The sample for the study will be drawn from nurses working in an acute public hospital located in Perth, WA. Data will be collected using semi-structured interviews and some observation. It is estimated that approximately 10-15 interviews will be performed. Theoretical sampling will guide the selection of participants. The significance of this research will be to increase understanding of this complex phenomenon and contribute to efforts aimed at improving and maintaining quality nursing care within the current context of the WA health care system.
A substantive theory explaining the process of quality care, focussing on the nurses' perspective, in an acute public hospital setting, will be developed. Implications for practice will be discussed and directions for further research in this area will be provided. Objectives The purpose of this study is to explore and describe the delivery of quality nursing care from the perspective of practising nurses, working in the acute public hospital setting of WA. The study will examine the actions and interactions attributed to quality, and factors identified as enhancing or inhibiting the delivery of quality nursing care.
The objectives guiding this proposed study are: 1. To explore and describe nurses' perceptions of the meaning of quality nursing care. 2. To describe nurses' experiences in the delivery of nursing care given to patients in hospital and to compare these with their expectations of quality nursing care. 3. To explore factors identified by nurses as enhancing and as inhibiting quality nursing care. 4. To develop a substantive theory which explains the process used to deliver quality nursing care in an acute public hospital setting, as perceived by nurses. Background
The provision of quality patient care is a priority in all health care institutions (Erith-Toth & Spencer, 1991). Formal definitions of what constitutes quality are numerous (Ambler Peters, 1991), as are the approaches used to assess the quality of patient care (Harvey, 1991; MacGuire, 1991). Although much has been written about the phenomenon of quality care, significant variations exist in its interpretation and use, "unaware or undeterred by the conceptual confusion, quality care continues to be assured, controlled, evaluated and managed in the Health Service today" (Attree, 1993, p. 55). Furthermore, definitions and assessment of quality have rarely considered the reality faced by nurses on a daily basis, in the practice and delivery of quality care. Quality nursing care has been studied from various perspectives using different methods. Much of the research reported in the literature has been quantitative in nature and undertaken in countries other than Australia, particularly North America.
Some studies have focussed on the measurement of quality nursing care (Gilloran, McGlew, McKee, Robertson & Wight, 1993; MacGuire, 1991; Pearson, Durant & Punton, 1989; Kitson, 1985), or the meaning of quality nursing care from either the nurses' perspective (Janhonen, 1993; Forchuk ; Kirkpatrick, 1991; Whelan, 1988; Jenkins, 1988) or the patients' perspective (Irurita, 1993; Erith-Toth & Spencer, 1991; Deeny & McCrea, 1991; Rempusheski, Chamberlain, Picard, Ruzanski & Collier, 1988).
Other studies have compared the perceptions of quality nursing care from the perspective of nurses and patients (Norman, Redfern, Tomalin & Oliver, 1992; Yonge, 1989; Varholak, 1989; Board, 1988). Of the studies that have explored nurses' perceptions of quality care, two included some elements of the delivery of nursing care (Forchuk ; Kirkpatrick, 1991; Jenkins, 1988). Those studies differ from this proposed study in context, as both were carried out in North America and used health settings other than acute public hospitals.
Forchuk ; Kirkpatrick (1991) used survey methods in their study of quality care in a psychiatric facility where nurses indicated that the nursing care they 2 delivered was "... the best possible under unfavourable conditions" (p8). Barriers to quality nursing care were identified as "heavy workload and staffing issues" (p8). However, the results of this study are limited by use of a convenience sample and administration of a questionnaire for which reliability and validity were not demonstrated. Jenkins studied quality nursing care in a small hospital in the United States and used a similar design to that proposed for this study.
Using the grounded theory method, the characteristics of quality nursing care from the nurses' perspective were found to be "technical care, adequate time, assessment, observation, teaching, communication, and individualised care". Some enhancing and inhibiting factors were identified, as well as positive and negative outcomes in the status of the patients. This proposed study is justified in that although the methodology is similar, the study by Jenkins was undertaken in a small hospital, whilst this study will be undertaken in a large acute public hospital. Furthermore, the cultural aspects of this proposed study are different.
Another study of quality nursing care was carried out within the context of an acute public hospital setting in WA (Irurita, 1993). This study used grounded theory to explore quality nursing care from the patients' perspective. Patients described different levels of care and suggested that high quality nursing care could not be expected due to intervening conditions such as lack of time, high patient turnover, competing demands on the nurse, lack of consistency and continuity in nurses assigned to their care, ageism, shortage of staff, lack of co-ordination on ward, and communication problems between doctornurse- patients.
These findings raise questions requiring further exploration, including the nurses' perspective. A number of factors may determine the quality of care delivered by nurses to patients. A review of the literature by Fitzpatrick, While, and Roberts (1992) identified nursing competence, use of research, communication skills, care management and organisation of workload, provision of health education and health promotion, creative thinking and reflection as elements of high quality patient care.
A number of research studies have equated the quality of nursing with the ability of the nurse to exhibit caring behaviours towards their patients. Some of these studies have explored the behaviours identified by nurses (From, 1992; Clarke & Wheeler, 1992; Mangold, 1991; Chipman, 1991; Schaefer & Lucke, 1990; Morrison, 1990; Forrest, 1989; Larson, 1986), while others the behaviours identified by patients (Fosbinder, 1991; Cronin & Harrison, 1988; Brown, 1986; Rieman, 1986; Larson, 1984).
Some of the research has compared the views of nurses and patients (Appleton, 1993; Smit & Spoelstra, 1991; Lapsley, 1989; Larson, 1987; Mayer, 1986). Whereas caring has been described as an important component of quality nursing care, exploratory research is lacking in the study of factors which may influence the nurses' ability to exhibit caring behaviours under varying conditions, and what additional factors may be involved in the delivery of quality nursing care.
There is evidence in the literature to suggest that although nurses may be capable of providing quality care and know what constitutes quality care, their performance in practice may be affected by factors such as decreased numbers and the resulting reduction in available time, which can prevent the delivery of quality nursing care (Forchuk ; Kirkpatrick, 1991; Hendrickson, Doddato ; Kovner, 1990). A recent survey of 2,488 Australian nurses (Millis ; Tattam, 1994) found that budgetary cuts and management restructuring were having a negative impact on nurses' work environment.
Increased workload, reduced standards of care (particularly in the public sector), and a lack of improvement in patient care were also said to be apparent. In WA, hundreds of nurses protested at a rally organised by the Australian Nursing Federation to express concerns about the effects of economic cutbacks in the WA health environment. Specifically, the dismantling of the WA Nurses' Career Structure and the reduction of nursing positions were said to be having a negative effect on the delivery of quality nursing care (Bartley, 1994).
Nursing staff in the hospital environment of WA are currently challenged to maintain and improve the quality of care in the face of changing work patterns and moves to promote earlier discharge of hospitalised patients resulting from increasing economic restrictions (Health Observer, 1994). The indication that problems exist in the delivery of quality nursing care in WA warrants closer examination, to discover how nurses deliver quality care and factors which nurses perceive to affect the delivery of quality nursing care in the resent context of acute public hospitals in WA. Increasingly it is recognised that gaps exist between theory and practice (Chine ; Jacobs, 1987; Riley ; Oermann, 1992), an understanding may exist among nurses as to what constitutes quality nursing care, but what actually occurs in practice, under varying conditions, may differ from the recognised standard. Documentation of strategies used by nurses to maintain quality when conditions are adverse are 3 bsent in the literature, as is information indicating what circumstances are favourable to quality care provision and what constitutes the highest quality of nursing care. The suggestion that the delivery of quality nursing care within the public hospital context of WA may be subject to variation and be influenced by different conditions requires further investigation. As stated earlier in this proposal, some research has been performed in other countries on this phenomenon, but few studies have explored quality nursing care from the perspective of practising nurses.
The use of the grounded theory method to research the phenomenon of quality nursing care allows exploration in terms of the current time, place and culture and can give new insights into a topic central to the practice of nursing (Chenitz ; Swanson, 1986). Furthermore, the gap between theory and practice may be reduced by a substantive theory developed in this way. Significance The significance of this research will be to increase our understanding of this complex phenomenon and contribute to efforts aimed at improving and maintaining quality nursing care, within the context of the WA health care system.
A substantive theory explaining the process of quality nursing care, focussing on the nurses' perspective, in an acute public hospital setting will be developed. Implications for practice will be discussed and directions for further research in this area will be provided. Research Method A qualitative research method is proposed for this study, using the grounded theory approach (Glaser & Strauss, 1967). This method, which has its roots in Symbolic Interactionism, will reveal the reality of the quality ursing for nurses by interpreting data using a systematic set of procedures to develop a theory of the phenomenon, grounded in the findings (Strauss & Corbin, 1990). Sample Selection The sample for the study will be drawn from nurses working in one area of an acute public hospital located in Perth, WA. Initially, a purposive sampling technique will be used to select nurses for interview. Only Registered Nurses with a minimum of six months post registration nursing experience (of which at least three must have been worked in the study area) will be approached.
Participants will need to be able to reflect on and be willing to share detailed experiential information about the phenomenon. Volunteers will be sought initially at staff meetings and a contact number will be left on the notice board in each of the ward areas. Further participants will be approached using a theoretical sampling technique where initial analysis of data guides the researcher to subsequent specific data sources (Glaser & Strauss, 1967). When this technique is used, sampling continues until 'theoretical saturation' occurs.
This is recognised by the establishment and denseness of identified categories as well as an absence of new concepts in the data (Strauss & Corbin, 1990). It is estimated that approximately 10-15 participants will be selected for interview, the final number being determined by theoretical saturation. Procedure Data will be collected from nurses through tape-recorded interviews guided by questions reflecting the objectives of the study (Appendix A). A semi-structured interviews technique will be used where, "use of the interview guide is not rigidly adhered to by the interviewer" (Chenitz & Swanson, 1986, p. 67).
In this technique the researcher explores different aspects of the topic in detail using probes such as how, what, where and when. Interviews will take place in mutually agreeable private venues where the risk of interruptions is perceived to be minimal. Basic demographic information will be gathered from participants before the interview commences (Appendix B). The primary source of data will be the transcribed interviews, however, published literature and some observation will be used as additional data sources. The observations will be performed by the researcher (who is regularly assigned to clinical areas) and recorded by field notes.
The main objective of these observations will be to verify data obtained by interview. Furthermore, additional aspects may be noted to be included in subsequent interviews. Data Analysis The constant comparative method of data analysis will be used, whereby data are simultaneously collected, coded and analysed, in a way that allows the creativity necessary for the generation of a theory (Glaser & Strauss, 1967). Interviews will be transcribed verbatim on a word processor and organised for 4 analysis using the Ethnograph computer software (Seidel, 1988).
This package numbers each line of the interview transcript and allows for segments of the interview to be coded and selected as required. Firstly, interview transcripts will be coded line by line, sentence by sentence, by a process of 'open coding', to identify and label common themes and categories by asking questions about the content (Strauss & Corbin, 1990). This will be done by extensively reading the data and listening to the tapes. Categories and subcategories will be developed from this, abbreviated and 'mapped' onto the numbered interview transcript through the Ethnograph.
Coded segments from the interviews will be accessed from the computer for 'Axial Coding'. This involves putting the data back together again in new ways by making connections between the coded categories and subcategories. 'Memos' and 'diagrams' will be used throughout the process of analysis. 'Selective coding' in which the core category is identified, relationships validated and sub-categories expanded, will take place before a 'conditional matrix' is constructed and a substantive theory developed (Strauss & Corbin, 1990). Reliability and Validity A number of strategies will be employed throughout this study to ensure that he data collection and interpretation accurately reflects the phenomenon. Guba (1981) and LeCompte and Goetz (1982) discuss a number of ways in which reliability and validity issues of qualitative research can be addressed. This study has been designed to incorporate measures to address these issues as follows: • To avoid bias in the data collection and analysis, the researcher (who possesses current personal experience of nursing in a hospital setting) will raise awareness of own preconceptions and bias to the topic by being interviewed by another researcher, using the proposed interview guide.
The researcher will avoid imposing these preconceptions on the data collection and analysis. Furthermore, interview transcripts will be reviewed by an independent person to detect the presence of any such bias. A personal diary will also be kept. • Interviews will be transcribed verbatim and transcripts will be checked for accuracy by listening to the tape recording. • The process of data collection and analysis will be clearly described. • During the coding of the data, other researchers will be asked to separately code segments of the transcripts to confirm the categories identified by the researcher. Once the description of the phenomenon is complete, a sample of participants will be approached and asked to validate the description by reading it and seeing if it makes sense in terms of their own experience. Ethical Issues The proposed research will be submitted through the Human Research Ethical Committee at Curtin University of Technology. The study has already been approved for implementation by the Nursing Research and Ethical Review Committee at Sir Charles Gairdner Hospital. Each participant will be informed of the purpose of the study.
Participants' personal contribution together with their human rights will be explained and the opportunity to ask questions about the study will be provided. Once the participant is satisfied with the requirements of the study, a consent form will be signed. The consent outlines the purpose of the study, its voluntary nature, the right to withdraw at any time without penalty, as well as providing an assurance that all information provided will be treated in a non-identifiable, confidential manner (Appendix C). The consent form will be signed by the participant and the researcher, and a copy will be kept by each.
Participants will be identified on the interview transcript by a numerical number. The identity of the participants will be known only to the researcher who will keep names and workplace details in a secure place, separate to the transcripts (this information will be required if further contact is necessary). In keeping with the requirements of the University, the transcribed interviews and field notes will be kept for a period of five years. Facilities and Resources The majority of expenses related to this project have already been funded by the Nursing Division of Sir Charles Gairdner Hospital.
Additional expenses are estimated as follows: Photocopying and paper 5 reams @ $8 $440 5 Inter-Library Loans $200 Audio tapes 5 tapes @ $3 $15 Batteries 6 batteries @ $1 $6 Travel $100 Micro cassette recorder $400 Total: $1 161 Data Storage Data collected will be qualitative in nature and will be stored on a computer while analyses using Ethnograph computer software are completed. The data files will be maintained for five years after which they will be destroyed. Timeline June-August Year 1 Proposal submitted to University Ethics Committee August Year 1-January Year 2 Data collection and analysis
February-June Year 2 Writing of final report 6 References Ambler Peters, D. (1991). Measuring quality: Inspection of opportunity. Holistic Nurse Practitioner, 5(3), 1-7. Appleton, C. (1993). The art of nursing: The experience of patients and nurses. Journal of Advanced Nursing, 18, 892-899. Attree, M. (1993). An analysis of the concept "quality" as it relates to contemporary nursing care. International Journal of Nursing Studies, 30(4), 355-369. Bartley, J. (1994). Hundreds of nurses protest parliament rally huge success. Australian Nursing Federation Newsletter, 10(4), 1-4. Board, R. F.
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Chipman, Y. (1991). Caring: Its meaning and place in the practice of nursing. Journal of Nursing Education, 30(4), 171-175. Clarke, J. B. , ; Wheeler, S. J. (1992). A view of the phenomenon of caring in nursing practice. Journal of Advanced Nursing, 17, 1283-1290. Cronin, S. N. , ; Harrison, B. (1988). Importance of nurse caring behaviours as perceived by patients after myocardial infarction. Heart and Lung, 17(4), 374-380. Deeny, P. , ; McCrea, H. (1991). Stoma care: the patient's perspective. Journal of Advanced Nursing, 16, 39-46. Erith-Toth, P. , & Spencer, M. (1991).
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D. , & Goetz, J. P. (1982). Problems of reliability and validity in ethnographic research. Review of Educational Research, 52(1), 31-60. MacGuire, J. M. (1991). Quality care assessed: using the Senior Monitor index in three wards for the elderly before and after a change in primary nursing. Journal of Advanced Nursing, 16, 511-520. Mangold, A. M. (1991). Senior nursing students’ and professional nurses’ perceptions of effective caring behaviours: A comparative study. Journal of Nursing Education, 30(3), 134-9. Mayer, D. K. (1986). Cancer patients’ and families perceptions of nursing caring behaviours.
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Columbia University Teachers College. Whelan, J. (1988). Ward sisters' management styles and their effects on nurses' perceptions of quality care. Journal of Advanced Nursing, 13, 125-138. Yonge, O. J. ( 1989). Nurses ' and patients' ' perceptions of constant care in an acute care psychiatric facility: A descriptive qualitative study. Unpublished PhD Thesis, University of Alberta, Canada. 8 APPENDIX A Interview Guide What does quality nursing care mean to you? How does one ensure that quality nursing care is given? Give examples, in your experience, where you think high quality nursing care was given. Describe an incident). What are some of the most important aspects to consider in the delivery of quality nursing care? Can these be prioritised? What factors (if any) prevent you from achieving the delivery of quality nursing care to your patients (or patients generally)? What factors enable or help in the delivery of quality nursing care? Give examples of where improvements in nursing care delivery could have been made. How would you rate the quality of care given to patients in your area of work? 9 APPENDIX B Demographic Information 1. Length of time employed at this hospital:_____________ 2.
Length of time employed as a nurse:_____________ 3. Length of time employed on present ward:___________ 4. Level: New graduate______ Level 1_____ Level 2______ 5. Part-time______ Full-time______ 6. Initial nursing education: Hospital_________ College/University__________ 7. Year completed__________ 8. Post basic educational achievements: ____________________________________________________ ____________________________________________________ 9. Current studies: ____________________________________________________ ____________________________________________________ 10. Male_______ Female________ 11. Age_________