hf. J. Mm.
Stud. Vol. 16, pp.65-72.
@Pergamon
Press Ltd., 1979. Printed in Great Britain.
CO204878/79/0301-C065%02CWO
Clinical research: translation into nursing practice JUNE T. CUDDIHY,
R.N., M.A.
College of Nursing, Seton Hall University, South Orange, New JerseyOlQ79, U.S.A.
One of the most significant ways in which we can improve nursing practice and the delivery of nursing care is to initiate research programs designed to evaluate these functions in individual institutions and agencies. It is through this process of analysis, documentation and evaluation of the nursing process in relation to patient outcomes that positive changes can be produced. However, it is widely recognized that a gap exists between reported research and its application in clinical nursing practice. This has been carefully documented by Notter (1973), Ketefian (1975) and others. All too often nursing research is conducted in an educational institution and published in a scholarly journal. This process does not assure that the findings will indeed be incorporated into nursing practice at the individual practitioner level. Furthermore, as greater portions of research programs become team research efforts, the interaction of team members may also serve to totally sustain continuation of a particular line of research without assuring its implementation in daily professional activities (Ackerman, 1976). It may be that the efficient translation of research findings into nursing practice at the individual practitioner level could be augmented by the use of other communication methods. This paper will describe a pilot study of nursing practice in which the proper communication of the findings had a significant and documented effect on nursing care. In this research project, we elected to study the potential impact of the evaluation of the quality of care on subsequent nursing practice in a single pediatric nursing unit of a hospital. Our purpose was to determine if nursing practice could be improved by the presentation of nursing audit results to the nursing staff of this selected unit. Particular attention was focused upon the methodical design in conceptualizing the research project. Both process and outcome audit tools were employed. These were based upon established audit instruments but were specifically tailored to evaluate the care provided to ambulatory, partial-care pediatric patients. The quality assurance for nursing care can be approached from various frames of reference such as structure, process and outcome. A strong case has been made for each of these frames of reference. 65
66
JUNE T. CUDDIH Y
Quality assurance has presented the nursing profession with an opportunity to define publicly the expectations consumers should anticipate from nursing and quality assurance criteria stated in terms of outcomes, i.e. alterations in the health status of the consumer, will help articulate these definitions. At the 1972 convention, the American Nurses Association (ANA) set, as one of its priorities, the promotion of peer review as a means of maintaining standards of care (Hauser, 1975). Two years later, the ANA Congress for Nursing Practice issued “Guidelines for Peer Review”. Considerable debate has focused upon whether patient care evaluation should be process-focused or outcome-focused (Donabedian, 1966, 1969). However, only an evaluation that encompasses both process and outcome has the potential for great impact upon accountability for quality of care (Deniston et al., 1968; Block, 1975). A number of interesting efforts have been reported in the recent literature attempting to evaluate nursing care for colostomy patients (Hilger, 1974), adults with congestive heart failure (Anderson, 1974), neurological patients (Taylor, 1974) and well babies (Long, 1974). Other more general papers have focused primarily upon methodology rather than specific diseases. They have studied counselling and written goal-setting (Dyer et al., 1975), retrospective audits (Rinaldi, 1975) and the development of further general audit instruments (Risser, 1975). Particularly valuable have been the instruments developed by Jelinek (1974), by Pfaneuf (1976) and that designed and field tested by Hausmann and Hegyvary (1976). These papers have delineated systematic patient-centered nursing audit methodology based upon the seven functions of nursing. These papers also illustrate the proper statistical analysis of these data. A recent paper has pointed out the further utility of these audit tools (Felton er al., 1976). In this publication, Felton reported the experiences of a large nursing service with deliberate planning for change to improve the quality of nursing care. “Quality assurance accompanies the acceptance of accountability for professional practice.”
Methods
Patients Two groups of 10 ambulatory partial care pediatric patients were randomly selected for the study. The first 10 were evaluated using both the process and the outcome audit instruments described below. The second 10 were evaluated subsequent to the staff presentation, using only the outcome audit instrument.
Audit instruments The process instrument used in this study was derived from that developed jointly by the Rush-Presbyterian-St. Luke’s Medical Center and the Medicus Systems Corporation (Hegyvary and Haussmann, 1975). This tool defines 6 objectives and 28 sub-objectives as representative of the nursing process. By use of the objectives and sub-objectives to define the nursing care process, a framework is provided within which the process of nursing care, however defined by a particular institution, could be evaluated. Patients are classified by intensity of illness and each criterion is classified according to the type or types of patient to which it would most likely apply: self-care, partial care, complete care and intensive care. In this study, our derived instrument consisted only of those criteria that were intended to apply to partial care patients. The outcome instrument used was the Pfaneuf Nursing Audit-a process-oriented
CLINICAL
RESEARCH:
TRANSLATIONINTO
NURSING
PRACTICE
67
outcome nursing audit consisting of 50 criteria (Pfaneuf, 1972). This audit provides a retrospective evaluation of the quality of care provided for individual patients as documented in the patient care records. Its basis rests upon the seven fundamental functions of nursing. Evaluation procedures Ten ambulatory pediatric patients requiring partial care were randomly selected from the population of a single hospital unit. Each patient and the patient record were evaluated using the two previously-described audit instruments to establish the current standards of nursing practice for that hospital unit. Strengths, weaknesses, omissions and other observations were tabulated in summary form. These data were then presented at a unit nursing staff meeting as an evaluation of current levels of practice. Recommendations were offered for alterations in care practices. Beginning with patients admitted at least 1 week after the presentation, another random sample of 10 ambulatory pediatric patients receiving partial care were selected and evaluated using only the Pfaneuf Nursing Audit technique. The data derived from this second audit were compared, using standard statistical methods, with that obtained earlier to determine if the level of nursing care provided had been altered after the staff presentation. Statistical calculations were performed using a programable Texas Instruments SR-56 microprocessor calculator using statistical programs provided by the manufacturer.
(a) Initial evaluation Evaluation of the total nursing care provided to the first group of 10 patients produced the patient scores shown in Table 1.
Table
I. Total process and outcome instrument
scores by patient
Patient
Process Outcome
instrument
(a)
instrument(b)
I
2
3
4
5
6
7
8
81.5
83.6
15.4
15.8
91.6
84.1
84.1
83.1
89
69.1
140.5
129
126
143
182
126
125
142
142
141.5 _.
9
10
a: scored as a percentage of positive values found b: scored as a raw score with a maximum possible total of 200
Examination of these total raw scores suggested that a generally high level of care was consistently provided to this patient group. However, closer examination of the raw data for individual segments and subsets of the tests revealed somewhat less consistency in the various subsets of nursing care from patient to patient. This is illustrated in Tables 2 and 3. From these data we see that while a generally high level of nursing care was provided to each patient and total patient scores fell within a relatively narrow range, there were some subsets from each instrument in which particularly high or low scores were noted and further refinement of the data analysis revealed inconsistent levels of practice between individual patients.
JUNE
68
T. CUDDIH
Table 2. Process instrument
Y
scores by subset
Mean (%)
Item
1.1
Patient
1.2
Data relevant
condition
1.4
Written
assessed admission
to hospital
nursing
care assessed on admission
care plan formulated
1.5
Nursing
2.1
Patient
care plan and medical plan coordinated
2.2
Need for physical
2.3
Need for physical
2.5
Need for activity
2.6
Need for nutrition
2.1
Need for elimination
3.1
Patient
oriented
3.2
Patient
extended
3.3
Patient
privacy and civil rights honored
3.4
Need for psychological-emotional
protected
taught
from accident comfort
and injury
f 17.85
55.43
-t- 10.53
0.19
31.4
? 18.02
0.579
72.5
t 24.86
0.343
0.249
+O
0
attended
16.61
lr 22.5
0.293
hygiene attended
65.68
f 14.23
0.217
37.5
k 48.95
I.31
71.5
-+ 22.92
0.32
30.0
+ 48.3
1.61
55.33
+ 23.89
0.448
66.15
f 15.68
0.237
and fluid balance
attended
attended
to hospital
on admission
social courtesies
3.4
Patient
3.6
Patient’s
4.1
Records document
patient
4.2
Patient’s
to therapy
6.1
Nursing
6.3
Clerical services provided
6.4
Environmental _
by staff
100
well-being
attended
response
in nursing
care process
care evaluated
follows prescribed
and support
standards
services provided
Item
I
Execution
11
Observation
of symptoms
111
Supervision
IV
Supervision
of physicians
*O
51.64
health maintenance
family included
Table 3. First set of outcome
instrument
0
? 14.04
0.212
73.32
+ 10.54
0.144
40.0
*
8.61
0.215
86.37
2 12.41
0.144
50.0
231.2
0.624
92.5
-+ 10.54
0.114
98.75
L 3.95
0.04
90.7
k 12.41
0.137
scores by subset
Highest possible score
Mean raw score
Standard deviation
Coefficient of variation
42
40.6
? 2.95
0.0727
40
32.8
k 5.53
0.169
of patient
28
19.2
t 4.92
0.256
of staff
20
3.9
k 3.84
0.984
20
10.1
k 4.33
0.429
32
25.5
I? 3.71
0.148
18
7.6
+- 4.12
0.621
V
Reporting/recording
VI
Execution
VII
Promotion
of nursing
orders & reactions
procedures
of health by teaching
High scores were achieved
in the following
areas:
(1) privacy and civil rights; of patient care; (2) documentation (3) (4) (5) (6)
Coefficient of variation
11.61
100.0
attended
reporting
Standard deviation
nursing reporting followed prescribed standards; clerical sefvice provided; patient protected from accident or injury; environmental and support services provided;
,
CLINICAL
RESEARCH:
TRANSLATION
INTO NURSING
PRACTICE
69
(7) execution of physician orders; (8) observation of symptoms and reactions. Low scores were observed for:
(1) written nursing care plan formulated; (2) need for activity attended; (3) (4) (5) (6) (7) (8) (9)
need for elimination attended; need for psychological-emotional well-being attended; patient’s family included in nursing care process; patient’s response to therapy evaluated; supervision of staff; reporting/recording; promotion of health by teaching.
inconsistent practices on an inter-individual patient basis (detected by unusually high coefficient of variation values) included the following items: (1) need for activity attended; (2) patient response to therapy evaluated; (3) patient orientation to hospital attended; (4) supervision of nursing staff; (5) promotion of health by teaching. (b) Presentation of initial findings to nursing staff All of the above data, supported by direct observation of practices on the hospital unit, was presented in a 1-hr nursing staff conference on the unit. Strengths, weaknesses and inconsistencies in nursing care practices were reviewed and discussed. Participants were encouraged to review their individual practice patterns. (c) Results obtained after presentation to Ten randomly selected patients who presentation were then evaluated for the outcome instrument. The scores achieved
staff had been admitted at least 1 week after this pattern of nursing care received, using only the are outlined in Table 4.
Table 4. Second set of outcome instrument Item
Highest possible score
scores by subset
Mean raw score
Standard deviation
Coefficient of variation
1
Execution
42
42
*O
0
II
Observation
of symptoms and reactions
40
39.4
I? 1.9
0.048
of physicians orders
III
Supervision
of patient
28
26.8
* 1.55
0.058
IV
Supervision
of staff
20
15.2
+ 4.73
0.311
V
Reporting/recording
20
19.4
k 1.26
0.065
VI
Execution
of nursing procedures
32
31.5
k 0.82
0.026
VI1
Promotion
of health by teaching
18
15.6
k 2.95
0.189
From a comparison of the data contained in Tables 3 and 4 we can see that a considerable elevation of total scores and a greater consistency in scoring within subsets or on an inter-
JUNE T. CUDDIHY
70
individual patient basis was observed for the second group of patients evaluated at a minimum interval of greater than one week after the staff review of the first set of observations. Statistical analysis of the difference in outcome instrument scores between the two groups of patients showed that the difference between the two groups was significant at the P< 0.0001 level using each of three standard statistical techniques: .z scores (one-tailed test), student’s t test and the chi-square analysis, using 9 degrees of freedom.
Discussion
Three major components of the nursing care system have a significant relationship to the quality of nursing care. These are: (1) the setting in which the care is provided; (2) the nursing process and (3) patient outcome (Lindeman, 1976). This small-scale study involving partial-care pediatric patients represented an attempt to evaluate aspects of the latter two of these components. Our approach followed the basic steps used in measuring quality of nursing care as outlined by Berg (1974): (1) define what should be present; (2) compare what should be with what is; (3) identify the gaps and take action. Validated rating tools were selected. Evaluations were performed and care defects identified. The investigator met with the staff to encourage corrective action. Thereafter a second outcome audit was performed to determine if any alteration had indeed occurred. Review of the process data collected on the first 10 patients prod,uced data similar to those observed by Haussmann et al. (1976) and by Jelinek et al. (1974) in a number of larger trials. Similarly, the evaluation of the first 10 patients using the outcome instrument produced a general level of results quite similar to those noted by Pfaneuf (1976). Thus we felt quite confident that the evaluation tools were being properly applied. Review of the initial process and outcome data revealed a number of care deficits. lnterestingly, the individual patient scores correlated (Pearson product moment method revealed a 0.55 correlation) with the scores achieved on the outcome audit instrument. Outcome
v7strument
scores by subset
- - First group -Second group ----Moxnum possible score
I
0
I
I
I
II
I Ill
I
I
lIL
P
Item group
I I!l
I m
CLINICAL
RESEARCH:
TRANSLATION
INTO NURSING
PRACTICE
71
The l-week minimum waiting period (before evaluating the impact of the staff conference) was adopted to enable the initial stimulatory effects of the presentation to settle out into a more consistent level of practice. However, the second group of 10 patients were entered into the study within a short time after the l-week period in order to minimize the likelihood of the entrance of any new variable such as staff changes, other educational influences etc. that might interfere with the interpretation of the observations. Comparing the two groups, outcome audit data, we found that a highly significant positive alteration in nursing care patterns had developed after the staff review of the data collected on the initial group of patients. Subsequent interview of several of the nursing staff involved indicated that there were several particularly valuable aspects of the manner in which the initial results were communicated to the staff that may have helped to produce the positive results observed. These included: (1) the growing acceptance of the nursing audit tool; (2) the investigator was familiar to the staff but had the stature and authority of a university appointment; (3) the initial results were presented in a non-judgemental manner and the staff was encouraged to review their individual practices; (4) the positive aspects, expressed in terms of improved patient care, were stressed throughout the study to allay suspicion about its objectives. These communications efforts may have played a significant role in assuring that the research project findings were incorporated into daily nursing practice. These data indicate that even small pilot studies involving modest numbers of patients on individual hospital units can potentially produce a significant impact upon nursing care practices in a hospital setting. We therefore recommend that additional studies along this line be performed to confirm the utility of this approach. Additionally, we recommend that the audit technique outlined in this paper may prove very useful as an easilyadministered quality control assessment tool in situations where it may be impractical to employ more complex and extensive techniques but where an audit tool would be useful to identify health care practices requiring improvement. References Ackerman, W. B. (1976) The place of research in the master’s program. Nun. Outlook 24,754-758. Anderson, M. I. (1974) Development of outcome criteria for the patient with congestive heart failure. Nurs. C/in. N. Am. 9,349-358. Berg, H. V. (1974) Nursingaudit and outcome criteria. Nurs. Clin. N. Am. 9, 331.335. Block, D. (1975) Evaluation of nursing care in terms of process and outcome. Issues in research and quality assurance. Nurs. Res. 24,256-263. Deniston, 0. L., Rosenstock, 1. M. and Getting, V. A. (1968) Evaluation of program effectiveness. Pub/. Hlrh. Rep. 83,323.325. Donabedian, A. (1966) Evaluating the quality of medical care. Milbank Meml. Fund. Q. BUN. 44 (part II), 166-206. Donabedian, A. (1969) Part I. Some issues in evaluating the quality of nursing care. Am. J. Publ. Hlth. 59, 1833-1836. Dyer, E. D., Monson, M. A. and Cape, M. J. (1975) Increasing the quality of patient care through performance counseling and written goal setting. Nurs. Res. 24, 138-144. Felton, G., Freverb, E., Galligan, K., Neil], M. K. and Williams, F. (1976) Pathway to accountability: implementation of a quality assurance program. J. Nurs. Admin. 6,20-24. Hauser, M. A. (1975) Initiation into peer review. Am. J. Nurs. 75.2204-2207. Haussmann, R. K. D., Hegyvary, S. T. and Newman, J. F., Jr. (1976) Monitoring quality of nursing care. Part II. Assessment and study of correlates. U.S. Dept. of Health, Education and Welfare, DHEW Publication No. (HRA) 76-7.
12
JUNE T. CUDDIHY
Haussman, R. K. D. and Hegyvary, S. T. (1976) Field testing the nursing quality monitoring methodology: Phase II. Nurs. Res. 15,324-331. Hegyvary, S. T. and Haussman, R. K. D. (1975) Monitoring nursing care quality. J. Nurs. Admin. 5, 17-26. Hilger, E. E. (1974) Developing nursing outcome criteria. Nuts. Clin. N. Am. 9,323~330. Jelinek, R. C. (1976) Methodology for monitoring quality of nursing care. U.S. Dept. of Health, Education and Welfare, Bureau of Health Manpower, Division of Nursing, DHEW Publication No. (HRA) 76-25, Bethseda, Maryland. Ketefian, S. (1975) Application of selected nursing research findings into nursing practice. Nurs. Res. 24, 89-92. Lindeman, C. A. (1976) Measuring quality of nursing care. Part I. J. Nurs. Admin. pp. 7-9. Long, N. B. (1974) A model for quality assurance in nursing. Doctoral Dissertation, Marquette University, Milwaukee, Wisconsin. Notter, L. E. (1973) The Editors report. Nurs. Res. 22,3. Pfaneuf, M. C. (1972) The NursingAudif: ProfileforExcellence. Appleton-Century-Crofts, New York. Pfaneuf, M. C. (1976) The Nursing Audit: Self-Regulation in Nursing Practice, 2nd Edn. Appleton-CenturyCrofts, New York. Rinaldi, L. A. and Rubin, C. F. (1975) Adding retrospective audit. Am. J. Nurs. 75, 256-257. Risser, N. L. (1975) Development of an instrument to measure patient satisfaction with nurses and nursing in primary care settings. Nurs. Res. 14,45-52. Taylor, J. E. (1974) Measuring the outcome of nursing care. Nurs. Clin N. Am. 9,337-348. (Received27
June 1978: accepted 19 July 1978)
Stud. Vol. 16, pp.65-72.
@Pergamon
Press Ltd., 1979. Printed in Great Britain.
CO204878/79/0301-C065%02CWO
Clinical research: translation into nursing practice JUNE T. CUDDIHY,
R.N., M.A.
College of Nursing, Seton Hall University, South Orange, New JerseyOlQ79, U.S.A.
One of the most significant ways in which we can improve nursing practice and the delivery of nursing care is to initiate research programs designed to evaluate these functions in individual institutions and agencies. It is through this process of analysis, documentation and evaluation of the nursing process in relation to patient outcomes that positive changes can be produced. However, it is widely recognized that a gap exists between reported research and its application in clinical nursing practice. This has been carefully documented by Notter (1973), Ketefian (1975) and others. All too often nursing research is conducted in an educational institution and published in a scholarly journal. This process does not assure that the findings will indeed be incorporated into nursing practice at the individual practitioner level. Furthermore, as greater portions of research programs become team research efforts, the interaction of team members may also serve to totally sustain continuation of a particular line of research without assuring its implementation in daily professional activities (Ackerman, 1976). It may be that the efficient translation of research findings into nursing practice at the individual practitioner level could be augmented by the use of other communication methods. This paper will describe a pilot study of nursing practice in which the proper communication of the findings had a significant and documented effect on nursing care. In this research project, we elected to study the potential impact of the evaluation of the quality of care on subsequent nursing practice in a single pediatric nursing unit of a hospital. Our purpose was to determine if nursing practice could be improved by the presentation of nursing audit results to the nursing staff of this selected unit. Particular attention was focused upon the methodical design in conceptualizing the research project. Both process and outcome audit tools were employed. These were based upon established audit instruments but were specifically tailored to evaluate the care provided to ambulatory, partial-care pediatric patients. The quality assurance for nursing care can be approached from various frames of reference such as structure, process and outcome. A strong case has been made for each of these frames of reference. 65
66
JUNE T. CUDDIH Y
Quality assurance has presented the nursing profession with an opportunity to define publicly the expectations consumers should anticipate from nursing and quality assurance criteria stated in terms of outcomes, i.e. alterations in the health status of the consumer, will help articulate these definitions. At the 1972 convention, the American Nurses Association (ANA) set, as one of its priorities, the promotion of peer review as a means of maintaining standards of care (Hauser, 1975). Two years later, the ANA Congress for Nursing Practice issued “Guidelines for Peer Review”. Considerable debate has focused upon whether patient care evaluation should be process-focused or outcome-focused (Donabedian, 1966, 1969). However, only an evaluation that encompasses both process and outcome has the potential for great impact upon accountability for quality of care (Deniston et al., 1968; Block, 1975). A number of interesting efforts have been reported in the recent literature attempting to evaluate nursing care for colostomy patients (Hilger, 1974), adults with congestive heart failure (Anderson, 1974), neurological patients (Taylor, 1974) and well babies (Long, 1974). Other more general papers have focused primarily upon methodology rather than specific diseases. They have studied counselling and written goal-setting (Dyer et al., 1975), retrospective audits (Rinaldi, 1975) and the development of further general audit instruments (Risser, 1975). Particularly valuable have been the instruments developed by Jelinek (1974), by Pfaneuf (1976) and that designed and field tested by Hausmann and Hegyvary (1976). These papers have delineated systematic patient-centered nursing audit methodology based upon the seven functions of nursing. These papers also illustrate the proper statistical analysis of these data. A recent paper has pointed out the further utility of these audit tools (Felton er al., 1976). In this publication, Felton reported the experiences of a large nursing service with deliberate planning for change to improve the quality of nursing care. “Quality assurance accompanies the acceptance of accountability for professional practice.”
Methods
Patients Two groups of 10 ambulatory partial care pediatric patients were randomly selected for the study. The first 10 were evaluated using both the process and the outcome audit instruments described below. The second 10 were evaluated subsequent to the staff presentation, using only the outcome audit instrument.
Audit instruments The process instrument used in this study was derived from that developed jointly by the Rush-Presbyterian-St. Luke’s Medical Center and the Medicus Systems Corporation (Hegyvary and Haussmann, 1975). This tool defines 6 objectives and 28 sub-objectives as representative of the nursing process. By use of the objectives and sub-objectives to define the nursing care process, a framework is provided within which the process of nursing care, however defined by a particular institution, could be evaluated. Patients are classified by intensity of illness and each criterion is classified according to the type or types of patient to which it would most likely apply: self-care, partial care, complete care and intensive care. In this study, our derived instrument consisted only of those criteria that were intended to apply to partial care patients. The outcome instrument used was the Pfaneuf Nursing Audit-a process-oriented
CLINICAL
RESEARCH:
TRANSLATIONINTO
NURSING
PRACTICE
67
outcome nursing audit consisting of 50 criteria (Pfaneuf, 1972). This audit provides a retrospective evaluation of the quality of care provided for individual patients as documented in the patient care records. Its basis rests upon the seven fundamental functions of nursing. Evaluation procedures Ten ambulatory pediatric patients requiring partial care were randomly selected from the population of a single hospital unit. Each patient and the patient record were evaluated using the two previously-described audit instruments to establish the current standards of nursing practice for that hospital unit. Strengths, weaknesses, omissions and other observations were tabulated in summary form. These data were then presented at a unit nursing staff meeting as an evaluation of current levels of practice. Recommendations were offered for alterations in care practices. Beginning with patients admitted at least 1 week after the presentation, another random sample of 10 ambulatory pediatric patients receiving partial care were selected and evaluated using only the Pfaneuf Nursing Audit technique. The data derived from this second audit were compared, using standard statistical methods, with that obtained earlier to determine if the level of nursing care provided had been altered after the staff presentation. Statistical calculations were performed using a programable Texas Instruments SR-56 microprocessor calculator using statistical programs provided by the manufacturer.
(a) Initial evaluation Evaluation of the total nursing care provided to the first group of 10 patients produced the patient scores shown in Table 1.
Table
I. Total process and outcome instrument
scores by patient
Patient
Process Outcome
instrument
(a)
instrument(b)
I
2
3
4
5
6
7
8
81.5
83.6
15.4
15.8
91.6
84.1
84.1
83.1
89
69.1
140.5
129
126
143
182
126
125
142
142
141.5 _.
9
10
a: scored as a percentage of positive values found b: scored as a raw score with a maximum possible total of 200
Examination of these total raw scores suggested that a generally high level of care was consistently provided to this patient group. However, closer examination of the raw data for individual segments and subsets of the tests revealed somewhat less consistency in the various subsets of nursing care from patient to patient. This is illustrated in Tables 2 and 3. From these data we see that while a generally high level of nursing care was provided to each patient and total patient scores fell within a relatively narrow range, there were some subsets from each instrument in which particularly high or low scores were noted and further refinement of the data analysis revealed inconsistent levels of practice between individual patients.
JUNE
68
T. CUDDIH
Table 2. Process instrument
Y
scores by subset
Mean (%)
Item
1.1
Patient
1.2
Data relevant
condition
1.4
Written
assessed admission
to hospital
nursing
care assessed on admission
care plan formulated
1.5
Nursing
2.1
Patient
care plan and medical plan coordinated
2.2
Need for physical
2.3
Need for physical
2.5
Need for activity
2.6
Need for nutrition
2.1
Need for elimination
3.1
Patient
oriented
3.2
Patient
extended
3.3
Patient
privacy and civil rights honored
3.4
Need for psychological-emotional
protected
taught
from accident comfort
and injury
f 17.85
55.43
-t- 10.53
0.19
31.4
? 18.02
0.579
72.5
t 24.86
0.343
0.249
+O
0
attended
16.61
lr 22.5
0.293
hygiene attended
65.68
f 14.23
0.217
37.5
k 48.95
I.31
71.5
-+ 22.92
0.32
30.0
+ 48.3
1.61
55.33
+ 23.89
0.448
66.15
f 15.68
0.237
and fluid balance
attended
attended
to hospital
on admission
social courtesies
3.4
Patient
3.6
Patient’s
4.1
Records document
patient
4.2
Patient’s
to therapy
6.1
Nursing
6.3
Clerical services provided
6.4
Environmental _
by staff
100
well-being
attended
response
in nursing
care process
care evaluated
follows prescribed
and support
standards
services provided
Item
I
Execution
11
Observation
of symptoms
111
Supervision
IV
Supervision
of physicians
*O
51.64
health maintenance
family included
Table 3. First set of outcome
instrument
0
? 14.04
0.212
73.32
+ 10.54
0.144
40.0
*
8.61
0.215
86.37
2 12.41
0.144
50.0
231.2
0.624
92.5
-+ 10.54
0.114
98.75
L 3.95
0.04
90.7
k 12.41
0.137
scores by subset
Highest possible score
Mean raw score
Standard deviation
Coefficient of variation
42
40.6
? 2.95
0.0727
40
32.8
k 5.53
0.169
of patient
28
19.2
t 4.92
0.256
of staff
20
3.9
k 3.84
0.984
20
10.1
k 4.33
0.429
32
25.5
I? 3.71
0.148
18
7.6
+- 4.12
0.621
V
Reporting/recording
VI
Execution
VII
Promotion
of nursing
orders & reactions
procedures
of health by teaching
High scores were achieved
in the following
areas:
(1) privacy and civil rights; of patient care; (2) documentation (3) (4) (5) (6)
Coefficient of variation
11.61
100.0
attended
reporting
Standard deviation
nursing reporting followed prescribed standards; clerical sefvice provided; patient protected from accident or injury; environmental and support services provided;
,
CLINICAL
RESEARCH:
TRANSLATION
INTO NURSING
PRACTICE
69
(7) execution of physician orders; (8) observation of symptoms and reactions. Low scores were observed for:
(1) written nursing care plan formulated; (2) need for activity attended; (3) (4) (5) (6) (7) (8) (9)
need for elimination attended; need for psychological-emotional well-being attended; patient’s family included in nursing care process; patient’s response to therapy evaluated; supervision of staff; reporting/recording; promotion of health by teaching.
inconsistent practices on an inter-individual patient basis (detected by unusually high coefficient of variation values) included the following items: (1) need for activity attended; (2) patient response to therapy evaluated; (3) patient orientation to hospital attended; (4) supervision of nursing staff; (5) promotion of health by teaching. (b) Presentation of initial findings to nursing staff All of the above data, supported by direct observation of practices on the hospital unit, was presented in a 1-hr nursing staff conference on the unit. Strengths, weaknesses and inconsistencies in nursing care practices were reviewed and discussed. Participants were encouraged to review their individual practice patterns. (c) Results obtained after presentation to Ten randomly selected patients who presentation were then evaluated for the outcome instrument. The scores achieved
staff had been admitted at least 1 week after this pattern of nursing care received, using only the are outlined in Table 4.
Table 4. Second set of outcome instrument Item
Highest possible score
scores by subset
Mean raw score
Standard deviation
Coefficient of variation
1
Execution
42
42
*O
0
II
Observation
of symptoms and reactions
40
39.4
I? 1.9
0.048
of physicians orders
III
Supervision
of patient
28
26.8
* 1.55
0.058
IV
Supervision
of staff
20
15.2
+ 4.73
0.311
V
Reporting/recording
20
19.4
k 1.26
0.065
VI
Execution
of nursing procedures
32
31.5
k 0.82
0.026
VI1
Promotion
of health by teaching
18
15.6
k 2.95
0.189
From a comparison of the data contained in Tables 3 and 4 we can see that a considerable elevation of total scores and a greater consistency in scoring within subsets or on an inter-
JUNE T. CUDDIHY
70
individual patient basis was observed for the second group of patients evaluated at a minimum interval of greater than one week after the staff review of the first set of observations. Statistical analysis of the difference in outcome instrument scores between the two groups of patients showed that the difference between the two groups was significant at the P< 0.0001 level using each of three standard statistical techniques: .z scores (one-tailed test), student’s t test and the chi-square analysis, using 9 degrees of freedom.
Discussion
Three major components of the nursing care system have a significant relationship to the quality of nursing care. These are: (1) the setting in which the care is provided; (2) the nursing process and (3) patient outcome (Lindeman, 1976). This small-scale study involving partial-care pediatric patients represented an attempt to evaluate aspects of the latter two of these components. Our approach followed the basic steps used in measuring quality of nursing care as outlined by Berg (1974): (1) define what should be present; (2) compare what should be with what is; (3) identify the gaps and take action. Validated rating tools were selected. Evaluations were performed and care defects identified. The investigator met with the staff to encourage corrective action. Thereafter a second outcome audit was performed to determine if any alteration had indeed occurred. Review of the process data collected on the first 10 patients prod,uced data similar to those observed by Haussmann et al. (1976) and by Jelinek et al. (1974) in a number of larger trials. Similarly, the evaluation of the first 10 patients using the outcome instrument produced a general level of results quite similar to those noted by Pfaneuf (1976). Thus we felt quite confident that the evaluation tools were being properly applied. Review of the initial process and outcome data revealed a number of care deficits. lnterestingly, the individual patient scores correlated (Pearson product moment method revealed a 0.55 correlation) with the scores achieved on the outcome audit instrument. Outcome
v7strument
scores by subset
- - First group -Second group ----Moxnum possible score
I
0
I
I
I
II
I Ill
I
I
lIL
P
Item group
I I!l
I m
CLINICAL
RESEARCH:
TRANSLATION
INTO NURSING
PRACTICE
71
The l-week minimum waiting period (before evaluating the impact of the staff conference) was adopted to enable the initial stimulatory effects of the presentation to settle out into a more consistent level of practice. However, the second group of 10 patients were entered into the study within a short time after the l-week period in order to minimize the likelihood of the entrance of any new variable such as staff changes, other educational influences etc. that might interfere with the interpretation of the observations. Comparing the two groups, outcome audit data, we found that a highly significant positive alteration in nursing care patterns had developed after the staff review of the data collected on the initial group of patients. Subsequent interview of several of the nursing staff involved indicated that there were several particularly valuable aspects of the manner in which the initial results were communicated to the staff that may have helped to produce the positive results observed. These included: (1) the growing acceptance of the nursing audit tool; (2) the investigator was familiar to the staff but had the stature and authority of a university appointment; (3) the initial results were presented in a non-judgemental manner and the staff was encouraged to review their individual practices; (4) the positive aspects, expressed in terms of improved patient care, were stressed throughout the study to allay suspicion about its objectives. These communications efforts may have played a significant role in assuring that the research project findings were incorporated into daily nursing practice. These data indicate that even small pilot studies involving modest numbers of patients on individual hospital units can potentially produce a significant impact upon nursing care practices in a hospital setting. We therefore recommend that additional studies along this line be performed to confirm the utility of this approach. Additionally, we recommend that the audit technique outlined in this paper may prove very useful as an easilyadministered quality control assessment tool in situations where it may be impractical to employ more complex and extensive techniques but where an audit tool would be useful to identify health care practices requiring improvement. References Ackerman, W. B. (1976) The place of research in the master’s program. Nun. Outlook 24,754-758. Anderson, M. I. (1974) Development of outcome criteria for the patient with congestive heart failure. Nurs. C/in. N. Am. 9,349-358. Berg, H. V. (1974) Nursingaudit and outcome criteria. Nurs. Clin. N. Am. 9, 331.335. Block, D. (1975) Evaluation of nursing care in terms of process and outcome. Issues in research and quality assurance. Nurs. Res. 24,256-263. Deniston, 0. L., Rosenstock, 1. M. and Getting, V. A. (1968) Evaluation of program effectiveness. Pub/. Hlrh. Rep. 83,323.325. Donabedian, A. (1966) Evaluating the quality of medical care. Milbank Meml. Fund. Q. BUN. 44 (part II), 166-206. Donabedian, A. (1969) Part I. Some issues in evaluating the quality of nursing care. Am. J. Publ. Hlth. 59, 1833-1836. Dyer, E. D., Monson, M. A. and Cape, M. J. (1975) Increasing the quality of patient care through performance counseling and written goal setting. Nurs. Res. 24, 138-144. Felton, G., Freverb, E., Galligan, K., Neil], M. K. and Williams, F. (1976) Pathway to accountability: implementation of a quality assurance program. J. Nurs. Admin. 6,20-24. Hauser, M. A. (1975) Initiation into peer review. Am. J. Nurs. 75.2204-2207. Haussmann, R. K. D., Hegyvary, S. T. and Newman, J. F., Jr. (1976) Monitoring quality of nursing care. Part II. Assessment and study of correlates. U.S. Dept. of Health, Education and Welfare, DHEW Publication No. (HRA) 76-7.
12
JUNE T. CUDDIHY
Haussman, R. K. D. and Hegyvary, S. T. (1976) Field testing the nursing quality monitoring methodology: Phase II. Nurs. Res. 15,324-331. Hegyvary, S. T. and Haussman, R. K. D. (1975) Monitoring nursing care quality. J. Nurs. Admin. 5, 17-26. Hilger, E. E. (1974) Developing nursing outcome criteria. Nuts. Clin. N. Am. 9,323~330. Jelinek, R. C. (1976) Methodology for monitoring quality of nursing care. U.S. Dept. of Health, Education and Welfare, Bureau of Health Manpower, Division of Nursing, DHEW Publication No. (HRA) 76-25, Bethseda, Maryland. Ketefian, S. (1975) Application of selected nursing research findings into nursing practice. Nurs. Res. 24, 89-92. Lindeman, C. A. (1976) Measuring quality of nursing care. Part I. J. Nurs. Admin. pp. 7-9. Long, N. B. (1974) A model for quality assurance in nursing. Doctoral Dissertation, Marquette University, Milwaukee, Wisconsin. Notter, L. E. (1973) The Editors report. Nurs. Res. 22,3. Pfaneuf, M. C. (1972) The NursingAudif: ProfileforExcellence. Appleton-Century-Crofts, New York. Pfaneuf, M. C. (1976) The Nursing Audit: Self-Regulation in Nursing Practice, 2nd Edn. Appleton-CenturyCrofts, New York. Rinaldi, L. A. and Rubin, C. F. (1975) Adding retrospective audit. Am. J. Nurs. 75, 256-257. Risser, N. L. (1975) Development of an instrument to measure patient satisfaction with nurses and nursing in primary care settings. Nurs. Res. 14,45-52. Taylor, J. E. (1974) Measuring the outcome of nursing care. Nurs. Clin N. Am. 9,337-348. (Received27
June 1978: accepted 19 July 1978)
