Literature review: measurement of adequate care

'If it is not recorded, it has not been done!'? consistency between nursing records and observed nursing care in an Italian hospital

AIMS

The aim of this study is to evaluate the consistency between the care given to patients and that documented, by comparing care observations with nursing records and describing which interventions were reported and which were omitted.

BACKGROUND

Assumptions have been made about the relationship between documentation and care actually delivered, but there is insufficient evidence on the relationship between the actual care given and its recording.

DESIGN

Observational study of the care given, completed by interviews and retrospective survey of records.

METHODS

Structured observation during day shifts in the first six days of admission of pre and postsurgical care provided to 21 consecutive patients undergoing major abdominal surgery and audit of their nursing records. Each observation was completed by short interviews to nurses to ensure observations validity.

RESULTS

Only 40% of nursing activities observed were included in the nursing records (37% of the assessments and 45% of the interventions). This indicated that nurses carry out more activities than they report. Consistency between performed and recorded care decreased significantly during the days when a higher number of activities were performed. Consistency between recording and observation of assessment activities was 38% for physical needs and 0% for educational needs. Consistency was higher for the assessments of physical signs/symptoms and risk factors for complications compared to the assessment of basic needs and pain. Consistency was 47% for technical interventions and 3% for educational activities.

CONCLUSIONS

Nursing records were not found to be an adequate tool for quality care evaluation, because they did not include all the caring activities that the nurses had carried out.

RELEVANCE TO CLINICAL PRACTICE

This study supports the need to identify documentation systems that are easy to complete. Moreover, nursing education should pay more attention to the competences in the field of holistic care and patient education.

Structured implicit review: a new method for monitoring nursing care quality

BACKGROUND

Nurses' independent decisions about assessment, treatment, and nursing interventions for hospitalized patients are important determinants of quality of care. Physician peer implicit review of medical records has been central to Medicare quality management and is considered the gold standard for reviewing physician care, but peer implicit review of nursing processes of care has not received similar attention.

OBJECTIVE

The objective of this study was to develop and evaluate nurse structured implicit review (SIR) methods.

RESEARCH DESIGN

We developed SIR instruments for rating the quality of inpatient nursing care for congestive heart failure (CHF) and cerebrovascular accident (CVA). Nurse reviewers used the SIR form to rate a nationally representative sample of randomly selected medical records for each disease from 297 acute care hospitals in 5 states (collected by the RAND-HCFA Prospective Payment System study).

SUBJECTS

The study subjects were elderly Medicare inpatients with CHF (n = 291) or CVA (n = 283).

MEASURES

We developed and tested scales reflecting domains of nursing process, evaluated interrater and interitem reliability, and assessed the extent to which items and scales predicted overall ratings of the quality of nursing care.

RESULTS

Interrater reliability for 14 of 16 scales (CHF) or 10 of 16 scales (CVA) was > or = 0.40. Interitem reliability was > 0.80 for all but 1 scale (both diseases). Functional Assessment, Physical Assessment, and Medication Tracking ratings were the strongest predictors of overall nursing quality ratings (P < 0.001 for each).

CONCLUSIONS

Nurse peer review with SIR has adequate interrater and excellent scale reliabilities and can be a valuable tool for assessing nurse performance.

Intraoperative nursing care as experienced by surgical patients

Researchers studied the expectations and experiences related to intraoperative nursing care of patients who underwent hip replacement procedures with regional anesthesia at University Hospital, Tampere, Finland. They used patients' perspectives to develop a conceptual framework that describes quality intraoperative nursing care.

A corporate needs assessment for the purchase of district nursing: a qualitative approach

A qualitative research methodology was applied to a corporate assessment of need for district nursing services. Semi-structured interviews were held with district nurses and the transcripts analysed for common themes. The major determinants of district nurses' roles were the priorities and practices of other community-based services, particularly social services and primary care. Purchasing and contract setting in this area needs to focus more on the interface with other services.

Using tracers to link health services to training through evaluation

The tracer concept was applied to evaluate the delivery of family health care and the training of family health workers. A retrospective evaluation permitted linking the products of care to process, input and context, by isolating and analysing potential factors contributing to a limited number of representative concerns. Contributory learning deficiencies identified in health workers, one input to health care as well as a product of training, enabled the evaluation of training programmes to be focused on related segments of the courses. The latter were evaluated through a pathway analysis which followed the same deficiency model as the evaluation of health care. Links were thus established between the traditionally compartmentalized training and service sectors in health.

Assessing the outcomes of nursing care

There are many dimensions to outcome measurement for patient care and this study focuses on one aspect of outcome, namely that which is most concerned with the immediate effects of nursing care. Traditionally, outcome studies have been almost exclusively concerned with measuring the clinical outcomes of care with very little attempt being made to assess the effect of the nurses' contributions to that care. One of this study's purposes has been to redress this imbalance. As part of a research project on skill mix and the effectiveness of nursing care, a number of patient-focused standards related to the outcome of nursing care were designed. These were tested, in a case study situation, on 15 wards at seven acute hospitals. Initial testing indicates that these outcome measures show promise as a valid and reliable evaluation instrument with the utility for easy application in the clinical setting. They are being presented as a possible way forward to assessing the outcomes of nursing care.

Audits of nursing care in Britain: a review and a critique of approaches to validating them

The literature on audits of nursing care shows a strong link between the quality of nursing care and nursing labour force issues. Early attempts to develop a universally applicable formula to set nurse staffing levels on the basis of variations in patient dependency were shown to have been based on unrealistic assumptions about the ability of scientific methods to remove the influence of judgement from such areas of decision-making. The extent to which the validity of audit instruments has been established is reviewed, showing the number of studies to be small, almost exclusively in relation to American instruments, and with inconclusive results. An extension of the concept of validity is discussed, based on House's approach [House, E.R. (1980). Evaluating with Validity. Sage Publications, London, Beverly Hills] towards establishing validity in educational evaluation. This approach explicitly acknowledges the role of judgement in the evaluative enterprise, and widens the debate about how to settle questions of validity for audits of nursing care.

The hospital ward sister: professional gatekeeper

This study is a shortened report of research exploring ward sisters/charge nurses' perceptions of their responsibilities. (Throughout the study, the title 'ward sister' is used to refer to ward sister/charge nurse.) Using semi-structured interview technique, 10 hospital sisters from two large hospitals in the south of England were interviewed. The emergent data were analysed using grounded theory method. From the analysis, the substantive theory was developed that ward sisters act to gatekeep the professional function of the nurse. Many previous British studies have explored the role of the ward sister, reporting the powerful influence that the ward sister exerts over her environment. This study suggests that one of the reasons the ward sister is able to exert such power is because of her professional gatekeeper role. The shift in emphasis from the clinical to the managerial function of ward sister could therefore have important implications for the professional nursing function. Some possible implications are discussed and recommendations are made.