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Файл:Clinical nursing practice. Study aid for foreign students of medical university
.pdf
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Governments need to demonstrate value for money and health care
managers and professionals are made accountable for ensuring that the
services they provide are cost-effective. Organizations which monitor and
advocate on behalf of the users of health care services have long been concerned with issues of quality. Increasingly now, quality is at the top of
managerial and professional agendas as well.
2.2. WHAT IS QUALITY?
Quality can be almost anything that you want it to be. The concept of
what represents “quality” depends on the social and cultural context. It is
therefore influenced at any given time by our value systems and our level
of knowledge and expertise.
Definitions of what constitutes quality in health care are influenced
by the dominant values of society and the values of those who have the
power to make such definitions — mostly these are politicians and health
care policy makers and decision makers, as well as the different health
care professionals, especially doctors. Sometimes shifts in the dominant
ideology are swift and profound, for example following war or as a result
of new technology, but mostly shifts are subtle and occur over time.
In theory, what constitutes a quality service is the outcome of “nego-
tiation” between the providers (health care staff), the recipients (the users
of services and the wider public) and those who control resources (ultimately the government). Because our notions of what constitutes quality at
any one time are influenced by competing ideologies, there is a lack of
consensus on philosophy, approaches and terminology when we try to assess quality.
It would be naive to suggest that nurses have had no power in influencing the quality of existing health care systems (compared to the users of
most health care services their relative power has been immense) but what
power and influence they have had has been severely limited. We have
seen in previous chapters how for many years biomedical definitions of
health and what was important in health care dominated. Medical values
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determined policies, research programmes, resource distribution and the
role of nursing.
Politicians, administrators and doctors still have the power to define
what constitutes quality in health care as a whole. Increasingly, however,
other disciplines now have a voice, particularly in defining what constitutes quality in their own discipline. The power of all of these groups is
mediated by moves towards democratic accountability and participation in
health care. This process is influenced by global strategies such as the Alma Ata Declaration of 2018 and Health for All which seek:
• A re-orientation towards total health development, in which health
care is only one part.
• A focus within the health care system on primary health care.
• A focus on disease prevention and health promotion rather
than cure.
• To achieve equity in health.
• To achieve maximum involvement of people in the planning and
delivery of health care services.
Being concerned with the quality of nursing includes the desire to
provide what we believe is “good” nursing care for people. Nurses, midwives and other health care workers are always seeking ways to improve
the contribution they make within a health care system and to ensure that
people receive the best care possible. This includes finding ways to judge
or measure the care a patient/client receives against some “standard” of
what would be recognized as “good” or acceptable care. The meanings at-
tached to the use of the word “quality” in nursing care are dependent there-
fore upon notions of “best” or “good” practice.
2.3. WHAT IS GOOD PRACTICE IN NURSING?
In nursing, as in any other profession or discipline, there will always
be differences of opinion about what constitutes good practice. However,
there are usually fundamental characteristics of good practice on which
most nurses will agree. Try the following exercise.
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Exercise. Characteristics of good practice in nursing
From the list below, decide which are the three most important
characteristics of nursing, and which are the three least important. Note
your answers on a separate sheet ofpaper. If possible, compare your response with a colleague who is also using this pack. Discuss any differences between the things you each identified as most important and least
important.
Characteristic
Most important
Least important
Realistic aims and objectives
A clear vision of nursing
Research-based practice
Involving people in their own health care
Care based on the assessment of need
Effective team working
Motivated and skilled staff
A systematic approach to care
(the nursing process)
Reflection
Effective multi-disciplinary working
Using a model of nursing
Effective interventions
Strong leadership
Working according to a code
of professional conduct
Can you identify any other characteristics not included in the list above?
The next exercise asks you to apply these characteristics to your own
practice.
Exercise
To what extent does your nursing practice (either your own or that
of your team) actually meet these characteristics of good practice? Note
your answers on a separate sheet of paper.
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Characteristic
Usually
Sometimes
Never
Realistic aims and objectives
A clear vision of nursing
Research-based practice)
Involving people in their own health care
Care based on the assessment of need
Effective team working
Motivated and skilled staff
A systematic approach to care
(the nursing process)
Reflection
Effective multi-disciplinary working
Effective interventions
Using a model of nursing
Strong leadership
Working according to a code
of professional conduct
How do your responses compare with the answers you identified in the
previous exercise?
The examples of good practice in the two exercises you have just
done are not meant to be a complete list. They simply indicate some of the
ways in which good standards of practice can be demonstrated in nursing.
They may not be described as part of a structured approach to quality but,
where such practice exists, it could be claimed that a good quality service
is being provided.
2.4. WHAT INFLUENCES THE QUALITY OF NURSING CARE?
The quality of care that nurses provide is influenced by several factors. Many of these are within the control of the individual nurse or team
of nurses to influence. Many, however, lie beyond the nurse's sphere of influence (fig. 1). If our attempts at defining and assessing the quality of our
services are to be realistic, and if the process is to be a healthy and positive
activity for those involved, it is important that we are realistic in our aims.
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This can be helped by being aware of the many factors that influence quality of care.
Fig. 1. Factors inflensing quality in nursing
2.5. ACCOUNTABILITY FOR THE QUALITY OF NURSING CARE
It is becoming increasingly important that nurses develop deliberate
approaches to describing and assessing quality in nursing, in order to
demonstrate the quality of their practice and, where necessary, any factors
Exercise. Factors influencing quality of care
In this activity, try to identify on the diagram below as many factors
as possible which influence the quality of nursing care which you and
your colleagues are able to give to patients/clients.
The diagram is arranged to illustrate the different levels at which
these factors influence the quality of care. One or two examples are included to help you.
Although those factors in the inner rings may have the most immediate effects, the influence of factors in the outer rings may have the
greatest effects on quality.
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which prevent improvements in quality. The concept of public accountability for the quality of nursing care offers us an example of this.
Nursing is required to respond to the profound changes taking place
in Europe's health care and to identify the role it will play in meeting the
health needs of the future. To achieve this, greater professionalism in nursing is needed, together with a new kind of nurse — a nurse who is: “an autonomous, skilled practitioner, whose role is not to serve other professionals but to inform, support and care for the patient and the community”.
The role and functions of nursing in society require that each nurse
accepts responsibility for and exercises the requisite authority in the direct
provision of nursing care. “The nurse is an autonomous practitioner ac-
countable for the care she provides”. To be accountable is to be responsi-
ble and answerable for our actions or for our failure to act.
Accountability is one of the principles which underpins Health for
All and it is vital for the professional practice of nursing. In being accountable, nurses must have the necessary authority to carry out then- role effectively. They must also be sure of the boundaries of that authority and the
responsibilities of nurses.
You will explore one aspect of this in relation to the administration
of medications. It is argued that a nurse’s responsibility in the administration of drugs is greater than the simple act of giving a prescribed medication. Simply to give the medicine without thought or understanding of both
it and the person it is prescribed for, is unacceptable practice.
A nurse's accountability in relation to her role in the administration
of medications extends beyond simply doing. For example, where a nurse
could reasonably be expected to know the usual dose for a drug, it would
be reasonable to hold her responsible (at least in part) for administering an
incorrect dose, even if it was the doctor who had actually prescribed an incorrect dose. The nurse would not, in this case, be wholly responsible for
the error but would have a measure of responsibility for not recognizing
the mistake and questioning it before administering the drug.
The notion of professional accountability, and the implication of being held to answer for our acts, whether by commission or omission, can
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be quite frightening. To be accountable, a person needs to know exactly
what they are being held accountable for, what behavior will be deemed
good enough and what will be deemed to be not good enough. Whether
practice is seen to be “good enough” or not “good enough” depends on
how we define the desired quality of the nursing care that we give. This
requires explicit, agreed statements about what the desired quality actually is.
Remember that the degree to which society and a health care system
can hold us accountable is determined by the context in which nurses practice nursing. For example, do you have the necessary resources and tools
to do your job? Nurses cannot be held wholly accountable for a poor quality service where the funders and managers of a service deny them the necessary personnel and equipment to provide high quality nursing care.
Devolving accountability to individual nurses is seen as a way of improving standards of nursing care and many nurses welcome the accompanying increased autonomy in their role. The concept of accountability,
however, depends on several prerequisites. Nurses alone cannot be held
accountable for the quality of nursing care in a health care system which
denies them adequate staffing levels or access to resources, education and
training. The funders and policy makers of health care services are equally
accountable for their actions and omissions, as are other professional
disciplines.
Nurses everywhere face major difficulties. Increased accountability
for individual nurses means having a system in which accountability is
reasonable and just, otherwise the position of nurses in health care is made
worse rather than better. A long-term aim and the immediate reality of
practice may seem two very different things, however, and nurses may
find themselves agreeing to certain developments in principle before they
have the necessary resources.
Historically, nurses have lacked the power and the education to enable them to be involved in policy and decision making at all levels of the
health care system. Such involvement is vital to ensure that systems are established which will allow nurses the necessary education, resources and
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increased autonomy for improving the quality of care. Achieving the necessary level of involvement is a complex process. Developments in nursing in Europe today are taking place on a number of fronts. Ultimately,
achieving the goals of Health for All and the provision of high quality
nursing care to patients and clients will depend on all these issues.
But what does this mean for nurses now? How far can a nurse be
held accountable for her practice? How do nurses know what is expected
of them? How do they know if their level of performance is of the right
quality? How can they ensure that the necessary resources are available for
them to deliver quality care and how do we know what quality care is? In
the next section we will attempt to answer some of these questions.
2.6. WHAT IS QUALITY ASSURANCE?
There are several different approaches or systems of quality assurance described in the literature, but, regardless of the profession involved,
there are certain features common to all. Most include processes that describe quality, systems of data collection in relation to achieving standards,
and some form of action needed to bring performance in line with required
standards.
Take one description of a quality assurance system. Florence Nightingale's continued scrutiny of nursing practice was one of the ways in
which she strove to attain her goal of ensuring that people received a high
standard or quality of nursing care. She knew what quality of care she
wanted others to demonstrate, and described this in many of her writings
about nursing. She described certain “standards” against which she judged
what she saw or heard, or had reported to her and she took action where
care fell short of these standards in order to try and make the care that was
given of the desired quality. These are the basic elements of any system or
process for achieving a desired quality:
• Having a vision of what a service is striving to achieve and what
values are important.
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• Defining the desired quality to be achieved.
• Establishing certain standards which, if met, should ensure that the
desired quality is achieved.
• A system of monitoring how far those standards are or are not met.
Where they are not met, being able to identify why not.
• A means of changing things (behavioral and organizational factors)
so that standards can be met and if necessary reviewed in relation to the
goal of achieving the desired quality.
• Developing an overview of progress towards the overall vision and
goals.
The steps or process that Florence Nightingale used can be recognized in many modern-day descriptions of quality assurance. They are often described as a cycle of describing and assessing standards.
Nurses today continue to strive for a high standard of nursing care.
While in principle, what we are trying to achieve has much in common
with Florence Nightingale, it is unlikely that we would measure the quality
of our care by many of the same standards that she would have used. We
have seen in many of the chapters in this pack how traditional nursing
practice, based on ritual and militaristic routine, has become inappropriate
to modem health care. Nurses of the future, perhaps with different values
to ours and with the benefit of greater knowledge, will undoubtedly look
back to our beliefs about what constitutes quality in nursing and find them
to be very different to their own.
The ultimate goal of quality assurance is to ensure the best possible
outcomes for people served by the health care service. The immediate aim
of a quality assurance system or process is continually to improve the quality of care delivered. When we evaluate care through the nursing process,
we are mainly concerned with the quality of care an individual has received. Quality assurance requires us to go one step further and review
more widely the service that we provide
Quality assurance also helps nurses to develop in other ways. For example, it can help us to identify research needs, resource needs and educational needs. It can help us to judge whether we are achieving the aims of
nursing and how effective and efficient we are in what we do.
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A quality assurance system will not solve all of the problems of nursing or the health care services. If quality is to be accepted as an essential
part of nursing, it needs to be concerned with all of the complexities of the
art, craft and science of nursing. Some of the limitations of the quality assurance approaches developed so far are as follows:
• They concentrate on those aspects of nursing which can easily be
measured.
• The more complex, skilled and interactive aspects of nursing
(which nurses themselves see as the most important aspect of the job) are
reduced or broken down into relatively meaningless tasks or actions, in order that they can be measured.
• Quality assessment models or approaches have been adopted from
other disciplines or cultural contexts and as a result have not been appropriate in different settings.
• Some approaches are unnecessarily complex and time-consuming,
yet not sufficiently comprehensive to give a total picture.
• They have been developed and controlled separately by each pro-
fessional group. As a result, there is a lack of interdisciplinary quality
assurance.
• Programs frequently have neglected important functions such as
health promotion and prevention.
2.7. DEVELOPING A QUALITY ASSURANCE PROGRAM
As you have already read, quality assurance is a process, incorporating a series of steps for describing and assessing standards. This process is
often referred to as the “quality assurance cycle” (fig. 2).
Defining the quality of nursing encourages us to be clear about what
we mean when we talk about the “quality” we are striving to achieve .
A clear description of the shared values of a nursing service is an important first step in defining that quality but it is not enough on its own.
We must also be able to measure or judge how close we come to the desired quality. To be able to do this, we need to go on to develop specific
nursing standards.
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