Quality of nursing care perceived by patients and their nurses: an application of the critical incident technique. Part 1

The quality of nursing care as perceived by nursing personnel: Critical incident technique

AIMS

To identify the determinants of the quality of nursing care from the perceptions of nursing personnel.

BACKGROUND

The quality of nursing care is often measured with standards, expectations, satisfaction and outcomes, but in developing countries, it relies mostly on negative indicators.

METHODS

A descriptive qualitative study was used. Semi-structured interviews based on the critical incident technique were conducted with a convenience sample of 136 nursing personnel who told 225 stories.

RESULTS

Seven quality determinants of nursing care were identified as follows: standard of care, triage and assessment, emergency care, communication with the patient or family, communication with colleagues, multidisciplinary teamwork and helping colleagues. The most important one was the standard of care.

CONCLUSION

Quality nursing care is based on the degree of excellence nursing personnel show with regard to their competences in technical care, communication and teamwork. A key attribute of quality nursing care is defined by the related standards, and the focus is mostly on the nursing care process.

IMPLICATIONS FOR NURSING MANAGEMENT

These findings can increase awareness of the determinants of nursing quality and the qualities of the nursing personnel involved and can help managers to evaluate nursing practice, select new employees and organise teams.

Following-up midwives after adverse incidents: How front-line management practices help second victims

OBJECTIVE

To describe how front-line managers of maternity wards provide support to midwives as second victims in the aftermath of an adverse incident.

DESIGN

A qualitative study using critical incident technique and a content analytic approach of semi-structured in-depth interviews.

SETTING

Maternity wards in 10 Norwegian hospitals with more than 200 registered births annually were included in the study.

PARTICIPANTS

A purposeful sample of 33 midwives with more than two years' working experience described 57 adverse incidents.

FINDINGS

Maternity ward managers utilised four types of practices to support midwives after critical incidents: management, transformational leadership, distributed leadership and laissez-faire leadership.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The study shows that proactive managers who planned for how to handle critical incidents provided midwives with needed individual support and learning. Proactive transformational leadership and delegating roles for individual support should be promoted when assisting second victims after critical incidents. Managers can limit the potential harm to second victims by preparing for the eventuality of a crisis and institute follow-up practices.

Adolescents' experiences of distress on an acute mental health inpatient unit: A qualitative study

Adolescents admitted to acute mental health inpatient units can experience episodes of distress for numerous reasons. Little is known about how they attempt to cope with this distress. This paper explores adolescent experiences of distress in an acute mental health inpatient unit. Fifty hours of non-participant observations were conducted and documented using a critical incident technique (CIT) framework. An interpretive descriptive approach was used to analyse the observation data collected. Nineteen episodes of adolescent distress were observed and five themes emerged, of which two will be explored in this paper: clinical contexts and triggers, and coping or help-seeking actions. The findings of this study will help mental health nurses working on acute adolescent units understand how adolescents attempt to cope with, and seek help for, episodes of distress, and enhance early responses to prevent escalation of distress.

The Critical Incident Technique: Method or Methodology?

The critical incident technique (CIT) is a qualitative research tool that is frequently used in health services research to explore what helps or hinders in providing good quality care or achieving satisfaction with care provision. However, confusion currently exists on the nature of the CIT: Is it a method for data collection and analysis or a methodology? In this article, I explain why this distinction is important and I argue that the CIT is a methodology (and not a method) for the following reasons: Key methodological dimensions are described for the CIT; it has a clear focus; studies that apply this technique make use of various methods for data collection and analysis; it describes, explains, evaluates, and justifies the use of a specific format for those methods; it implies philosophical and practical assumptions; and studies that use the CIT cannot easily make use of additional methodologies simultaneously.

Interprofessional teamwork in stroke care: Is it visible or important to patients and carers?

Interprofessional teamwork is seen in healthcare policy and practice as a key strategy for providing safe, efficient and holistic healthcare and is an accepted part of evidence-based stroke care. The impact of interprofessional teamwork on patient and carer experience(s) of care is unknown, although some research suggests a relationship might exist. This study aimed to explore patient and carer perceptions of good and poor teamwork and its impact on experiences of care. Critical incident interviews were conducted with 50 patients and 33 carers in acute, inpatient rehabilitation and community phases of care within two UK stroke care pathways. An analytical framework, derived from a realist synthesis of 13 'mechanisms' (processes) of interprofessional teamwork, was used to identify positive and negative 'indicators' of teamwork. Participants identified several mechanisms of teamwork, but it was not a subject most talked about readily. This suggests that interprofessional teamwork is not a concept that is particularly important to stroke patients and carers; they do not readily perceive any impacts of teamwork on their experiences. These findings are a salient reminder that what might be expected by healthcare professionals to be important influences on experience may not be perceived to be so by patients and carers.

Challenges in the communication between 'communication vulnerable' people and their social environment: an exploratory qualitative study

OBJECTIVE

Communication vulnerable people are often unable to communicate effectively within their social environment, hindering client-centered care and participation in daily life. This study aims to explore the experiences of communication and the factors that influence this in long term care settings.

METHODS

A qualitative study using the critical incident method. Communication vulnerable clients and people within their immediate environment were interviewed about their communication experiences.

RESULTS

Thirty-nine individuals in three settings participated in the interviews, of which 14 were clients. Specific challenges in communication were presented in different relationships. The main influencing factors in the communication between clients and professionals were: effort put into improving the communication, knowledge of the professional, augmentative and alternative communication, time for communication and the influence and power of the client.

CONCLUSION

Communication vulnerable people and people within their immediate environment face daily challenges in communicating with each other. In particular, communication among clients, can be very difficult. Augmentative and alternative communication tools are only rarely used.

PRACTICE IMPLICATIONS

Professionals need to develop adequate knowledge and skills to improve their communication. Also, more attention should be focussed on use of AAC, communication between professionals and family members, and support in the communication among clients.

Creative power of metaphorical expression

Gathering metaphors of holistic nurses provides for an exploration of how that metaphor is captured in real-life experiences. Metaphors are a way of describing an experience or a perceived notion as a personal expression of thought. The metaphoric understanding of what practicing as a holistic nurse means is discussed with reference to the personal, emotional, and spiritual component of being a holistic nurse. Capturing the superfluity and vividness of these beautiful expressions embedded in participants' metaphors produced insight and a deeper apprehension of the connectedness in nursing. This study used a qualitative exploratory approach to collect data from 75 holistic nurses. Data were collected using participants' own expression of the metaphor of holistic nursing and correlating critical incident reports of how that metaphor was expressed in practice. Metaphors were not analyzed but correlated by themes. The critical incident reports were analyzed to uncover and isolate key aspects of commonalities. The results capture the abundance and diversity of metaphorical expressions embedded in participants' metaphors produced insight and a deeper appreciation of the connectedness in nursing.

Quality nursing care for hospitalized patients with advanced illness: concept development

The quality of nursing care as perceived by hospitalized patients with advanced illness has not been examined. A concept of quality nursing care for this population was developed by integrating the literature on constructs defining quality nursing care with empirical findings from interviews of 16 patients with advanced illness. Quality nursing care was characterized as competence and personal caring supported by professionalism and delivered with an appropriate demeanor. Although the attributes of competence, caring, professionalism, and demeanor were identified as common components of quality care across various patient populations, the caring domain increased in importance when patients with advanced illness perceived themselves as vulnerable. Assessment of quality nursing care for patients with advanced illness needs to include measures of patient perceptions of vulnerability.

Development of the Nursing Relationships Scale: a measure of interpersonal approaches in nursing care

Background

There is no comprehensive measure of dimensions describing the nursing relationship that is suitable for use with survey samples and that is focused on nursing particular types of patients. The objective of this study was to develop a measure to investigate significant dimensions of the nurse-patient relationship, the Nursing Relationship Scale (NRS).

Methods

Hypothetical cases (diabetes or mental illness) in vignette format were presented to 132 psychiatric and 76 general nurses. Thirty-four questions about the nurse-patient interaction were asked. Principal component analyses (with oblique rotation) were used to identify underlying dimensionality in the correlations of items, combining ratings from the two case vignettes. Scales were constructed from the final solution and Cronbach's alpha coefficients calculated. Subscale score variations were analysed across nurse type and patient type to examine the discriminant validity of the subscales.

Results

Principal components analysis revealed five dimensions accounting for 52 percent of the variation within items. Four 'conceptual' factors were derived. These were labeled Caring/Supportive Approach, Nursing Satisfaction, Authoritarian Stance, and Negativity. Developed as subscales, reliability analysis indicated high internal consistency with respective alpha coefficients for the diabetes case 0.91, 0.75, 0.65, and 0.78 and for the mental illness case of 0.91, 0.75, 0.73, and 0.85. There was significant variation in scale scores according to nurse type (psychiatric versus general) and patient type (diabetes versus mental illness). Nurses endorsed more highly items from the subscales Caring/Supportive Approach and Nursing Satisfaction than items from Authoritarian Stance (with intermediate endorsement) and Negativity (lowest endorsement) subscales.

Conclusions

Psychometric evaluation of the NRS suggests it is a reliable instrument for measuring four key dimensions of the nurse-patient relationship and enables the study of this relationship in large samples.

Community nurses' perceptions of a good death: a qualitative exploratory study

AIMS

This study sought to gain an insight into perceptions of a 'good death' among community nurses, and to identify its central components. By understanding these factors, it was hoped that common difficulties could be identified, enabling recommendations to be made to enhance patient care and reduce the pressures to which nurses are exposed.

METHOD AND SAMPLE

This qualitative exploratory study relied on semi-structured interviews, incorporating the critical incident technique to elicit retrospective accounts of experiences of palliative care and a good death. Data was obtained from a purposive sample of 17 community nurses, working in a single primary care trust in south-east England.

RESULTS

The participants identified eight key themes in supporting a good death: symptom control, patient choice, honesty, spirituality, interprofessional relationships, effective preparation and organization and provision of seamless care. When these are in place, a good death is possible. Factors such as lack of necessary medication/resources, unsuccessful interprofessional relationships and lack of teamwork were significant determinants of less successful care. The provision of seamless care was an important criterion for success.

CONCLUSIONS

In identifying the contributory factors, this study has shown that a good death can be provided in the community, although it has also revealed many challenges associated with such care. While it could be argued that due to the unpredictability of death, such challenges may always be a threat to effective care anticipatory planning and a recognition that patients need and are entitled to specialist care many of these difficulties could be overcome.

An exploration of personal initiative theory in the role of consultant nurses

The aim in this paper is to investigate the contribution personal initiative theory makes in understanding the consultant nurse role. The role was introduced in the UK in 2000 to improve patient outcomes, clinical leadership and retention of experienced clinicians. A larger study used a multi-method approach to collect quantitative and qualitative data from focus groups, interviews and a questionnaire administered nationally at two time points. Findings from longitudinal telephone interviews with 30 consultant nurses are the focus of this paper.

Three consultant nurses were selected as case studies to examine the potential of personal initiative theory when applied to new nursing roles. The activities of two of the three demonstrated a high level of personal initiative in the job. They persisted in overcoming problems faced in improving practice. The third scored lower: she emerged as a reactive conformist and less likely than the other two to pursue initiatives of her own.

Personal initiative theory has potential as a framework for evaluating the consultant nurse role, although further research is needed to test it. The longitudinal analysis revealed a determination to stay in the job and overcome difficult challenges when consultants show initiative and are making progress in achieving change.

Inconsistent use of the critical incident technique in nursing research

AIM

This paper is a critique of the use of critical incident technique in nursing and a demonstration of how its development has resulted in inconsistency and confusion.

BACKGROUND

Critical incident technique is used globally by nurse researchers to explore a plethora of nursing issues. Its main strengths are flexibility and adaptability, but its popularity has resulted in ambiguity and confusion.

DATA SOURCES

A search of the CINAHL database for the period 1956-2007 was performed using the search terms critical incident technique and nursing. Together with hand searching, this produced a total of 59 papers. The papers were analysed according to country of origin, research topic, sample size, data collection method, inclusion/exclusion criteria, data analysis and terminology. We then categorized the results of this analysis depending on similarities and differences in the papers.

DISCUSSION

We focus on two areas: methodology and terminology. From a methodological perspective critical incident technique has become inconsistent and in relation to terminology, the diverse language associated with the technique has created confusion. Moreover, issues of rigour may be compromised as a result of this inconsistency. A great deal of inconsistency has been created by nurse researchers' attempts to advance critical incident technique. This has led to confusion, which is not helpful for advancing nursing knowledge.

CONCLUSION

While embracing the continued development of critical incident technique, we advocate a standardized approach to its use. Unless nurse researchers are alert to the methodological and terminological inconsistencies in use of the critical incident technique, it risks becoming an interminable quagmire through which navigation will be impossible.

[Patient satisfaction in hospital: critical incident technique or standardised questionnaire?]

BACKGROUND

Questionnaires are usually used for the measurement of patient satisfaction, however, it is increasingly being recognized that the critical incident technique (CIT) also provides valuable insight.

METHODS

Questionnaires of the "Hamburger questionnaire on hospital stay" were distributed to 650 consecutive patients before discharge. Additionally 103 interviews were conducted in which the patients were asked to describe positive and negative incidents during their hospital stay. The results of both methods were then compared.

RESULTS

A total of 369 patients returned the questionnaire and 103 patients participated in the interviews. The duration of a single interview was between 5 and 45 min with a mean of 12.7 min+/-10.1 min standard deviation (SD). Cronbach's alpha of the questionnaire was 0.9. A total of 424 incidents were reported, 301 of them were negative compared to 123 positive events. The questionnaires and interviews yielded partly similar and partly different results at category and subcategory levels concerning the areas of weaknesses and strengths in quality performance. The CIT was more concrete but did not give results for all aspects of quality. The CIT, but not the questionnaire, was able to detect 40/56 (71%) of the positive and 33/75 (44%) of the negative reports regarding medical performance and 25/42 (60%) of the positive and 15/51 (29.4%) of the negative reports of the performance of the nurses were revealed by the CIT and not by the questionnaires.

CONCLUSION

The CIT gives valuable insights into the patient's perspective of strengths and weaknesses in hospital care, which might be overlooked by the questionnaire alone. However, the CIT is probably not suited for routine use because it is very time-consuming.

Critique of the critical incident technique

The CIT is a practical and efficient methodology that encourages participants to tell their story; with happenings that are memorable events in participants' lives. It is a form of story-telling, as participants share their singular experience as a story to the researcher. It is a qualitative, systematic, open-ended technique for educing descriptive data from participants as well as being an effective naturalistic tool for focusing participants' on a specific event. The CIT is a user-friendly instrument that can foster reflection and promote personal expression. The development of the CIT to generate indicators of specific happenings relative to research questions demonstrates the technique's suppleness and emphasises the capability of this methodology in nursing research. As nurses learn more about this methodology and its application to the study of nurses and nursing care, they will begin to comprehend how simple and effortless this technique is to use. The CIT can be developed to conform to any area of nursing and provide a more comprehensive awareness of what nurses do and the needs of our clients.

Patient's self-determination in intensive care-from an action- and confirmation theoretical perspective. The intensive care nurse view

When becoming an intensive care patient life changes dramatically. In order to save life, different actions are performed by the caregivers and the patient's ability to exercise self-determination is non-existent. After the acute phase the patient is more awake and the possibilities for self-determination change. The purpose of this study was to describe intensive care nurses' (ICNs) views of patient's self-determination in an intensive care unit and to systematize ICNs' nursing actions for supporting patient's self-determination from an action- and confirmation-theoretic perspective. In order to answer these questions, 17 interviews with ICNs were conducted by the use of the Critical Incident Technique (CIT). The transcripts were then analysed using a hermeneutic analysis method and structured by the SAUC model for confirming nursing. The main findings were that the ICN thought that the ICU patient's self-determination was low and restricted. It was more common that the ICN acted to strengthen the patient's self-determination in nursing care, but there were no specific nursing goals for patient's self-determination. The most common actions for supporting self-determination were supplying the patient with information and engaging the patient in making a day plan. The nursing implications are that the ICN's view of human being as an acting subject is important for the ICN's awareness to recognise the patient's own personal resources to handle the critically ill situation and that the ICN's competence to manifest qualified nursing is necessary for strengthening patient's self-determination.

Nurse managers' perceptions of Quality of life of older adults living in long-stay care in Ireland: is it time for a bill of rights?

The aim of this study was to explore nurse managers' perceptions of quality of life of older adults living in residential care in Ireland and key policy issues. Residential care facilities ultimately determine residents' quality of life. A qualitative descriptive design was used in all seven focus groups with 67 participants. Two themes were identified: Factors Influencing Quality of Life and Factors Influencing Policy. Managers highlighted that the physical environment, making it like home, involving the family, the social environment, meaningful recreational activities, and community connections were central to residents' quality of life. It is argued that a Bill of Rights for older adults should be developed.

Performance assessment in health care providers: a critical review of evidence and current practice

AIM

To evaluate methods of performance assessment through an international literature review and a survey of current practice.

BACKGROUND

Over the past two decades health care organizations have focussed on promoting high quality care in conjunction with retaining motivated staff. Cognisant of such initiatives, we sought to evaluate assessment methods for qualified staff according to their utility in the working environment.

METHODS

A systematic literature search was completed and each paper independently reviewed. All health care organizations in Northern Ireland submitted details of their performance assessments. Each was critically appraised using a utility index.

RESULTS

Performance was not universally defined. A broad range of assessments were identified, each method had advantages and disadvantages. Although many lacked rigorous testing, areas of good practice were also noted.

CONCLUSIONS

No single method is appropriate for assessing clinical performance. Rather, this study endorses proposals for a multi-method strategy to ensure that performance assessment demonstrates all attributes required for effective nursing and midwifery practice.

Home percutaneous endoscopic gastrostomy feeding: perceptions of patients, carers, nurses and dietitians

AIM

This paper is a report of a study to compare the perceptions of adult patients, family carers, nurses and dietitians regarding home percutaneous endoscopic gastrostomy feeding.

BACKGROUND

Healthcare professionals have a major role in patient selection for gastrostomy placement and the provision of aftercare but it is not clear if patients, their carers and healthcare professionals have similar perceptions of the initiation and delivery of feeding and of the care in general.

METHOD

A cross-sectional mixed-method study using purposive sampling, semi-structured interviews and questionnaires was performed. Interviews were undertaken during 2005 with adult patients and carers of adults receiving home feeding. A questionnaire containing comparable questions was distributed to the lead district nurse and dietitian providing the individual patient's care. Binomial regression was used to analyse any differences in perceptions across the groups of respondents.

RESULTS

Nurses and dietitians had similar perceptions of gastrostomy feeding in adults. Family carers' perceptions matched those of professionals more closely than did those of patients. The greatest difference in perceptions was between patients and their family carers. Respondents' views about success of feeding and the appropriateness of the feeding regimen were similar, but greater differences existed regarding quality of life, withdrawal of feeding and choice in decision-making about tube placement.

CONCLUSION

There is a need for increased patient and carer involvement in decision-making and for sufficient, appropriate information to facilitate informed decision-making. Practitioners who involve carers in decision-making, where patients lack capacity, need to be aware that carers may not represent the views of patients.

Empowerment of nursing students in the United Kingdom and Japan: a cross-cultural study

AIM

This paper is a report of a study to explore the phenomenon of empowerment cross-culturally by comparing the situations in which nursing students from the United Kingdom and Japan experienced empowerment and disempowerment in clinical practice.

BACKGROUND

Empowerment has been the focus of many studies, but most focus on the experience of Registered Nurses and few have explored the phenomenon cross-culturally.

METHOD

This was a cross-cultural, comparative study using the critical incident technique. Anonymous written data were collected from nursing students in Japan and United Kingdom between November 2005 and January 2006. Japanese data were translated and back-translated. Analysis of the transcripts revealed three themes: Learning in Practice, Team Membership, Power.

FINDINGS

Nursing students in these countries are exposed to different educational and clinical environments, but their experiences of empowerment and disempowerment are similar. For both, learning in practice, team membership and power are associated with either empowerment or disempowerment; depending on the context. United Kingdom students are aware of the importance of acting as patient advocates, although they cannot always find the voice to perform this. Japanese students however, appear to be unaware of the concept of advocacy.

CONCLUSION

Student nurse empowerment may transcend cultural differences, and learning in practice, team membership and power may be important for the empowerment of nursing students globally. Further cross-cultural exploration is required into the association between advocacy and empowerment.

The meaning of empowerment for nursing students: a critical incident study

AIM

This paper is a report of a study to explore the meaning of empowerment for nursing students in relation to their clinical practice experiences.

BACKGROUND

Empowerment and power are well-researched areas of nursing practice, particularly in relation to Registered Nurses. Furthermore, several studies have considered the experiences of nursing students in terms of nursing culture and socialization. However, few researchers have focused specifically on nursing student empowerment.

METHOD

The critical incident technique was used and anonymous data were collected between November 2005 and January 2006. One hundred and nine written critical incidents were provided by 66 nursing students relating to empowering and disempowering experiences in clinical practice. The data were content analysed.

FINDINGS

Nursing students experience both empowerment and disempowerment in clinical placements, centring on three issues: learning in practice, team membership and power. Continuity of placement, the presence of a mentor and time underpinned empowering experiences whereas their absence had a disempowering effect.

CONCLUSION

The consequences of nursing student empowerment are high self-esteem, motivation for learning and positive regard for placement. Supportive mentors play a pivotal role in the empowerment of nursing students and it is essential for the nursing profession that they are supported to undertake their mentorship role.

Factors influencing nurses? decisions to raise concerns about care quality

AIM

To explore factors that influence nurses' decisions to raise concerns about standards of practice.

BACKGROUND

Health care practitioners have a key role in monitoring care quality. Nurses are required by their professional body to raise concerns about standards; however, under-reporting is the norm.

METHOD

Grounded theory was used to collect and analyse data from semi-structured interviews with 142 practising nurses, theoretically sampled from three Acute NHS Trusts in England.

FINDINGS

Fear of repercussions, retribution, labelling and blame for raising concerns, about which they predicted nothing would be done, were identified as disincentives to raising concerns. Reporting was perceived as a high-risk:low-benefit action. Nurses lacked confidence in reporting systems.

CONCLUSIONS

Disincentives to reporting need to be addressed if an open culture, which promotes quality, safety and learning, is to be developed. Findings give cause for concern and indicate a need to review organizational and professional guidelines, and organizational reporting systems.

The experiences of district nurses caring for people receiving palliative chemotherapy

The treatment options being offered to people with advanced cancer are increasing with growing use of palliative chemotherapy. As people are experiencing shorter hospital stays and receiving treatment on an outpatient basis, this has implications for primary health-care provision. This study aimed to explore the experiences of district nurses caring for patients receiving palliative chemotherapy: how they viewed their role, factors that influenced their role and their attitudes to palliative chemotherapy. Data were collected using qualitative interviews that incorporated critical incident technique (n=10). Themes that emerged from the content analysis included the role of the district nurse, knowing the patient and family, the interface between hospital and primary care, and uncertain ground. District nurses saw their role as having relevance at all stages of the patient's cancer journey and the provision of holistic care based on good interpersonal relationships was valued. However, difficulties were perceived at the interface between hospital and primary care. District nurses had ambivalent attitudes to palliative chemotherapy but had positive attitudes towards optimizing quality of life and care in the palliative stages of illness.

Nurse-patient communication: an exploration of patients' experiences

BACKGROUND

Patient-centred communication is a basic component of nursing and facilitates the development of a positive nurse-patient relationship which, along with other organizational factors, results in the delivery of quality nursing care. Nurses are frequently described in the literature as poor communicators, however, very few studies have examined patients' experiences of how nurses communicate.

AIMS AND OBJECTIVES

The aim of the study was to explore and produce statements relating to patients' experiences of how nurses communicate.

DESIGN

A qualitative perspective using an hermeneutic phenomenological approach was considered to be the most appropriate methodology for this study.

METHODS

Using purposeful sampling, eight patients in a general teaching hospital in the Republic of Ireland were interviewed. Data were collected using unstructured interviews. Data analysis was a reflective process and the findings were presented through the description and interpretation of themes and sub-themes.

RESULTS

Following data analysis four themes emerged. These were, 'lack of communication', 'attending', empathy' and 'friendly nurses'.

CONCLUSIONS

The findings of this study indicate that, in contrast to the literature that suggests that nurses are not good at communicating with patients, nurses can communicate well with patients when they use a patient-centred approach. However, health care organizations do not appear to value or recognize the importance of nurses using a patient-centred approach when communicating with patients to ensure the delivery of quality patient care.

RELEVANCE TO CLINICAL PRACTICE

The implication of these findings for clinical practice is that the task-centred approach to patient care that is associated with nursing in the past, appears to be alive and well. If health care management want to ensure that patients receive quality nursing care, they will need to consider patient-centred communication to be essential to encourage and support nurses to communicate in this manner.

The validity and reliability of methods to assess the competence to practise of pre-registration nursing and midwifery students

This paper reports findings from a study funded by the National Board for Nursing, Midwifery and Health Visiting for Scotland to test selected nursing and midwifery clinical competence assessment tools for reliability and validity. The study, which took place over two years from July 1997, involved comparing items in the selected tools with statutory competencies for nurses and midwives, collecting assessment data from a sample of 257 nursing and 43 midwifery students in four educational institutions and administering additional assessment measures (the Nursing Competencies Questionnaire (NCQ) (Bartlett et al., An evaluation of pre-registration nursing education: a literature review and comparative study of graduate outcomes, Oxford Centre for Health Care Research & Development, Oxford Brookes University, Oxford, 1998) and the Key Areas Assessment Instrument-KAAI) to the total student sample (and to their lecturers and practice assessors) at two time points which were six months apart. Our focus was the programme-specific clinical competence assessment tools but by testing these tools we also provide evidence on the validity of other methods of competence assessment. Validity of the methods was assessed, primarily, by calculating multivariate and univariate correlation coefficients between them. The NCQ and KAAI were analysed for internal consistency. The NCQ and the versions of KAAI for lecturers and practice assessors were found to have good internal consistency. The version of the KAAI tool developed for students showed reasonable internal consistency for nursing students, but less consistency for midwifery students. Correlational analysis of data collected on students showed that there is little or no relationship between most of the clinical competence assessment methods in current use, or between these methods and those introduced by the research team. This finding supports previous research, particularly in medical education and confirms that the different methods address different abilities.A clear finding from this study is that no single method is appropriate for assessing clinical competence. A multi-method UK-wide strategy for clinical competence assessment for nursing and midwifery is needed if we are to be sure that assessment reveals whether or not students have achieved the complex repertoire of knowledge, skills and attitudes required for competent practice.

The quality of nursing care as perceived by individuals with chronic illnesses: the magical touch of nursing

Providing high quality nursing care is the vision of nursing. The literature has revealed gaps between the perspectives of patients and nurses regarding the quality of nursing care. The purpose of this study was to investigate how individuals with chronic illnesses perceive the quality of nursing care in order to enhance the quality of care. The participants were 11 Icelandic individuals, aged 39-80 years with various chronic illnesses. Phenomenology was the research approach and in-depth dialogues were used. Five themes emerged: nurses who provided high quality nursing care, the effects of high quality nursing care, the lack of good quality nursing care and its effects, ancillary factors, and the art of being a patient. Based on the findings I conclude that professional caring is the most important part of quality of care as perceived by individuals with chronic illnesses.