CLINICAL ONCOLOGY/QUALITY ASSURANCE
A quality system for oncology nursing Patric Devitt BA (Hons), RGN, RSCN, is Charge Nurse, Bone Marrow Unit. Royal Manchester Children’s Hospital.
The benefits of three quality monitoring systems. Monitor, Qualpacs and the Dynamic Standards Setting System are explored in relation to oncology nursing. ’The author concludes that the flexibility provided by the ‘hottom-up’ design of the DynamicStandards Setting System is admirably suited to the needs of nurses working with cancer patients. Quality assurance is very much a popular con cept in nursing circles at present. One only has to pick up one of the professional journals to be confronted by descriptive and prescriptive articles on quality assurance and standard set ting. Frequently there is a lack of clarity in the definition of these terms, which inevitably serves only to blur the meaning and, indeed, the underlying aims of such articles. To avoid this, a clear understanding of what is meant by quality assurance should be established. According to Schofield, quality assurance is . . concerned with ensuring all those in a health care setting are working together and using available resources to provide the best possible care of patients’ (1). Rowden states . . [quality assurance] requires a patientcentred approach, rooted in clinical practice and based, wherever possible, on credible research’ (2). There are other factors which must also be considered. The first and most important is that quality assurance is not an end in itself; it is a tool to ensure that the patient/client receives the most appropriate and effective care at a level and of a type acceptable to both receivers and providers of care. A suitable quality assurance tool will identify any areas where remedial action needs to be taken and will also provide the basis for decisions about the nature of such action. There are also a number of reasons why qual ity assurance is important: • Professional nurses must not only provide but be seen to provide the highest possible standard of care. • The changing climate within the National Health Service provides incentives to ensure quality of care. • It appears likely that a formal nursing audit will be introduced within five years. • Increased consumer awareness generates pressure on health care professionals not only
to provide the best care possible, but also to be able to provide a rationale for the chosen provision. • From the point of view of the individual ‘carer’, it is only natural to want to provide care of the highest possible standard. All of the above considerations apply to oncolo gy nursing, but there are particular aspects of the specialty which give an added importance to the concept of quality assurance. The rapidly developing and changing meth ods of medical, paramedical and complementary care mean that nurses must constantly examine and evaluate the care they provide to ensure that it is of the highest standard, and is the best and most appropriate available. The combination of this and the often highly charged emotional atmosphere of oncology units places particular demands on any quality assurance tool used. It must be sufficiently flexible to cope with chang ing situations, while still providing clear crite ria for judging care.
Satisfaction with service A very basic way of monitoring quality is to define staff and patient satisfaction with the ser vice. At its simplest level, rates of complaints and staff sickness are monitored, and the system can be refined, to a degree, by the issue of ques tionnaires to patients. While this may be illu minating in particular areas, such as waiting times in A Sc F departments, it is basically a very crude tool and does little to provide information on a wider base about the quality of care given. One of the most commonly used methods of quality assurance in this country is Monitor (3), with a reported uptake of 35.7 per cent among English district health authorities (DBAs) (4). This is a British system, adapted from the Rush Medicus Index, an American system originally designed for use on acute adult medical and sur gical wards. It has, however, been significantly refined for use in a number of specialties, includ ing oncology, notably at The Royal Marsden Hospital. Monitor is divided into two parts; Patient Monitor (subdivided into assessment and plan ning, physical needs, psychological needs and evaluation of care) and Ward Monitor (subdi vided into quality of practice, procedure and
June 10/Volume 6/Number 38/1992 Nursing Standard 35 Downloaded from RCNi.com by ${individualUser.displayName} on Jul 25, 2017. For personal use only. No other uses without permission. Copyright © 2017 RCN Publishing Company Ltd
Patric Devitt: ‘DySSSy must be focused on the patient/client and be situation based.'
i
L 5
7
■k
Table 1: Example of Monitor scoring (7) Topic
Score
Assessment & planning Physical needs Psychological needs Evaluation
25.0% 47.6% 56.3% 81.8%
Overall total
49.3%
il
t 9
management of the ward). Data are collected over a full clay under a number of evaluative criteria (200 lor Patient Monitor, 43 tor Ward Monitor) by trained nurse assessors, usually two per ward. The data come from a variety of sources includ ing direct observation of care, patient and staff interviews and a review of patient records. Major emphasis appears to be placed on the last source. After collation and analysis of data, a percentage score is given in each of the seven areas men tioned above. It has the advantage of being able to be used as an ongoing system - repeating the assessment at intervals-to monitor, for instance, the effect of any changes introduced. Monitor has its share of admirers (5,6) and detractors (7,8) as a quality assurance system. In its favour is the fact that it is a well-tried and tested tool, and is adaptable to a wide range of specialties and clinical settings. Additional advantages claimed for the system include the suggestion that it can provide an overview of the care provided on a ward, rather than singling out individuals for praise or blame, and also that its findings tend to match those of the ‘common sense’ appraisal of the quality of care in any given clinical setting. In spite of (or perhaps because of) its widespread use, Monitor has attracted critics. Wheelan (6), commenting on its use at The Royal Marsden Hospital, was concerned about observer bias. It must be acknowledged that if the case she advances is justified, then Monitor represents a less useful tool than it may have first appeared. Another criticism advanced (7,8) is that the system is more reliant on what is record-
ed about the care than the care itself; 70 per cent of items can be answered without any observa tion of patient care. As any practising nurse can confirm, the care actually given and what is recorded are not always the same thing (this is perhaps an area worthy of assessment and improvement in its own right). A further criticism of Monitor concerns the scoring system for Patient Monitor; the four areas are scored separately, although they must be seen as being interlinked - how is it possible to eval uate care of physical needs when it was not assessed orgiven? Consider the example in Table 1, taken from Barnet and Wainwrighr (7), which appears to provide a satisfactory result, but is less impressive on closer examination. If only one quarter of the actual needs are assessed and planned, and only approximate ly one half are met and four-fifths ol these are evaluated, the overall picture is that 12 per cent of needs are met and a mere 9.5 per cent of total needs are evaluated. This makes the total score of 49.3 per cent seem generous. Another quality assurance tool that appears widely in nursing literature is Qualpacs (9). In 1987 the reported uptake of this system in English health authorities was 3.6 percent (4). This is an American system, developed at Wayne State University anti implemented without major alteration in this country. It consists of a 68-item scale covering six sec tions; psychosocial (individual), psychosocial (group), physical, general, communication and professional implications. It is marked on a five point scale: best care, between, average care, between and poorest care. Assessors spend two hours directly observing the giving of care and then one hour examining the records of care given. It is recommended that there should be a minimum of two nurse asses sors per ward. According to research carried out in North America, Qualpacs produces replicable results.
Professional judgement The most obvious criticism of Qualpacs is that its base values, concepts and ideals, which are American in origin, are arguably alien to British nurses and nursing, though the fact that Oxford region has used Qualpacs as a quality assurance tool suggests that this prob lem can be overcome. Critics have also suggested that the Qualpacs definition of‘quality’ is excessively narrow and that it places too much emphasis on the psychosocial and communicative aspects of nursing care. In addition, the sys tem has been criticised for a perceived overreliance on the individual assessor’s
36 NursingDownloaded Standard Junefrom 10/Volume 6/Number 3b/1992 RCNi.com by ${individualUser.displayName} on Jul 25, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
SION TOUHIG
CLINICAL ONCOLOGY/QUALITY ASSURANCE
«
A quality system for oncology nursing Patric Devitt BA (Hons), RGN, RSCN, is Charge Nurse, Bone Marrow Unit. Royal Manchester Children’s Hospital.
The benefits of three quality monitoring systems. Monitor, Qualpacs and the Dynamic Standards Setting System are explored in relation to oncology nursing. ’The author concludes that the flexibility provided by the ‘hottom-up’ design of the DynamicStandards Setting System is admirably suited to the needs of nurses working with cancer patients. Quality assurance is very much a popular con cept in nursing circles at present. One only has to pick up one of the professional journals to be confronted by descriptive and prescriptive articles on quality assurance and standard set ting. Frequently there is a lack of clarity in the definition of these terms, which inevitably serves only to blur the meaning and, indeed, the underlying aims of such articles. To avoid this, a clear understanding of what is meant by quality assurance should be established. According to Schofield, quality assurance is . . concerned with ensuring all those in a health care setting are working together and using available resources to provide the best possible care of patients’ (1). Rowden states . . [quality assurance] requires a patientcentred approach, rooted in clinical practice and based, wherever possible, on credible research’ (2). There are other factors which must also be considered. The first and most important is that quality assurance is not an end in itself; it is a tool to ensure that the patient/client receives the most appropriate and effective care at a level and of a type acceptable to both receivers and providers of care. A suitable quality assurance tool will identify any areas where remedial action needs to be taken and will also provide the basis for decisions about the nature of such action. There are also a number of reasons why qual ity assurance is important: • Professional nurses must not only provide but be seen to provide the highest possible standard of care. • The changing climate within the National Health Service provides incentives to ensure quality of care. • It appears likely that a formal nursing audit will be introduced within five years. • Increased consumer awareness generates pressure on health care professionals not only
to provide the best care possible, but also to be able to provide a rationale for the chosen provision. • From the point of view of the individual ‘carer’, it is only natural to want to provide care of the highest possible standard. All of the above considerations apply to oncolo gy nursing, but there are particular aspects of the specialty which give an added importance to the concept of quality assurance. The rapidly developing and changing meth ods of medical, paramedical and complementary care mean that nurses must constantly examine and evaluate the care they provide to ensure that it is of the highest standard, and is the best and most appropriate available. The combination of this and the often highly charged emotional atmosphere of oncology units places particular demands on any quality assurance tool used. It must be sufficiently flexible to cope with chang ing situations, while still providing clear crite ria for judging care.
Satisfaction with service A very basic way of monitoring quality is to define staff and patient satisfaction with the ser vice. At its simplest level, rates of complaints and staff sickness are monitored, and the system can be refined, to a degree, by the issue of ques tionnaires to patients. While this may be illu minating in particular areas, such as waiting times in A Sc F departments, it is basically a very crude tool and does little to provide information on a wider base about the quality of care given. One of the most commonly used methods of quality assurance in this country is Monitor (3), with a reported uptake of 35.7 per cent among English district health authorities (DBAs) (4). This is a British system, adapted from the Rush Medicus Index, an American system originally designed for use on acute adult medical and sur gical wards. It has, however, been significantly refined for use in a number of specialties, includ ing oncology, notably at The Royal Marsden Hospital. Monitor is divided into two parts; Patient Monitor (subdivided into assessment and plan ning, physical needs, psychological needs and evaluation of care) and Ward Monitor (subdi vided into quality of practice, procedure and
June 10/Volume 6/Number 38/1992 Nursing Standard 35 Downloaded from RCNi.com by ${individualUser.displayName} on Jul 25, 2017. For personal use only. No other uses without permission. Copyright © 2017 RCN Publishing Company Ltd
Patric Devitt: ‘DySSSy must be focused on the patient/client and be situation based.'
i
L 5
7
■k
Table 1: Example of Monitor scoring (7) Topic
Score
Assessment & planning Physical needs Psychological needs Evaluation
25.0% 47.6% 56.3% 81.8%
Overall total
49.3%
il
t 9
management of the ward). Data are collected over a full clay under a number of evaluative criteria (200 lor Patient Monitor, 43 tor Ward Monitor) by trained nurse assessors, usually two per ward. The data come from a variety of sources includ ing direct observation of care, patient and staff interviews and a review of patient records. Major emphasis appears to be placed on the last source. After collation and analysis of data, a percentage score is given in each of the seven areas men tioned above. It has the advantage of being able to be used as an ongoing system - repeating the assessment at intervals-to monitor, for instance, the effect of any changes introduced. Monitor has its share of admirers (5,6) and detractors (7,8) as a quality assurance system. In its favour is the fact that it is a well-tried and tested tool, and is adaptable to a wide range of specialties and clinical settings. Additional advantages claimed for the system include the suggestion that it can provide an overview of the care provided on a ward, rather than singling out individuals for praise or blame, and also that its findings tend to match those of the ‘common sense’ appraisal of the quality of care in any given clinical setting. In spite of (or perhaps because of) its widespread use, Monitor has attracted critics. Wheelan (6), commenting on its use at The Royal Marsden Hospital, was concerned about observer bias. It must be acknowledged that if the case she advances is justified, then Monitor represents a less useful tool than it may have first appeared. Another criticism advanced (7,8) is that the system is more reliant on what is record-
ed about the care than the care itself; 70 per cent of items can be answered without any observa tion of patient care. As any practising nurse can confirm, the care actually given and what is recorded are not always the same thing (this is perhaps an area worthy of assessment and improvement in its own right). A further criticism of Monitor concerns the scoring system for Patient Monitor; the four areas are scored separately, although they must be seen as being interlinked - how is it possible to eval uate care of physical needs when it was not assessed orgiven? Consider the example in Table 1, taken from Barnet and Wainwrighr (7), which appears to provide a satisfactory result, but is less impressive on closer examination. If only one quarter of the actual needs are assessed and planned, and only approximate ly one half are met and four-fifths ol these are evaluated, the overall picture is that 12 per cent of needs are met and a mere 9.5 per cent of total needs are evaluated. This makes the total score of 49.3 per cent seem generous. Another quality assurance tool that appears widely in nursing literature is Qualpacs (9). In 1987 the reported uptake of this system in English health authorities was 3.6 percent (4). This is an American system, developed at Wayne State University anti implemented without major alteration in this country. It consists of a 68-item scale covering six sec tions; psychosocial (individual), psychosocial (group), physical, general, communication and professional implications. It is marked on a five point scale: best care, between, average care, between and poorest care. Assessors spend two hours directly observing the giving of care and then one hour examining the records of care given. It is recommended that there should be a minimum of two nurse asses sors per ward. According to research carried out in North America, Qualpacs produces replicable results.
Professional judgement The most obvious criticism of Qualpacs is that its base values, concepts and ideals, which are American in origin, are arguably alien to British nurses and nursing, though the fact that Oxford region has used Qualpacs as a quality assurance tool suggests that this prob lem can be overcome. Critics have also suggested that the Qualpacs definition of‘quality’ is excessively narrow and that it places too much emphasis on the psychosocial and communicative aspects of nursing care. In addition, the sys tem has been criticised for a perceived overreliance on the individual assessor’s
36 NursingDownloaded Standard Junefrom 10/Volume 6/Number 3b/1992 RCNi.com by ${individualUser.displayName} on Jul 25, 2017. For personal use only. No other uses without permission.
Copyright © 2017 RCN Publishing Company Ltd
SION TOUHIG
CLINICAL ONCOLOGY/QUALITY ASSURANCE
«
