Joumal of Advanced Nursing,
1992,17,1I95-1I99
Good nursing practice as perceived by clients: a starting point for the development of professional nursing Paivi Astedt-Kurb RN MA(Nursing) Licentiate m health care Assistant in Nursmg, Department of Nursing, University of Tampere, Tampere
arwl Arja Haggman-Laitila RN MA(Nursing) Project Manager (Co-operation project in soaal services and health care) Hausjarvi, Finland
Accepted for pubiicahon 30 Mardi 1992
ASTEDT-KURKI P & HAGGMAN-LAITILA A (1992) journal of Advanced
Nursing 17,1195-1199 Good nursmg practice as perceived by clients: a starting point for the development of professional nursing This paper presents chents' experiences of health care and nursmg services m the Finnish pnmary health care and hospital system These are descnbed to find evaluation cntena for good nursing care and to pomt out challenges for development of the nursing profession INTRODUCTION
care services are developed Accordmg to the nahonal The development of the Finnish public health care system Fmnish health pohcy programme, the number of places m and of nursing practice as part of it is faced with many hospitals and other health care mstitutions wiU not be different challenges National health policy is naturally mcreased even though the number of long-term illnesses is influenced by vanous programmes and pubhc statements growing conhnuously Health care services are provided The programme Health for All by the Year 2000 (see more and more fi-equently in the form of commumty serTargets for Health For All 1986), for example, states as the vices which mainly consist of visits to the out-pahents goals of health pohcy chent-centredness, implementation umts of hospitals and the clients' homes Moreover, of health services in a human manner, and flexibdity of patients are expeded to stay m hospital for a shorter penod of time than m the past services TTie orgamzahon of health care alone bnngs pressure on the development of this activity m order to substitute a more chent-onented model for the bureaucrahc, speciahstdommated machinery, we must look at the services cnhcally and then see to their re-orgamzmg (Kokko I99I, Raivio 1991) The important role of dients m the Firmish health care system is emphasized because a large number of the commonest diseases are actually caused by people's own hfestyle and the prevention and care of these diseases requires that the individual himself takes an active part m this own health care However, the dients are not only responsible for the prevenhon of common diseases, but their overaU responsibility for their own health care is also maeased as health CorrtsponJkna Paim A^e^-tdah. Assi^imt m Nursmg. Department of Nursing, Ibaversfy (4 Tampere, PO Bex607 ST-33101 Tamptre. Fmknd.
Clients' knowledge Today clients generally know more about health services Consequently, they have greater expectahons but, at the same hme, they are also more cntical m their athtudes AU this presents a chaUenge for the health care professionals who need to redefine the starhng pomts of their own practice There is a consaous effort among the Finmsh nursmg practitioners to develop their own practice Quality assurance programmes, for example, have been implemented as an mtegral part of nursing practice, and the model of pnmary nursmg, adapted to the Finmsh condihons, IS now used m many hospitals (e g Laitmen 1989, Hallila 1990, Laaksonen 1990, Niemela 1990, Perala 1990a,b,c 1195
P Astedt-Kurkt and A Haggman-Lattila
Luotolmna-Lybeck 1991, Timonen 1991) Similarly, nursmg research in Fmland focuses on nursmg prachce and the development of practice is based on research data (see Lemo-Kilpi 1990, Liukkonen 1990, Vehvilamen-Julkunen 1990, Kiikkala I99I) So far only a lunited amount of research has been done m Finland on the opimons and expenences of clients/patients who have been cared for withm the health care system The majonty of studies have been made as recently as the 1980s The projects can be divided into two groups according to their approach first, studies of the services provided for patients (eg Rmnevuon & Salmela 1986, Keski-Suomen sairaanhoitopunn kuntamlutto 1987, Laitmen-Pesola 1989) and, secondly, studies based on need theones (e g Niemela & Makmen 1982, Kuosmanen 1988, Smkkonen etal 1988) In these studies the evaluahon of 'good nursmg' has happened on the basis of evaluation cntena set m advance The present paper discusses how the users of health care services perceive the care they have received The goal is to add to the knowledge of the 'goodness' of the services speafically m relahon to the dients' own concephons which, in tum, have been mterpreted to determme the evaluahon cntena ldentifymg the cntena based on the patients'/clients' own f)erception of the services provided IS useful m developing better structured methods, and with their help it will ultimately be possible to penetrate the chents' expenential world m greater depth
RESEARCH DATA The results reported m this paper are based on qualitative data collected from 100 Fmnish adults (see HaggmanLaitilal989,Astedt-Kurki 1989) Sixty of them were clients visitmg vanous speciahst dmics of a central hospital while 40 were reapients of basic health care services In order to ensure a diverse body of expenenhal knowledge, the study mduded men and women who had used difiFerent kmds of health care services The central hospital sample consisted of 27 men and the health centre sample consisted of 16 men, while the correspondmg figures for women were 33 and 24 Some of the parhapants had only visited the outpahents' umt of a hospital or health centre, while others also had expeneiKe of nursmg care m a ward The ages of the parhapants m the central hospital group vaned frixn 30 to 50 years, whereas the ages m the basic health care group ranged from 32 to 88 All partiapants had personally visited the health care mshtuhon m queshon. The research data were gathered by means of focused mterviews The mterviewees were allowed to talk fi:«ely 1196
about their own expenences related to health and health care services Tlie interviews lastedfi'om45 mmutes to an hour emd a half and they were recorded to ensure accuracy of information Afterwards the mterview recordmgs were transcnbed for analysis The researdiers also kept a socaUed diary of each interviewee, which was helpful at the stage of analysis iTie data obtained consisted of expenences which the mformants themselves considered meanmgful As to health care services, the data also contamed developmental ideas from the perspective of the dient In addition to general expenences of health care, the interviews focused on expenences of nursing practice m particular This report deals with that section of the mterview data which concentrated on the foUowmg themes the matters m which the dient has tumed to health care services, his expenences of the care he has received, his opimon as to whether he has received the help he wanted, those aspects of care which the chent has been sahsfied with and those which he has found defechve The evaluation cntena for good nursmg care presented here were estabhshed as the researchers mterpreted the dients' expenences of the care they had received The objective was tofind,by means of interpretahon, totahties which would descnbe good nursmg care from the perspective of the dients The thoughts and expenences of the research subjects were then conceptualized to depid good care (For an interpretative approach, see for example Parse el al 1985, Oiler 1986, Field & Morse 1988) Questions which related to the rehabihty of research data m qualitahve, phenomenological research deviate fi'om those of so-called traditional research It is important to mterpret the ideas of the research subjects as 'corredly' and accurately as possible Rehability is mcreased by the fact that people partiapatmg m the study had an idea of the research object and they also had personal expenence of it (e g Sandelowski 1986) The mterachve skills and nursmg experhse of the mterviewers, that is of the researchers themselves, were of importance m handimg the topic and canymg out the mterview Most subjects expenenced the researcher as reliable and they felt they could freely talk about thmgs which they regarded as most important (e g Swanson-Kauffinan 1986, Ammon-Gaberson & Piant
1992,17,1I95-1I99
Good nursing practice as perceived by clients: a starting point for the development of professional nursing Paivi Astedt-Kurb RN MA(Nursing) Licentiate m health care Assistant in Nursmg, Department of Nursing, University of Tampere, Tampere
arwl Arja Haggman-Laitila RN MA(Nursing) Project Manager (Co-operation project in soaal services and health care) Hausjarvi, Finland
Accepted for pubiicahon 30 Mardi 1992
ASTEDT-KURKI P & HAGGMAN-LAITILA A (1992) journal of Advanced
Nursing 17,1195-1199 Good nursmg practice as perceived by clients: a starting point for the development of professional nursing This paper presents chents' experiences of health care and nursmg services m the Finnish pnmary health care and hospital system These are descnbed to find evaluation cntena for good nursing care and to pomt out challenges for development of the nursing profession INTRODUCTION
care services are developed Accordmg to the nahonal The development of the Finnish public health care system Fmnish health pohcy programme, the number of places m and of nursing practice as part of it is faced with many hospitals and other health care mstitutions wiU not be different challenges National health policy is naturally mcreased even though the number of long-term illnesses is influenced by vanous programmes and pubhc statements growing conhnuously Health care services are provided The programme Health for All by the Year 2000 (see more and more fi-equently in the form of commumty serTargets for Health For All 1986), for example, states as the vices which mainly consist of visits to the out-pahents goals of health pohcy chent-centredness, implementation umts of hospitals and the clients' homes Moreover, of health services in a human manner, and flexibdity of patients are expeded to stay m hospital for a shorter penod of time than m the past services TTie orgamzahon of health care alone bnngs pressure on the development of this activity m order to substitute a more chent-onented model for the bureaucrahc, speciahstdommated machinery, we must look at the services cnhcally and then see to their re-orgamzmg (Kokko I99I, Raivio 1991) The important role of dients m the Firmish health care system is emphasized because a large number of the commonest diseases are actually caused by people's own hfestyle and the prevention and care of these diseases requires that the individual himself takes an active part m this own health care However, the dients are not only responsible for the prevenhon of common diseases, but their overaU responsibility for their own health care is also maeased as health CorrtsponJkna Paim A^e^-tdah. Assi^imt m Nursmg. Department of Nursing, Ibaversfy (4 Tampere, PO Bex607 ST-33101 Tamptre. Fmknd.
Clients' knowledge Today clients generally know more about health services Consequently, they have greater expectahons but, at the same hme, they are also more cntical m their athtudes AU this presents a chaUenge for the health care professionals who need to redefine the starhng pomts of their own practice There is a consaous effort among the Finmsh nursmg practitioners to develop their own practice Quality assurance programmes, for example, have been implemented as an mtegral part of nursing practice, and the model of pnmary nursmg, adapted to the Finmsh condihons, IS now used m many hospitals (e g Laitmen 1989, Hallila 1990, Laaksonen 1990, Niemela 1990, Perala 1990a,b,c 1195
P Astedt-Kurkt and A Haggman-Lattila
Luotolmna-Lybeck 1991, Timonen 1991) Similarly, nursmg research in Fmland focuses on nursmg prachce and the development of practice is based on research data (see Lemo-Kilpi 1990, Liukkonen 1990, Vehvilamen-Julkunen 1990, Kiikkala I99I) So far only a lunited amount of research has been done m Finland on the opimons and expenences of clients/patients who have been cared for withm the health care system The majonty of studies have been made as recently as the 1980s The projects can be divided into two groups according to their approach first, studies of the services provided for patients (eg Rmnevuon & Salmela 1986, Keski-Suomen sairaanhoitopunn kuntamlutto 1987, Laitmen-Pesola 1989) and, secondly, studies based on need theones (e g Niemela & Makmen 1982, Kuosmanen 1988, Smkkonen etal 1988) In these studies the evaluahon of 'good nursmg' has happened on the basis of evaluation cntena set m advance The present paper discusses how the users of health care services perceive the care they have received The goal is to add to the knowledge of the 'goodness' of the services speafically m relahon to the dients' own concephons which, in tum, have been mterpreted to determme the evaluahon cntena ldentifymg the cntena based on the patients'/clients' own f)erception of the services provided IS useful m developing better structured methods, and with their help it will ultimately be possible to penetrate the chents' expenential world m greater depth
RESEARCH DATA The results reported m this paper are based on qualitative data collected from 100 Fmnish adults (see HaggmanLaitilal989,Astedt-Kurki 1989) Sixty of them were clients visitmg vanous speciahst dmics of a central hospital while 40 were reapients of basic health care services In order to ensure a diverse body of expenenhal knowledge, the study mduded men and women who had used difiFerent kmds of health care services The central hospital sample consisted of 27 men and the health centre sample consisted of 16 men, while the correspondmg figures for women were 33 and 24 Some of the parhapants had only visited the outpahents' umt of a hospital or health centre, while others also had expeneiKe of nursmg care m a ward The ages of the parhapants m the central hospital group vaned frixn 30 to 50 years, whereas the ages m the basic health care group ranged from 32 to 88 All partiapants had personally visited the health care mshtuhon m queshon. The research data were gathered by means of focused mterviews The mterviewees were allowed to talk fi:«ely 1196
about their own expenences related to health and health care services Tlie interviews lastedfi'om45 mmutes to an hour emd a half and they were recorded to ensure accuracy of information Afterwards the mterview recordmgs were transcnbed for analysis The researdiers also kept a socaUed diary of each interviewee, which was helpful at the stage of analysis iTie data obtained consisted of expenences which the mformants themselves considered meanmgful As to health care services, the data also contamed developmental ideas from the perspective of the dient In addition to general expenences of health care, the interviews focused on expenences of nursing practice m particular This report deals with that section of the mterview data which concentrated on the foUowmg themes the matters m which the dient has tumed to health care services, his expenences of the care he has received, his opimon as to whether he has received the help he wanted, those aspects of care which the chent has been sahsfied with and those which he has found defechve The evaluation cntena for good nursmg care presented here were estabhshed as the researchers mterpreted the dients' expenences of the care they had received The objective was tofind,by means of interpretahon, totahties which would descnbe good nursmg care from the perspective of the dients The thoughts and expenences of the research subjects were then conceptualized to depid good care (For an interpretative approach, see for example Parse el al 1985, Oiler 1986, Field & Morse 1988) Questions which related to the rehabihty of research data m qualitahve, phenomenological research deviate fi'om those of so-called traditional research It is important to mterpret the ideas of the research subjects as 'corredly' and accurately as possible Rehability is mcreased by the fact that people partiapatmg m the study had an idea of the research object and they also had personal expenence of it (e g Sandelowski 1986) The mterachve skills and nursmg experhse of the mterviewers, that is of the researchers themselves, were of importance m handimg the topic and canymg out the mterview Most subjects expenenced the researcher as reliable and they felt they could freely talk about thmgs which they regarded as most important (e g Swanson-Kauffinan 1986, Ammon-Gaberson & Piant
