Joumal of Advanced Nurstng, 1992, 17, 1489-1495
Evaluating the quality of patient care in district nursing Eleanor C Toms BNurs(Hons) RGN DN Certificate StaffNurse, Addenbrooke's Hospttal Cambndge, England
Accepted for publication 13 Apnl 1992
TOMS E C (1992) Joumal of Advanced Nursmg 17,1489-1495 Evaluating the quality of patient care in district nursing This paper examines the process of evaluating the quahty of care provision m ciistnct nursing at a local level The definitions of audit and quality assurance are considered, anci the cnorrent situation m community nursing is briefly compared with that m hospitai settings Finally, the use of evaluative tools m practice is examined, together with ways m which distnct nursing evaluation can be improved AUDIT Audit IS 'a systematic method of obtaining, appraising, and reporting information about facets of care' (Stewart & Craig 1987) It is required to demonstrate explicitly all aspects lnvolveci in the provision of care, such as staff training and education, use and lack of resources for provision of care and methods used to aclmmister care This IS often taken to mean a formal process useci by health service managers to review the service However, audit as descnbed here should be relevant for all nurses who are aiming to provide the best possible service for patients The philosophy behind nursing audit is that nurses are accountable for the care they give, and this must be of good quality The overall aim of audit is cnhcally to evaluate care given, look at limitations and positive interventions, anci plan for improvements An analogy could be drawn with the nursing prcKess when it is used successfully Thus, evaluation is the part of the audit process which focuses on the outcomes of the care given Bergman (1982) defined evaluahon of care as the 'objechve measurement of phenomena, as well as subjective percephons and opinions of the "feehng" of care as reported by recipients, providers and important others' The recipients and providers of care, the health care services and the nursmg profession should all benefit from evaluation In order to achieve this, it is essential to set standards agamst which care can be measured, and which may represent goals to aim for The main outcome which can be Correspondence Eleanor C Toms 11 Howard Close Cambru^ CB5 8QU England
realistically achieved is appropnate and adequate care (Clague & Day 1987) This is quality assurance, defined by Hunt (1989) as 'a process in which standards descnbmg the level of quality both desired and feasible are set The level of achievement of those standards is measured and action is taken to correct identified deficiencies' Quality assurance usually involves the use of a number of selected evaluahon tools The defmition of quality itself remains elusive Beyer (1988) said that 'quality serves as the balance that demonstrates professional commitment to patient care' It shall be defined here as the overall expenence and sahsfaction of the patient with the distnct nursing service, from the moment of acimission until discharge Strategic quality management is the term coined to demonstrate the need for planning, defining and delivering nursing care in order to maintain high quality Somehow, quality must be included in delivery of care, documentahon of care and must also be based on rehable, vahd research
Current situation Recommendations for audit and evaluation of nursing care are not new In 1980 the Royal College of Nursing called for mcreased involvement of consumers in evaluating the effectiveness of nursing care (RCN, Society of Pnmary Care Nursing 1980) Some would say that the influence of the Gnffiths Report (DHSS 1983), which mh-oduced general management into the health service, increased the
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emphasis on quahty of service and cost-effectiveness (Harvey 1987, Hunt 1987) In 1981, Luker published a paper on evaluahon research, defmed as the 'utihsation of saentific methods and techniques for the purpose of making an evaluation', and pomted out the need to justify nursmg practice The evaluation process, as descnbed, involves recognition of values, setting goals and measunng them, putting them into action and assessing the effect The similanty between this, audit and the nursing process is clear Luker (1981) was, m fact, saymg 11 years ago that 'Bntish nurses have been slow m attemptmg to evaluate nursing practice' However, it has taken some time for recommendations to be put mto practice, and many would argue that there IS shll a long way to go Beyer (1988) points out that 'unhl this era of dramatic change, health care providers have depended on organisational habit, structures, and processes that have evolved over time and that had withstood the pressures of mtemal and extemal forces' This has taken on a new importance with the recent pubhcation of govemment proposals for audit of health care services (HMSO 1989) Commitment to quality underlies the six key management pnnciples menhoned m a report on community nursmg by the North West Thames Regional Health Authonty (1990), and 'everyone involved in commissioning, managing and providmg health care needs to be committed to secunng the highest quality services for users'
COMPARISON OF COMMUNITY NURSING WITH INSTITUTIONAL NURSING One way of exammmg the cairrent situation m distnct nursing is to compare and contrast it with the hospital settmg Despite the fact that auciit should be of importance to all practismg nurses, most emphasis has been placed on acute care withm the hospital setting (Widerquist 1988) This IS especially true m Amenca and Austraha, where mdividual mshtuhons have a greater degree of autonomy and finanaal interest in measunng quality (Stewart & Craig 1987) In 1986, iUsley & Goldstone pointed out that despite the existence of mdices m the acute sector, there was no tool with which to measure quality of nursmg care m the community In an attempt to rechfy the situahon, 240 queshonnaires were distnbuted to health authonhes and boards to mveshgate the use of evaJuahon techruques m Bntam, and 74% were retumed Despite the widespread use of the nursing process, only 38% reported usmg nursmg models Nurses were begmnmg to recognize that 1490
reviews of records could be used to measure care Unfortunately, these tended to be camed out by those in higher management positions This can perpetuate a perceived difference m mterests between prachsmg nurses and those managing them (Flynn & Ray 1979) Some nurses have accused managers of providmg insufficient support, and of making a poor distinction between saving money and mcreasmg quality of care The rephes also mdicated that clmical nurses felt upset at the idea of others reviewmg the quality of their care Some felt that quahty of care and audit are mamly academic processes which did not concem them, while others saw the possible introduction of audit as a threat to increase their workload The altemative view is that audit is essentially educational, and that distnct nurses should be taking a greater part m auditing the 'ordinary' care they give on a daily basis There is little work done on this Most has focused on evaluatmg individual service developments and schemes (Badger etal 1989) District nurses There appear to be a certam number of obstacles m distnct nursmg which slow down or prevent the process of effective auditing For example, it has been proposed that distnct nurses often look upon recordmg mformation as a secondary procedure to actually giving care, placing httle value and emphasis on it This can lead to poor, inaccurate evaluation of care if nursing records are used as a basis for measurement Studies by Gnffin (1988) and Stewart & Craig (1987) which used auciit tools to look at documentation of nursing care, and staff compliance with givmg that care, showed that the documentation did not represent the care provided However, the recordmg of mformation vanes between areas, and, before making any conclusions, a study of the records produced in each locality would need to be made Once a distnct nurse has cared for a patient dunng a speafic episode of llbess, this care is terminated Any further care is likely to depend on whether the patient is referred again Distnct nurses rarely carry out follow-up visits, except when a family has been bereaved Thus it is only possible to look at quality of care on a short-term basis In many cases, new nursmg notes are started for each episode, which breaks continuity of care, thus losing valuable mformahon In addihon, assessment is difificult m the case of chrome long-term illnesses with remissions and exacerbations because there is a less defined llhiess penod, and perhaps less clear requirements for care In hospital, care is provided on a 24-hour basis In the commuruty.
Patient care in distnct nursing
patients provide their own care and nurses fill m the gaps (Hastings 1987) Environments m which care takes place m the commumty are enormously different, unlike hospitai wards which tend to follow a similar layout, and hospitai audit methods cannot be used m the community Perhaps the problem of deciding on a system to measure quality is more difficult m the community where professionals work alone with lunited supervision and opportunity for compansons It would take longer to defme the cntena by which quality should be measured because there are a vanety of types of care provided
MODELS AND FRAMEWORKS A number of models and frameworks are currently in use (Wnght 1984) It is not the mtention to give details of available methods, but to outline and appraise them cntically Despite the problems mentioned with using an evaluative system, frameworks are required partly because of the trend in the health service towards this, and partly because they are potentially useful in approaching the subject systemahcally Unfortunately, most of the hterature concentrates on theoretical aspects of frameworks and there is a need for more prachcal guidelmes for nurses themselves The most commonly used model was proposed by Donabedian (1980) who looked at structure, process and outcome of care Structure mcludes the personnel mvolved and their environment Process is the method of providing care, and outcome refers to the end result Thus, an outcome measure may be the level of improvement m the health or quality of life for the patient, and a process approach could involve exammation of nursmg documentation, and observation of the care given Ideally, all should be combined to form the total audit The next part of the process, after choosmg a model, is to develop standards for care, and indicators used for this, which mclude the vanous audit tools available A number of these are in use, but most have cirawbacks of some bnd For example, one such system is the Finanaal Information Project, in which statistical mformahon is stored on computer (Famngton 1987) The background for this arose fi-om the Komer report (Komer 1984) However, this method is expensive, and nurses rarely receive feedback on the prcKess It is also hme-consuming, because detailed codmg systems are m operation An altemahve is the Dynamic Standard Settmg System, pioneered in West Berkshire health authonty, England (RCN 1990) Agam, the aim was to make links between practice and improvements in quality A group of professionals are required to set wntten standards for care
A number of cntena are set, such as the maximum group number, and the topics on which they will be workmg In reality, standards are difificult to set and achieve with consensus, but it is possible (Hunt 1989) Unfortunately, this method can be time-consummg and slow, and there may be a tendency to look for standards set by others, and copy these without cnticizmg them objectively Standards must also be reached and observed m practice (Schofield 1990) This may be more difficult to evaluate m distnct nursing where staff often work alone One of the most useful systems, devised by Illsley & Goldstone (1987), is the Distnct Nursmg Monitor This was an adaptahon of the Monitor system used in acute medical and surgical wards The process is based on a checklist with 136 quality-related cntena queshons about physical, social and psychological aspects of care Answers are provided by an expenenced distnct nurse or manager and are obtained from a variety of sources, mvolvmg nursing records, mterviews of patients and carers and observation, providmg good tnangulation Unfortunately, the system is expensive, and requires staff hme to operate it It is not contmuous, but designed to be camed out at specific pomts in time It is still auned for use by managers, cmd it could be critiazed for its heavy reliance on patient satisfaction and review of nursmg records rather than on observation, which can reduce rehabihty and mcrease bias m the results Managers have attempted to utilize nursmg skills with the formation of quality circles A quality circle is 'a small group of people workmg together who volunteer to meet to identify and resolve problems related to their work environment' (O'Bnan 1988) Although these have been seen to be successful (Freeman I99I), they are again limited when they have been initiated by a top-led approach (Hyde 1984) However, it is a step towards increasmg practical nursing involvement, which may increase quality of commumcahon, and ensure that stafif are more keen on decisions made
Assumptions The above audit tools are based on certam assumphons It IS taken for granted that care is planned accordmg to patient needs, that documentation reflects care given and that staff are accountable and quahfied to give the care In additioa auditing does not guarantee that practice will change It is also time-consummg, making it difficult for stafif to complete, and the collection of data may often only focus on nursmg tasks alone Currently, there is very httle mformation aimed at helping practismg dishnct nurses to audit their day-to-day care 1491
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RECOMMENDATIONS Distnct nursmg evaluahon can be improved First, targets need to be realishc, and standards must be attamable This can be achieved by examining the basic workload and analysmg it for possible improvements For example, it is not sensible to conhnue to wash patients if they can be taught to do this themselves, and it is not cost-effective to send quahfied staff to do this regularly if auxihary staff are available Most distnct nurses will already be observmg these basic aspects, and can be encouraged mihally to see what they are abeady succeeding with Then, it is necessary to move mto areas which are current problems Audit requires a higher level of staff mvolvement in monitonng care In one hospital unit, nurses themselves monitored practice, were active representahves on quality assurance programmes, and set up quality ardes themselves (O'Bnan 1988) This helped to improve nursing care directly, mcrease nurses' accountabihty and keep administrative costs low Nurses chd, however, have to organize staff levels carefully to release staff for meetmgs It was also found that feedback from the quality assurance committee was essential, and needed to be fairly rapid It is important that stafif set their own standards for quality of care, in order to mcrease mcentives for adhenng to them (Robmson & Fitzgerald 1990) It may be assumed that a change in attitude is necessary for nurses to carry out audit effechvely However, LemoKilpi (1989) compared the views of 269 practismg nurses with 223 nurse teachers and found that all recognized similar factors to be important when lookmg at quality of care These were that care should be comprehensive, be onentated towards mdividual patient needs, demonstrate mihahve, and use nursing as a process based on agreed philosophical prmciples The imphcations of research, however, were not mentioned, and this is a biased sample representahve of highly tramed and speaalist nurses, all of whom had attended a semmar on audit, and thus were motivated to look at quality of care
Networks Smith (1987), assummg that it is necessary m some cases to change athtudes to care provision, exammed the use of placing nurses mto networks She stated that 'members of a network share a common value system', and the aim is to use this to improve care by ensurmg that group members work together at a basic level Moore (1979) concludes that although nurses may have negahve opmions about audit these can be changed, and nurses may be helped to look 1492
more closely at what their contnbutions to health care were A wider range of prachcal, research-based tools available to nurses m the community is required Those developed tend to apply only to certain chnical areas, and were formed ongmally for use m research For example, Phillips et al (1990) developed a tool to measure the quality of family caregivmg for elders at home When tested, with 249 carer-elder dyads m the study, the instrument was methodologically sound, with good interrater rehabihty, mtemal consistencry, cntenon and construct validity It was suggested that the scale could, with alterations, he applied to nursing practice An observational ratmg scale was used, with six assessment areas for care, mcluding physical, medical, psychosoaal, environmental, human nghts and financial aspects Although the Likert scale format was easy to use, it was difficult in practice for nurses to agree what fell mto certam categones of care Too much rehance on the assessing nurse tends to introduce observer bias Kitson (1986) developed a tool called the 'therapeutic nursmg function indicator', designed to measure the quality of nursmg care for the elderly, although it could have application to other areas of nursing care Hastings (1987) has also designed a tool to look mamly at the appropnateness of nursmg care decisions, and the quality of care provided m both the community settmg and out-patient services The mam prmciples used are extremely useful, and include exammmg appropnate allocahon of resources, evaluatmg the appropnateness of care, evaluahng the effechveness of care, and identification and follow-up of patients at speaal nsk of developmg health problems However, it is not simple to use, and stafif would require trammg and extra time to use it Unfortunately, there is a danger that use of tools by distnct nurses themselves could mtroduce subjective bias Extemal observers have been used to avoid this, but are expensive, and not appropnate if distnct nurses are to evaluate their continuing care It is possible to compromise by usmg peer review t)etween groups of distnct nurses, and other members of the pnmary health care team Tools have been borrowed from other academic disaphnes, but we need more which focus speafically on nursing The few available either measure process or outcome, but not the two in conjunction with one another, which cannot present a clear picture of quahty One of the mam hopes is that as the number of tools mcrease, distnct nurses will gradually increase their emphasis on objechve measurements of care, rather than subjechve appraisal Most tools are designed for use dunng a certam penod of care Ideally, however, nursing audit should be a conhnuous process Examinahon of nursing documentahon
Patient care m dtstnct nurstng
has been proposed to overcome this problem, but a number of studies have concluded that the use of nursing records for audit is often extremely limited because they give insufficient details and explanations of care (Grififin 1988, Stewart & Craig 1987, Vogel 1988, Widerquist 1988) Thus an inaccurate reflection of nursing care is provided, which can be disastrous when an extemal auditor is employed The use of retrospective mformation, taken from nursing records of patients discharged from care, is only useful if a subsequent patient presents with similar needs
should receive feedback from all those in a position to appraise the service cntically This can be assisted by unplementmg a neighbourhood study (Drennan 1990) Methods of measunng patients views are available (Osinski 1987), but are at an early stage, and some consumer surveys have unreliable methodology, with problems of expenmenter and responder bias Audit should measure those aspects of care considered by pahents to be the most important, such as canng and mterpersonal relationships and sensitivity to needs rather than chnical sblls (Kelly 1989)
Documentation
CONCLUSION
Documentmg care accurately is essential, and can provide an encouraging record of nursing sblls It is also imjX)rtant to give good definitions of outcomes, such as measurements of clmical work and patient satisfaction, and time targets (Kirk 1990) Ideally, managers should adopt a more supportive and advisory role Previously they have taken a more prescnphve role, and by taking the lead have tended to isolate nurses, although this effect was not intentional (Cearlock 1980, Decker et al 1979) Staff should be encouraged to take the mitiahve (Hoesing & Kirk 1990) There is httle research available to demonstrate that organized quahty assurance programmes do influence the quality of care (Martin 1980), and more studies are needed to set researchbased standards Ultimately, it should be remembered that quality is established by those who deliver the service, especially in distnct nursing, where one person usually visits a patient each time Sblls, knowledge and attitudes are the mam factors influencing the provision of nursing care, and current courses such as the Distnct Nursing certificate course must be updated to produce well-qualified and motivated staff Those mvolved may have different views on quahty of care (Hams 1988) Patients may measure it accordmg to their level of satisfaction Managers may look m terms of meetmg goals within certain tune penods in order to make financial savings It is necessary to increase communications between managers, distnct nurses and pahents, in order to ascertam needs It has been shown that although the role of the 'patient' is changmg gradually, most people receive health care passively, rather than actively participating in it (Sharf 1988)
Feedback Community groups, such as those for carers, should be evaluahng the ciistnct nursmg service, and distnct nurses
A number of claims have been made concemmg the posihve effects of nursmg audit These mclude a greater awareness of community needs, staff needs, staffing pattems, improving pohaes, financial savmgs and costeffectiveness, and improvmg documentation Audit can also be used to justify nursmg services, improve the quality of nursmg care, raise queshons about nursmg practice, and bnng about a number of other benefits besides For these reasons, it is worth familianzmg nurses with the audit process In addition, the wider use of audit by practismg nurses may not only benefit them by increasing job satisfaction, but should, above all, benefit those receiving the service The Alma Ata declarahon (WHO 1978) proposed that nurses should focus on mcreasmg community mvolvement, paying attenhon to parhcular needs and widening client choice This would mean that every distnct nursing team should evaluate the care it is providing for its population
Quality of care Quality of care is therefore most important to the clmical nurses who are actually dealmg with the pahents It is not simply an academic issue, as has been suggested m the past It IS possible to make endless recommendations for research-based practice m nursmg, but unless these are mcorporated mto practice there will be no impact on clients themselves Ulhmately, those prachsmg nursmg sblls will be the ones who promote or demote the service m the future Measurement of quality is one way m which nurses can promote their contnbuhons to health care For example, the effects of care on quality of life may be espeaally relevant in commumty nursing where demographic trends pomt towards future increases m the termmally ill and 1493
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chronic elderly at home Nurses could be leading develop- Hyde P (1984) Somethmg for everyone Nurstng Times 80(42), 49-50 ments m this field while takmg the opportunity to prove their worth systemahcally This could be one way to Illsley V & Goldstone L (1986) Measunng quahty m distnct nursing Nursir^ Ttmes 82(27), 38-40 influence managers, possibly raismg the status of the Illsley V & Goldstone L (1987) Dtstnct Nurstng Monttor profession and the cdlocahon of resources needed to Newcastle upon Tyne Products Limited, Newcastle upon unprove quality of care
Tyne Kelly LS (1989) Image, mceness and the illusion of quality Nursmg Outlook 37(6), 259 References Kirk R (1990) Using workload analysis and acuity systems to facihtate quality and productivity Joumal of Nursing Badger F, Cameron E &EversH (1989) Distnct nurses'pahents Admimstrahon 20(3), 21-30 issues of caseload management Joumal of Advanced Nurstng Kitson A (1986) Inciicators of quality m nursmg care an altema14,518-527 hve approach Joumal of Advanced Nursing 11(2), 133-144 Bergman R (1982) Evaluation of nursmg care could it make a Komer E (1984) A Report on the Collection and Use of Informatton difference? Interrtattortal Joumal of Nurstng Studtes 19(2), 53—60 About Servtces for and tn the Communtty of the NHS NHS and Beyer M (1988) Quahty the banner of the I980's Nurstng DHSS Steenng Group on Health Services information, 5th Cltntcs of North Amenca 23(3), 617-623 report HMSO, London Ceariock HA. (1980) The development and lmplementahon of Lemo-Kilpi H (1989) Nursmg education and the quality of nursmg audit m a community health agency Joumal of Nurstng care towards a conceptuahsation of good nursmg care Nurse Educahon 19(8), 18-23 Educatton Today 9(5), 320-326 Qague J & Day M (1987) Quahty of care nursmg audit Recent Luker K (1981) An overview of evaluation research in nursing Advartces tn Nurstng 15, 74—98 Joumal of Advanced Nursing 6(2), 87-93 Decker F, Stevens L, Vanani M & Wedekmg L (1979) Usmg Martm P J (1980) One meter stick, the nursmg audit Joumal of patient outcomes to evaluate commumty health nursmg Advanced Nursmg 5(2), 199-208 Nursing Outlook 27(4), 278-282 Moore KR (1979) What nurses leam from nursmg auciit Nursing Deparhnent of Health and Socal Secunty (1983) Health Care Outlook 27(4), 254-258 and Its Cost The Development of the NHS tn England HMSO, North West Thames Regional Health Authonty (1990) Nursing London tn the Communtty Report of a Worhng Group NWTRHA, Donabedian A (1980) Explorahons tn Quahty Assexment and London Momtonng vol 1 Health Administration, Ann Aibor, O'Bnan B (1988) A commitment to excellence Nurstng Michigan Management 19(11), 33-34 Drennan V (1990) Gathermg mformahon from the field Nursing Osmski E (1987) Developmg patient outcomes as a quahty Ttmes 86(39), 46-48 Famngton K (1987) Takmg the commumty mto account Health measurement of nursmg care Nurstng Management 18(10), 28-29 Servtce Joumal 97(5072), (suppl) 12-14 Flynn B C & Ray D W (1979) Quahty assurance m commumty PbUips LR, Momson E F & Chae Y M (1990) The QUALCARE scale developing an mstrument to measure health nursmg Nurstng Outlook 27(10), 650-653 quahty of home care Interrtattortal Joumal of Nurstng Studtes Freeman C (1991) Gomg round m circles Nurstng Standard 5(24), 27(1), 61-75 6-7 Gnffin M (1988) Assumptions for success Nurstr^ Management Robmson K & Fitzgerald M (1990) A staff-centred approach Nurstng Ttmes 86(14), 42-43 19(1), 32U-32X. Hams M D (1988) TTie changmg scene m commumty health Royal College of Nursmg, Soaety of Pnmary Health Care Nursmg (1980) Pnmary Health Care Nurstng A Team Approach nursmg Nursing Clinics of North Amenca 23(3), 559-568 RCN, London Harvey G (1987) Compihng a directory Nurstng Ttrrtes 83(44), Royal College of Nursmg (1990) Quahty Pahent Care the 49-51 Dynamtc Standard Sethng System RCN, London Hastmgs C E (1987) Measurmg quahty assurance m ambulatory care nursmg Joumal of Nursing Admtntstratton 17(4), 12-20 Schofield I (1990) Practical standards Nurstng Ttmes 86(8), 31-32 Her Majesty's Stahonery Office (1989) Worhng for Pattents Sharf B F (1988) Teachmg pahents to speak up past and future Deparhnent of Health HMSO, London trends Pahent Educatton and Counselhng 11(2), 95-108 Hoesmg H & Kirk R (1990) Common sense quahty manageSttuih M J (1987) Valumg a key to netwoikmg quahty nursmg ment Jottmal of Nurstng Adrmnistrahon 20(10), 10-15 Hunt I (1987) Assunng quahty Nurstng Ttmes 83(44), 29-31 Nurstng Forum 23(2), 56-59 Hunt) (1989) Quahty assurance can it happen at a tune of cost Stewart M I & Craig D (1987) Adaptation of the nursmg audit to commumty health nursmg Nttrstng forum 23(4), 134—144 containment? Sentor Nurse 9(8), 11-12 1494
Pahent care tn dtstnct nursing Vogel N A (1988) Development and use of a nursmg process audit mstrument Nursmg Management 19(8), 71-73 World Health Orgamsahon/Umcef (1978) Pnmary Health Care WHO, Geneva Widerquist I G (1988) Development of a record review tool for public health nursmg Nursing Management 19(6), 49-50
Wnght D (1984) An lntrcxiuchon to the evaluation of nursing care a review of the hterature Joumal of Advanced Nursing 9(5), 457-467
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Evaluating the quality of patient care in district nursing Eleanor C Toms BNurs(Hons) RGN DN Certificate StaffNurse, Addenbrooke's Hospttal Cambndge, England
Accepted for publication 13 Apnl 1992
TOMS E C (1992) Joumal of Advanced Nursmg 17,1489-1495 Evaluating the quality of patient care in district nursing This paper examines the process of evaluating the quahty of care provision m ciistnct nursing at a local level The definitions of audit and quality assurance are considered, anci the cnorrent situation m community nursing is briefly compared with that m hospitai settings Finally, the use of evaluative tools m practice is examined, together with ways m which distnct nursing evaluation can be improved AUDIT Audit IS 'a systematic method of obtaining, appraising, and reporting information about facets of care' (Stewart & Craig 1987) It is required to demonstrate explicitly all aspects lnvolveci in the provision of care, such as staff training and education, use and lack of resources for provision of care and methods used to aclmmister care This IS often taken to mean a formal process useci by health service managers to review the service However, audit as descnbed here should be relevant for all nurses who are aiming to provide the best possible service for patients The philosophy behind nursing audit is that nurses are accountable for the care they give, and this must be of good quality The overall aim of audit is cnhcally to evaluate care given, look at limitations and positive interventions, anci plan for improvements An analogy could be drawn with the nursing prcKess when it is used successfully Thus, evaluation is the part of the audit process which focuses on the outcomes of the care given Bergman (1982) defined evaluahon of care as the 'objechve measurement of phenomena, as well as subjective percephons and opinions of the "feehng" of care as reported by recipients, providers and important others' The recipients and providers of care, the health care services and the nursmg profession should all benefit from evaluation In order to achieve this, it is essential to set standards agamst which care can be measured, and which may represent goals to aim for The main outcome which can be Correspondence Eleanor C Toms 11 Howard Close Cambru^ CB5 8QU England
realistically achieved is appropnate and adequate care (Clague & Day 1987) This is quality assurance, defined by Hunt (1989) as 'a process in which standards descnbmg the level of quality both desired and feasible are set The level of achievement of those standards is measured and action is taken to correct identified deficiencies' Quality assurance usually involves the use of a number of selected evaluahon tools The defmition of quality itself remains elusive Beyer (1988) said that 'quality serves as the balance that demonstrates professional commitment to patient care' It shall be defined here as the overall expenence and sahsfaction of the patient with the distnct nursing service, from the moment of acimission until discharge Strategic quality management is the term coined to demonstrate the need for planning, defining and delivering nursing care in order to maintain high quality Somehow, quality must be included in delivery of care, documentahon of care and must also be based on rehable, vahd research
Current situation Recommendations for audit and evaluation of nursing care are not new In 1980 the Royal College of Nursing called for mcreased involvement of consumers in evaluating the effectiveness of nursing care (RCN, Society of Pnmary Care Nursing 1980) Some would say that the influence of the Gnffiths Report (DHSS 1983), which mh-oduced general management into the health service, increased the
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emphasis on quahty of service and cost-effectiveness (Harvey 1987, Hunt 1987) In 1981, Luker published a paper on evaluahon research, defmed as the 'utihsation of saentific methods and techniques for the purpose of making an evaluation', and pomted out the need to justify nursmg practice The evaluation process, as descnbed, involves recognition of values, setting goals and measunng them, putting them into action and assessing the effect The similanty between this, audit and the nursing process is clear Luker (1981) was, m fact, saymg 11 years ago that 'Bntish nurses have been slow m attemptmg to evaluate nursing practice' However, it has taken some time for recommendations to be put mto practice, and many would argue that there IS shll a long way to go Beyer (1988) points out that 'unhl this era of dramatic change, health care providers have depended on organisational habit, structures, and processes that have evolved over time and that had withstood the pressures of mtemal and extemal forces' This has taken on a new importance with the recent pubhcation of govemment proposals for audit of health care services (HMSO 1989) Commitment to quality underlies the six key management pnnciples menhoned m a report on community nursmg by the North West Thames Regional Health Authonty (1990), and 'everyone involved in commissioning, managing and providmg health care needs to be committed to secunng the highest quality services for users'
COMPARISON OF COMMUNITY NURSING WITH INSTITUTIONAL NURSING One way of exammmg the cairrent situation m distnct nursing is to compare and contrast it with the hospital settmg Despite the fact that auciit should be of importance to all practismg nurses, most emphasis has been placed on acute care withm the hospital setting (Widerquist 1988) This IS especially true m Amenca and Austraha, where mdividual mshtuhons have a greater degree of autonomy and finanaal interest in measunng quality (Stewart & Craig 1987) In 1986, iUsley & Goldstone pointed out that despite the existence of mdices m the acute sector, there was no tool with which to measure quality of nursmg care m the community In an attempt to rechfy the situahon, 240 queshonnaires were distnbuted to health authonhes and boards to mveshgate the use of evaJuahon techruques m Bntam, and 74% were retumed Despite the widespread use of the nursing process, only 38% reported usmg nursmg models Nurses were begmnmg to recognize that 1490
reviews of records could be used to measure care Unfortunately, these tended to be camed out by those in higher management positions This can perpetuate a perceived difference m mterests between prachsmg nurses and those managing them (Flynn & Ray 1979) Some nurses have accused managers of providmg insufficient support, and of making a poor distinction between saving money and mcreasmg quality of care The rephes also mdicated that clmical nurses felt upset at the idea of others reviewmg the quality of their care Some felt that quahty of care and audit are mamly academic processes which did not concem them, while others saw the possible introduction of audit as a threat to increase their workload The altemative view is that audit is essentially educational, and that distnct nurses should be taking a greater part m auditing the 'ordinary' care they give on a daily basis There is little work done on this Most has focused on evaluatmg individual service developments and schemes (Badger etal 1989) District nurses There appear to be a certam number of obstacles m distnct nursmg which slow down or prevent the process of effective auditing For example, it has been proposed that distnct nurses often look upon recordmg mformation as a secondary procedure to actually giving care, placing httle value and emphasis on it This can lead to poor, inaccurate evaluation of care if nursing records are used as a basis for measurement Studies by Gnffin (1988) and Stewart & Craig (1987) which used auciit tools to look at documentation of nursing care, and staff compliance with givmg that care, showed that the documentation did not represent the care provided However, the recordmg of mformation vanes between areas, and, before making any conclusions, a study of the records produced in each locality would need to be made Once a distnct nurse has cared for a patient dunng a speafic episode of llbess, this care is terminated Any further care is likely to depend on whether the patient is referred again Distnct nurses rarely carry out follow-up visits, except when a family has been bereaved Thus it is only possible to look at quality of care on a short-term basis In many cases, new nursmg notes are started for each episode, which breaks continuity of care, thus losing valuable mformahon In addihon, assessment is difificult m the case of chrome long-term illnesses with remissions and exacerbations because there is a less defined llhiess penod, and perhaps less clear requirements for care In hospital, care is provided on a 24-hour basis In the commuruty.
Patient care in distnct nursing
patients provide their own care and nurses fill m the gaps (Hastings 1987) Environments m which care takes place m the commumty are enormously different, unlike hospitai wards which tend to follow a similar layout, and hospitai audit methods cannot be used m the community Perhaps the problem of deciding on a system to measure quality is more difficult m the community where professionals work alone with lunited supervision and opportunity for compansons It would take longer to defme the cntena by which quality should be measured because there are a vanety of types of care provided
MODELS AND FRAMEWORKS A number of models and frameworks are currently in use (Wnght 1984) It is not the mtention to give details of available methods, but to outline and appraise them cntically Despite the problems mentioned with using an evaluative system, frameworks are required partly because of the trend in the health service towards this, and partly because they are potentially useful in approaching the subject systemahcally Unfortunately, most of the hterature concentrates on theoretical aspects of frameworks and there is a need for more prachcal guidelmes for nurses themselves The most commonly used model was proposed by Donabedian (1980) who looked at structure, process and outcome of care Structure mcludes the personnel mvolved and their environment Process is the method of providing care, and outcome refers to the end result Thus, an outcome measure may be the level of improvement m the health or quality of life for the patient, and a process approach could involve exammation of nursmg documentation, and observation of the care given Ideally, all should be combined to form the total audit The next part of the process, after choosmg a model, is to develop standards for care, and indicators used for this, which mclude the vanous audit tools available A number of these are in use, but most have cirawbacks of some bnd For example, one such system is the Finanaal Information Project, in which statistical mformahon is stored on computer (Famngton 1987) The background for this arose fi-om the Komer report (Komer 1984) However, this method is expensive, and nurses rarely receive feedback on the prcKess It is also hme-consuming, because detailed codmg systems are m operation An altemahve is the Dynamic Standard Settmg System, pioneered in West Berkshire health authonty, England (RCN 1990) Agam, the aim was to make links between practice and improvements in quality A group of professionals are required to set wntten standards for care
A number of cntena are set, such as the maximum group number, and the topics on which they will be workmg In reality, standards are difificult to set and achieve with consensus, but it is possible (Hunt 1989) Unfortunately, this method can be time-consummg and slow, and there may be a tendency to look for standards set by others, and copy these without cnticizmg them objectively Standards must also be reached and observed m practice (Schofield 1990) This may be more difficult to evaluate m distnct nursing where staff often work alone One of the most useful systems, devised by Illsley & Goldstone (1987), is the Distnct Nursmg Monitor This was an adaptahon of the Monitor system used in acute medical and surgical wards The process is based on a checklist with 136 quality-related cntena queshons about physical, social and psychological aspects of care Answers are provided by an expenenced distnct nurse or manager and are obtained from a variety of sources, mvolvmg nursing records, mterviews of patients and carers and observation, providmg good tnangulation Unfortunately, the system is expensive, and requires staff hme to operate it It is not contmuous, but designed to be camed out at specific pomts in time It is still auned for use by managers, cmd it could be critiazed for its heavy reliance on patient satisfaction and review of nursmg records rather than on observation, which can reduce rehabihty and mcrease bias m the results Managers have attempted to utilize nursmg skills with the formation of quality circles A quality circle is 'a small group of people workmg together who volunteer to meet to identify and resolve problems related to their work environment' (O'Bnan 1988) Although these have been seen to be successful (Freeman I99I), they are again limited when they have been initiated by a top-led approach (Hyde 1984) However, it is a step towards increasmg practical nursing involvement, which may increase quality of commumcahon, and ensure that stafif are more keen on decisions made
Assumptions The above audit tools are based on certam assumphons It IS taken for granted that care is planned accordmg to patient needs, that documentation reflects care given and that staff are accountable and quahfied to give the care In additioa auditing does not guarantee that practice will change It is also time-consummg, making it difficult for stafif to complete, and the collection of data may often only focus on nursmg tasks alone Currently, there is very httle mformation aimed at helping practismg dishnct nurses to audit their day-to-day care 1491
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RECOMMENDATIONS Distnct nursmg evaluahon can be improved First, targets need to be realishc, and standards must be attamable This can be achieved by examining the basic workload and analysmg it for possible improvements For example, it is not sensible to conhnue to wash patients if they can be taught to do this themselves, and it is not cost-effective to send quahfied staff to do this regularly if auxihary staff are available Most distnct nurses will already be observmg these basic aspects, and can be encouraged mihally to see what they are abeady succeeding with Then, it is necessary to move mto areas which are current problems Audit requires a higher level of staff mvolvement in monitonng care In one hospital unit, nurses themselves monitored practice, were active representahves on quality assurance programmes, and set up quality ardes themselves (O'Bnan 1988) This helped to improve nursing care directly, mcrease nurses' accountabihty and keep administrative costs low Nurses chd, however, have to organize staff levels carefully to release staff for meetmgs It was also found that feedback from the quality assurance committee was essential, and needed to be fairly rapid It is important that stafif set their own standards for quality of care, in order to mcrease mcentives for adhenng to them (Robmson & Fitzgerald 1990) It may be assumed that a change in attitude is necessary for nurses to carry out audit effechvely However, LemoKilpi (1989) compared the views of 269 practismg nurses with 223 nurse teachers and found that all recognized similar factors to be important when lookmg at quality of care These were that care should be comprehensive, be onentated towards mdividual patient needs, demonstrate mihahve, and use nursing as a process based on agreed philosophical prmciples The imphcations of research, however, were not mentioned, and this is a biased sample representahve of highly tramed and speaalist nurses, all of whom had attended a semmar on audit, and thus were motivated to look at quality of care
Networks Smith (1987), assummg that it is necessary m some cases to change athtudes to care provision, exammed the use of placing nurses mto networks She stated that 'members of a network share a common value system', and the aim is to use this to improve care by ensurmg that group members work together at a basic level Moore (1979) concludes that although nurses may have negahve opmions about audit these can be changed, and nurses may be helped to look 1492
more closely at what their contnbutions to health care were A wider range of prachcal, research-based tools available to nurses m the community is required Those developed tend to apply only to certain chnical areas, and were formed ongmally for use m research For example, Phillips et al (1990) developed a tool to measure the quality of family caregivmg for elders at home When tested, with 249 carer-elder dyads m the study, the instrument was methodologically sound, with good interrater rehabihty, mtemal consistencry, cntenon and construct validity It was suggested that the scale could, with alterations, he applied to nursing practice An observational ratmg scale was used, with six assessment areas for care, mcluding physical, medical, psychosoaal, environmental, human nghts and financial aspects Although the Likert scale format was easy to use, it was difficult in practice for nurses to agree what fell mto certam categones of care Too much rehance on the assessing nurse tends to introduce observer bias Kitson (1986) developed a tool called the 'therapeutic nursmg function indicator', designed to measure the quality of nursmg care for the elderly, although it could have application to other areas of nursing care Hastings (1987) has also designed a tool to look mamly at the appropnateness of nursmg care decisions, and the quality of care provided m both the community settmg and out-patient services The mam prmciples used are extremely useful, and include exammmg appropnate allocahon of resources, evaluatmg the appropnateness of care, evaluahng the effechveness of care, and identification and follow-up of patients at speaal nsk of developmg health problems However, it is not simple to use, and stafif would require trammg and extra time to use it Unfortunately, there is a danger that use of tools by distnct nurses themselves could mtroduce subjective bias Extemal observers have been used to avoid this, but are expensive, and not appropnate if distnct nurses are to evaluate their continuing care It is possible to compromise by usmg peer review t)etween groups of distnct nurses, and other members of the pnmary health care team Tools have been borrowed from other academic disaphnes, but we need more which focus speafically on nursing The few available either measure process or outcome, but not the two in conjunction with one another, which cannot present a clear picture of quahty One of the mam hopes is that as the number of tools mcrease, distnct nurses will gradually increase their emphasis on objechve measurements of care, rather than subjechve appraisal Most tools are designed for use dunng a certam penod of care Ideally, however, nursing audit should be a conhnuous process Examinahon of nursing documentahon
Patient care m dtstnct nurstng
has been proposed to overcome this problem, but a number of studies have concluded that the use of nursing records for audit is often extremely limited because they give insufficient details and explanations of care (Grififin 1988, Stewart & Craig 1987, Vogel 1988, Widerquist 1988) Thus an inaccurate reflection of nursing care is provided, which can be disastrous when an extemal auditor is employed The use of retrospective mformation, taken from nursing records of patients discharged from care, is only useful if a subsequent patient presents with similar needs
should receive feedback from all those in a position to appraise the service cntically This can be assisted by unplementmg a neighbourhood study (Drennan 1990) Methods of measunng patients views are available (Osinski 1987), but are at an early stage, and some consumer surveys have unreliable methodology, with problems of expenmenter and responder bias Audit should measure those aspects of care considered by pahents to be the most important, such as canng and mterpersonal relationships and sensitivity to needs rather than chnical sblls (Kelly 1989)
Documentation
CONCLUSION
Documentmg care accurately is essential, and can provide an encouraging record of nursing sblls It is also imjX)rtant to give good definitions of outcomes, such as measurements of clmical work and patient satisfaction, and time targets (Kirk 1990) Ideally, managers should adopt a more supportive and advisory role Previously they have taken a more prescnphve role, and by taking the lead have tended to isolate nurses, although this effect was not intentional (Cearlock 1980, Decker et al 1979) Staff should be encouraged to take the mitiahve (Hoesing & Kirk 1990) There is httle research available to demonstrate that organized quahty assurance programmes do influence the quality of care (Martin 1980), and more studies are needed to set researchbased standards Ultimately, it should be remembered that quality is established by those who deliver the service, especially in distnct nursing, where one person usually visits a patient each time Sblls, knowledge and attitudes are the mam factors influencing the provision of nursing care, and current courses such as the Distnct Nursing certificate course must be updated to produce well-qualified and motivated staff Those mvolved may have different views on quahty of care (Hams 1988) Patients may measure it accordmg to their level of satisfaction Managers may look m terms of meetmg goals within certain tune penods in order to make financial savings It is necessary to increase communications between managers, distnct nurses and pahents, in order to ascertam needs It has been shown that although the role of the 'patient' is changmg gradually, most people receive health care passively, rather than actively participating in it (Sharf 1988)
Feedback Community groups, such as those for carers, should be evaluahng the ciistnct nursmg service, and distnct nurses
A number of claims have been made concemmg the posihve effects of nursmg audit These mclude a greater awareness of community needs, staff needs, staffing pattems, improving pohaes, financial savmgs and costeffectiveness, and improvmg documentation Audit can also be used to justify nursmg services, improve the quality of nursmg care, raise queshons about nursmg practice, and bnng about a number of other benefits besides For these reasons, it is worth familianzmg nurses with the audit process In addition, the wider use of audit by practismg nurses may not only benefit them by increasing job satisfaction, but should, above all, benefit those receiving the service The Alma Ata declarahon (WHO 1978) proposed that nurses should focus on mcreasmg community mvolvement, paying attenhon to parhcular needs and widening client choice This would mean that every distnct nursing team should evaluate the care it is providing for its population
Quality of care Quality of care is therefore most important to the clmical nurses who are actually dealmg with the pahents It is not simply an academic issue, as has been suggested m the past It IS possible to make endless recommendations for research-based practice m nursmg, but unless these are mcorporated mto practice there will be no impact on clients themselves Ulhmately, those prachsmg nursmg sblls will be the ones who promote or demote the service m the future Measurement of quality is one way m which nurses can promote their contnbuhons to health care For example, the effects of care on quality of life may be espeaally relevant in commumty nursing where demographic trends pomt towards future increases m the termmally ill and 1493
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chronic elderly at home Nurses could be leading develop- Hyde P (1984) Somethmg for everyone Nurstng Times 80(42), 49-50 ments m this field while takmg the opportunity to prove their worth systemahcally This could be one way to Illsley V & Goldstone L (1986) Measunng quahty m distnct nursing Nursir^ Ttmes 82(27), 38-40 influence managers, possibly raismg the status of the Illsley V & Goldstone L (1987) Dtstnct Nurstng Monttor profession and the cdlocahon of resources needed to Newcastle upon Tyne Products Limited, Newcastle upon unprove quality of care
Tyne Kelly LS (1989) Image, mceness and the illusion of quality Nursmg Outlook 37(6), 259 References Kirk R (1990) Using workload analysis and acuity systems to facihtate quality and productivity Joumal of Nursing Badger F, Cameron E &EversH (1989) Distnct nurses'pahents Admimstrahon 20(3), 21-30 issues of caseload management Joumal of Advanced Nurstng Kitson A (1986) Inciicators of quality m nursmg care an altema14,518-527 hve approach Joumal of Advanced Nursing 11(2), 133-144 Bergman R (1982) Evaluation of nursmg care could it make a Komer E (1984) A Report on the Collection and Use of Informatton difference? Interrtattortal Joumal of Nurstng Studtes 19(2), 53—60 About Servtces for and tn the Communtty of the NHS NHS and Beyer M (1988) Quahty the banner of the I980's Nurstng DHSS Steenng Group on Health Services information, 5th Cltntcs of North Amenca 23(3), 617-623 report HMSO, London Ceariock HA. (1980) The development and lmplementahon of Lemo-Kilpi H (1989) Nursmg education and the quality of nursmg audit m a community health agency Joumal of Nurstng care towards a conceptuahsation of good nursmg care Nurse Educahon 19(8), 18-23 Educatton Today 9(5), 320-326 Qague J & Day M (1987) Quahty of care nursmg audit Recent Luker K (1981) An overview of evaluation research in nursing Advartces tn Nurstng 15, 74—98 Joumal of Advanced Nursing 6(2), 87-93 Decker F, Stevens L, Vanani M & Wedekmg L (1979) Usmg Martm P J (1980) One meter stick, the nursmg audit Joumal of patient outcomes to evaluate commumty health nursmg Advanced Nursmg 5(2), 199-208 Nursing Outlook 27(4), 278-282 Moore KR (1979) What nurses leam from nursmg auciit Nursing Deparhnent of Health and Socal Secunty (1983) Health Care Outlook 27(4), 254-258 and Its Cost The Development of the NHS tn England HMSO, North West Thames Regional Health Authonty (1990) Nursing London tn the Communtty Report of a Worhng Group NWTRHA, Donabedian A (1980) Explorahons tn Quahty Assexment and London Momtonng vol 1 Health Administration, Ann Aibor, O'Bnan B (1988) A commitment to excellence Nurstng Michigan Management 19(11), 33-34 Drennan V (1990) Gathermg mformahon from the field Nursing Osmski E (1987) Developmg patient outcomes as a quahty Ttmes 86(39), 46-48 Famngton K (1987) Takmg the commumty mto account Health measurement of nursmg care Nurstng Management 18(10), 28-29 Servtce Joumal 97(5072), (suppl) 12-14 Flynn B C & Ray D W (1979) Quahty assurance m commumty PbUips LR, Momson E F & Chae Y M (1990) The QUALCARE scale developing an mstrument to measure health nursmg Nurstng Outlook 27(10), 650-653 quahty of home care Interrtattortal Joumal of Nurstng Studtes Freeman C (1991) Gomg round m circles Nurstng Standard 5(24), 27(1), 61-75 6-7 Gnffin M (1988) Assumptions for success Nurstr^ Management Robmson K & Fitzgerald M (1990) A staff-centred approach Nurstng Ttmes 86(14), 42-43 19(1), 32U-32X. Hams M D (1988) TTie changmg scene m commumty health Royal College of Nursmg, Soaety of Pnmary Health Care Nursmg (1980) Pnmary Health Care Nurstng A Team Approach nursmg Nursing Clinics of North Amenca 23(3), 559-568 RCN, London Harvey G (1987) Compihng a directory Nurstng Ttrrtes 83(44), Royal College of Nursmg (1990) Quahty Pahent Care the 49-51 Dynamtc Standard Sethng System RCN, London Hastmgs C E (1987) Measurmg quahty assurance m ambulatory care nursmg Joumal of Nursing Admtntstratton 17(4), 12-20 Schofield I (1990) Practical standards Nurstng Ttmes 86(8), 31-32 Her Majesty's Stahonery Office (1989) Worhng for Pattents Sharf B F (1988) Teachmg pahents to speak up past and future Deparhnent of Health HMSO, London trends Pahent Educatton and Counselhng 11(2), 95-108 Hoesmg H & Kirk R (1990) Common sense quahty manageSttuih M J (1987) Valumg a key to netwoikmg quahty nursmg ment Jottmal of Nurstng Adrmnistrahon 20(10), 10-15 Hunt I (1987) Assunng quahty Nurstng Ttmes 83(44), 29-31 Nurstng Forum 23(2), 56-59 Hunt) (1989) Quahty assurance can it happen at a tune of cost Stewart M I & Craig D (1987) Adaptation of the nursmg audit to commumty health nursmg Nttrstng forum 23(4), 134—144 containment? Sentor Nurse 9(8), 11-12 1494
Pahent care tn dtstnct nursing Vogel N A (1988) Development and use of a nursmg process audit mstrument Nursmg Management 19(8), 71-73 World Health Orgamsahon/Umcef (1978) Pnmary Health Care WHO, Geneva Widerquist I G (1988) Development of a record review tool for public health nursmg Nursing Management 19(6), 49-50
Wnght D (1984) An lntrcxiuchon to the evaluation of nursing care a review of the hterature Joumal of Advanced Nursing 9(5), 457-467
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