content analysis. The data obtained from the focus groups were analysed using content analysis and the development of emerging themes. Analysis of the data revealed that the nurses' views were similar to those highlighted in the existing literature. Nurses perceived primary nursing to relate to the responsibility for the care of one patient, from admission to discharge with the primary nurse assessing, planning, implementing and evaluating care and the associate nurse assisting in the delivery of this care. Thus, continuity of care was seen as the major advantage of primary nursing. The findings, however, suggested that further teaching on the concept of primary nursing was required. In addition, many of the nurses admitted they experienced considerable stress, particularly in relation to their close proximity over a long period of time, with patients and their relatives. This is an important finding and highlights the need for primary nurses in ICU to have the opportunity (in some instances), to be relieved of their responsibility for a named patient, thereby reducing some of the potential for stress. It is acknowledged that the findings of this study may not be generalized beyond the identified sample. Further empirical studies exploring nurses' perceptions and experiences of primary nursing in an ICU are therefore needed.

The use of patient perceptions in the evaluation of health-care delivery systems

OBJECTIVES

Patient perceptions are increasingly used to measure quality of care in a diversity of health-care delivery settings. The goals of this article are to review the current use of patient perceptions and to review what is known about the sensitivity of patient perceptions for discerning variations in care across delivery systems.

METHODS

This article first provides a rationale for using patient perceptions to evaluate delivery systems and reviews proposed frameworks for measuring perceptions. It then reviews illustrative studies that have used patient perceptions to compare delivery systems or that have examined associations between patient perceptions and other health-care indicators.

RESULTS

Although the results of these studies suggest some general relations between patient perceptions and characteristics of delivery systems, findings are often inconsistent across individual studies. These inconsistencies may be related to several potential methodological limitations, including failure to account for the impact of patient mix, ceiling effects of patient responses, nonresponse bias, differences in data collection methods and timing of surveys, use of proxy respondents, and differences in survey instruments.

CONCLUSIONS

The discussion concludes with five conceptual challenges and recommendations for further research: (1) to establish the sensitivity of patient perceptions for discerning differences across delivery systems; (2) to establish relations between alternative frameworks for measuring patient perceptions; (3) to standardize the measurement of patient perceptions; (4) to define optimal ways of presenting patient perceptions data to users; and (5) to broaden the "patient" populations in which perceptions of care have been measured.

Survey and critique of studies related to unlicensed assistive personnel from 1975 to 1997, Part 2

This article is part 2 of a descriptive integrated review of research on the use of unlicensed assistive personnel in nursing. Part 1, published last month, described the methods used to find and to critique 29 research articles; it included the conceptual model and the variables identified in the studies. Part 2 presents a synthesis of the 29 studies data conclusions, implications and recommendations.

Survey and critique of studies related to unlicensed assistive personnel from 1975 to 1997, Part 1

This descriptive integrated review of research on the use of unlicensed assistive personnel in nursing is presented in two parts. In this issue, part 1 describes the methods used to find and critique research related to unlicensed assistive personnel in nursing. It includes the conceptual model and findings related to the variables studied. Part 2 of this review, which is scheduled for publication in the next issue, will present research findings, conclusions, and recommendations.

Primary nursing and quality of care: a Dutch study

In an 850-bed Dutch hospital a study was carried out to compare the quality-of-care scores of a Primary Nursing group and a lagged experimental group. Process as well as outcome aspects of quality of care were investigated. The study consisted of three measuring moments: one pre-intervention at t1, March 1992, and two post-intervention moments at t2, November 1992 and t3, May 1993. The intervention was formed by the implementation of Primary Nursing in two experimental units after t1; this is the experimental group. After t2, Primary Nursing was also implemented in the three control units; this is the lagged experimental group. The process aspects of quality of care were covered by three dimensions: coordination of care, instrumental aspects of care and expressive aspects of care. The outcome aspects of quality of care were measured by evaluating four patient variables: self-care, initiative, patient stress and patient satisfaction. ANOVAs were used to test for significant differences between the experimental and lagged experimental group. The only significant difference in favour of the Primary Nursing group was found on the variable instrumental aspects of care. On the other variables no expected changes were observed. Finally, the implications of the findings are discussed.

Development and validation of scales to measure organisational features of acute hospital wards

In order to make comparisons between wards and explain variations in outcomes of nursing care, there is a growing need in nursing research for reliable and valid measures of the organisational features of acute hospital wards. This research developed The Ward Organisational Features Scales (WOFS); each set of six scales comprising 14 subscales which measure discrete dimensions of acute hospital wards. A study of a nationally representative sample of 825 nurses working in 119 acute wards in 17 hospitals, drawn from seven Regional Health Authorities in England provides evidence for the structure, reliability and validity of this comprehensive set of measures related to: the physical environment of the ward, professional nursing practice, ward leadership, professional working relationships, nurses' influence and job satisfaction. Implications for further research are discussed.

Management review of nursing systems

This paper describes the systems of nursing operating at a major cancer centre in the United Kingdom. The review was undertaken over a period of 8 weeks and 11 wards were included. The systems being implemented were primary nursing, team nursing and patient allocation. Methods of enquiry included questionnaires, non-participative observation and interviews. The results of the review found the nursing systems to be at various stages of implementation, and that in reality, not all wards were operating the system they said they were. A pragmatic mixture of team nursing and primary nursing as described by Hegyvary (1982) was being practised on some of the wards. The report makes recommendations for change, and concludes by discussing the future implications for cancer nursing at the centre.

Measuring patients' satisfaction with nursing care

Assessing patients' satisfaction with the care they receive is assuming greater importance and satisfaction with nursing is no exception. The kinds of study in which patient satisfaction has been used as an outcome are considered and show the range of conceptualizations and the general lack of rigour in its measurement. It is argued that research methods are often flawed by using inappropriate measures and greater care is warranted in their selection. Where appropriate measures do not exist, only then is the costly process of developing new assessments warranted. Some of the necessary steps in arriving at reliable and valid measures of patient satisfaction are discussed in the context of asking particular research questions.

Can patients evaluate the quality of hospital care?

We have found that patients have distinct opinions about many components of hospital care, but that little recent work has identified those components important to today's patients in the United States. Investigators have constructed reproducible scales to obtain evaluations. Patient evaluations of the interpersonal features of hospital care are influenced by interventions that physicians or nurses identify as "higher" quality of care. We do not know if patient reports and ratings of specific aspects of care accurately reflect the effects of hospital care on health outcomes--the quality standard that public agencies and payers may consider the most important. However, patient evaluations of nursing care and medical care are independently related to patients' overall satisfaction, overall assessments of quality, and intentions to recommend and return to the same hospital. More studies are needed to clarify whether other components of hospital care also contribute to these ratings and intentions and, if so, how much. Nonresponse bias affects patient surveys, making patient ratings of care in each sample more favorable than the population mean; we do not know how this affects conclusions of surveys that compare hospitals or treatments. Few studies have compared how different methods affect the reproducibility and accuracy of patient reports and ratings. Practical issues may be the most important obstacles for users of patient ratings, particularly regarding whether potential users will be able to interpret results and accept them. Finally, no comprehensive instrument or survey method in the published literature has been tested enough to be recommended as a reproducible, accurate, and interpretable quality measure: a few do, however, appear worthy of further testing.

Outcomes of nursing care: the case of primary nursing

Using primary nursing as a 'case study', this paper reviews research literature which attempts to measure the effectiveness of a mode of nursing using outcome measures. Previous research, it is argued, is hampered by a lack of conceptualization of structure and process and inadequate research design, with consequent uncertain findings. A shift in emphasis is suggested from an evaluation of global concepts, such as primary nursing, to an identification of the features of structures and processes of nursing care which interrelate with patient and nurse outcomes. For this purpose, multivariate research design and investment in methodological research are recommended.

The work style of students of mental health nursing undertaking the Project 2000 schemes of training: a logical analysis

The work methods of students of mental health nursing are analysed to see which are best suited to facilitate the central educational aims of the Project 2000 schemes of training. Supervised primary nursing is found to be best because it engenders a professional cognitive style and a heightened sensitivity to the empirical, research-based culture. It is argued that team nursing causes, in its practitioners, a bureaucratic cognitive style, which acts as a structural constraint upon the learning and mastery of the process skills advocated by the Project 2000 authors.

Nurse-patient interaction in primary nursing

The purpose of this study was to examine the nurse-patient interaction. During the study the nursing staff adapted primary nursing and changed multiple level communication model into a simplified one. The data were collected in the medical ward using nonparticipant observation both before the implementation of primary nursing and after. The content of recorded interactions were analyzed according to the initiator, type of communication, level of interaction and topic of discussions. Nurses engaged in more interactions and the quality of the nurse-patient interaction improved in some extent after the implementation of primary nursing. Interaction was evidently more profound, reciprocal information exchange. Only slight differences is seen in the patient's participation, the topics of discussions and in the activities during interaction.

Primary nursing: is it worth it?

In this paper a small sample of the massive, and largely North American, primary nursing literature is reviewed and three categories of writing identified: (1) descriptive literature, (2) literature of formative evaluation, and (3) literature of summative evaluation. The descriptive literature is examined in an attempt to decide whether primary nursing is worth trying. The literature of formative evaluation is then explored in order to determine whether the process of implementing primary nursing is, in itself, worthwhile. Finally, taking staff satisfaction, patient satisfaction, quality of care and the cost of primary nursing as the foci of evaluation, the literature of summative evaluation is considered to ascertain whether the outcomes of primary nursing merit the investment. The answers to each of these three questions of worth, posed by the three categories of writing, appear to be respectively a definite, a probable and tentative 'yes'.