INTRODUCTION:

Quality is the ability of a product and service to satisfy stated or implied needs[1] and the degree to meet customer or patient expectations[2]. Health care quality is the degree to which services for individuals and populations increase the likelihood of desired health outcomes[3] and which are clinically effective, efficient, and affordable[4]. Quality is not a single, homogeneous variable, but rather a complex construct incorporating values, beliefs, and attitudes of individuals involved in a health care interaction[5]. Any attempt to define quality must recognize the different views held by the major health care stakeholders: patients, providers, payers and the public[6].

As nurses comprise the largest group of health care providers [7] and are legally liable and morally responsible for the quality of care they provide to patients[8], their perspectives on the definition of nursing quality is important.

Many studies have discussed the impact of nurse staffing on health care outcomes and suggest that positive patient outcomes depend more on the quality of nursing than on the available technology. In response to these concerns, many investigators, managers and researchers attempt to define nursing quality care. Thus, the need to define quality of nursing care and to determine how is it measured, is urgent [9].

PROBLEM JUSTIFICATION:

[10]studied nurses, perspective on delivery of quality nursing care by a grounded theory study. Data was gathered by tape‐recorded interviews, published literatures and some participant observations. Findings revealed that the presence or absence of “needs” was seen as central to determining the quality of nursing care delivered. Quality was assessed by the participants in terms of the degree to which patients, needs (physical or psychosocial) were met by the nursing care provided. High quality nursing care was described as “meeting all needs of the patients or patients you are looking after”. Insufficient time (caused by lack of human and physical resources) was perceived as the main reason for inability to consistently provide quality‐nursing care. To deal with this, nurses used a process named “selective focusing”. It means that work was planned to most effectively utilize the time available, within the parameters of safety.

In a study by a qualitative methodology used a focus group discussion to find out clinical nurses, perceptions of important aspects of nursing care in surgical wards. Findings revealed 15 categories of important aspects of care, which could be condensed in two dimensions, called “prerequisites” (i.e. staffing, routines and attitudes) and “elements of performance” (i.e. detecting and acting on signs and symptoms and acting on behalf of the patients). [11]conducted a qualitative approach to develop a definition of quality of nursing care. This study consisted of two phases; the first phase consisted of individual in‐depth interviews and focus groups of various stakeholders concerning quality of care. The second phase used a consultative meeting of experts in nursing quality of care. The major emergent themes were:

· Meeting the physical needs of the patients;

· Providing psychosocial support;

· Eznsuring spiritual needs;

· Pzatients are satisfied with the care;

· Nursing care is responsive to the needs as defined by the patient; and

· Ensuring holistic-care.

The researchers then analyzed all definitions and summarized them into one definition as follows:

Quality of nursing care is nursing's response to the physical, psychological, emotional, social and spiritual needs of patients provided in a caring manner, so that the patients are cured, healthy, to live normal lives, and both patients and nurses are satisfied [12].

According to differences in definition of nursing care quality in some studies and related aspects as patient safety, nurse responsibility, patient and nurses, satisfaction, the purpose of this study was to define and describe quality from the perspective of experts and clinical nurses. In this study “nursing experts” are nurses with the MSN and PhD in nursing who work as faculty members in nursing schools or as top managers in governmental nursing departments and “clinical nurses” are nurses with BNS and higher who work in hospitals as manager, supervisor, head nurse and staff nurse.

The significance of this research was to identify nurses, perspective by a qualitative approach, based on the health care system, to contribute to a more developed research aimed at “designing a model for quality assurance in nursing care system”[13].

METHOD:

As qualitative studies can help to shape nurses, perceptions of a problem or situation content analysis was chosen to capture the definition of nursing care quality from the nurses. Following ethical approval, data was collected through ten tape‐recorded, individual semi‐structured interviews with nursing experts worked in nursing faculties or in top managerial nursing departments and five tape‐recorded focus group discussions with clinical nurses worked in five general teaching hospitals.

Sampling and data collection:

As qualitative inquiry depends on samples selected purposefully to understand the phenomenon of interest, subjects based on the research objectives were selected by purposive sampling. Following ethical approval, data was collected through tape‐recorded, semi‐structured interviews. Each participant was informed of the purpose of the research and a consent form was signed. The data collection was done in two phases:

Individual interviews:

In the first phase of data collection, participants were selected from nursing schools and managerial nursing departments. They included eight faculty members of three nursing colleges and two top managers in governmental nursing departments who were experts in nursing. Inclusion criteria for key informants were having at least MSN degree and experiences in teaching, leadership, researching, and writing books and articles in nursing management. Data was collected by semi‐structured interviews in working place of participants.

Group interviews:

In the second phase of data collection, participants were selected from five General teaching hospitals. They included 44 nurses who worked in different positions as nurse manager, supervisor, head nurse, and staff nurse with BNS and higher degree in nursing with a minimum of two years nursing experiences. Focus group discussion was conducted in each hospital. In addition five group interviews were done with the mean nine participants in each group. Focus group interview emphasizes interaction amongst participants. The researcher chose a focus group strategy to learn not only about participants, attitudes and opinions, but also their experiences and perspectives. This approach can produce a lot of information while being cost‐effective, flexible, and motivating. Prior to conducting each group interview, the researcher met the nurse manager of each hospital and discussed the research objectives and asked her to consider a suitable time and place to constitute focus groups in the hospital. The following two main questions were asked of participants in both phases:

1 What is the definition of quality on your opinion?

2 What is your specific definition on quality of nursing care as an expert/a nurse?

The researcher role was as a coordinator and encouraged discussion and clarification and redirected the discussion as necessary. At the end of each meeting, the researcher summarized the discussion and checked for the participant's agreement.

Data collection, in each phase, continued until data saturation. Saturation is the process of collecting data until the data become repetitive and redundant.

Demographic characteristics of the subjects:

In the first phase (nursing experts) five of the participants had MSN and five had PhD. Nine were female and one was male. The time for each individual interview ranged from 23 minutes to 81 minutes with the mean of 49 minutes.

In the second phase (clinical nurses) 44 nurses in five groups were conducted in‐group discussions. Seven of the participants had MSN and the rest had BNS. The time for each group interview ranged from 63 minutes to 84 minutes with the mean of 77.4 minutes.

DATA ANALYSIS:

Although most qualitative data is content analyzed there are nearly as many qualitative analysis strategies as there are qualitative researchers. Each interview was transcribed verbatim and then managed for analysis using “latent content analysis approach”, whereby collection, coding, and analysis occur simultaneously. The information was coded and categorized in order to develop a definition of quality of nursing care. Latent content analysis is the process of identifying, coding, and categorizing the primary patterns in the data. In this approach, the researcher seeks the meaning of specific passages within the context of all the data, develops a categorization scheme and then codes the data according to the categories. So in this study, the themes were categorized by identifying, exploring and coding by latent content analysis approach.

Two strategies were employed throughout the study to ensure that the data collection and interpretation accurately reflected the phenomenon. These included two other researchers separately coding segments of the some transcripts to confirm the categories identified by the researcher (peer check). Furthermore, once the description of the phenomenon was completed, it was returned for validation to three nurses from the focus group interviews (member check). This strategy as a test of credibility is a way of assuring validity.

ETHICAL CONSIDERATION:

Data were collected through tape‐recorded, semi‐structured interviews. Each participant was informed of the purpose of the research and consent form was signed for recording her/his voice and using it without her/his name. All of participants agreed on recording their voice, however just one participant did not consent to this method, but agreed that the researcher would transcribe her responses verbatim while she was talking.

FINDINGS:

Although both participant sets (nurses and experts) emphasized on some factors and prerequisites that influence on defining nursing quality care, they in the main considered two aspects in their definition of nursing care quality: “standards of care” and “patient satisfaction”. The final definition of nursing quality care from the perspective of expert and clinical nurses was: Quality of nursing care is the delivery of safety care based on nursing standards which eventuates patient satisfaction.

Standard care:

”Minimum optimized care” and “safe care for patients” were emphasized by both participant groups. Delivery nursing care based on nursing standards was an important aspect of quality care. The participants believed that nursing care must be effective, safe, and protected patients from any harm.

Patient satisfaction:

Satisfaction was expressed by participants as another important aspect in defining quality care. Based on participants, perspectives, patient satisfaction is a very important outcome in assessing nursing care quality and must be considered in defining quality.

Participation in care:

According to the participants perspectives it is necessary to provide facilities and conditions in order to deliver optimal care where patients experience satisfaction and come to no harm. All of participants emphasized that “teamwork” is a necessity for quality care. In the other words, quality will occur when all of the stakeholders in the health care setting include hospital directors, medical and paramedical team participate in the delivery of all services within a hospital. Assessing quality nursing care will be impossible if the roles of other services and the organizational management are not considered.

In this study, participants highly emphasized “teamwork” and “participation of all health care team” as being necessary to deliver quality care. As the aim of this study was quality defined by nurses based on their perspectives, participants emphasized two concepts “standard care” and “patient satisfaction” as most important aspects on quality nursing care. Both nurses and experts believed that there are many barriers in providing care with quality. Some factors such as organizational management and leadership, human resources and staffing, facilities and small budgets have influence on quality nursing care. Clinical nurses emphasized the socio‐cultural factors in their work in comparison to nursing experts. Clinical nurses believed that the lack of a high social position for nurses in our society and cultural perceptions on nurses as staff who just obey physician orders leads to lack of motivation and discourages them from delivering quality care. On the other hand, they emphasized highly on their “conscience” and “faith” as two important factors that conduct them to work in high quality.

DISCUSSION:

The findings from this qualitative study led to a definition of nursing care quality. Quality nursing care in this study was defined as: “the delivery safety care based on nursing standards which eventuates patient satisfaction”. The participants in this study placed great emphasis on standard and safe care and patient satisfaction. [14] in their findings identified a definition of quality of nursing care by nurse administrators and staff nurses as: “the conduct of nurses based on nursing standards to create safety and satisfaction for the patients”. [15] defined quality of nursing care in terms of patients’ needs. On the other hand, the role of organizational structure cannot be ignored in the quality of care delivery, as in their study concluded that adequate nurse staffing and organizational/managerial support for nursing are key to improve the quality of patient care.

In this study, clinical nurses and nursing experts emphasized the role of organizational factors and highly considered physician and other health care workers, role in delivering quality care. In a study emphasized teamwork and stated “a quality focus was not the quality nursing care delivered by a single individual, it was delivered by a team consistently assigned to the care of a particular patient, the doctor and the nurses all worked hard together, all equipment was present, there was adequate nurses and everything was done as it should have been for the patient”.

As nurses work on the first line of patient care and patients have more contact with nurses than other health care provider, our participants believed that, patients assess quality of care just as nursing care and usually ignore the role of the wider team. They highly emphasized that it is because of the negative social perspective about nurses as non‐professional staff. This perspective leads to nurses becoming discouraged in delivering quality care. The authors of this paper believe that assessing the truth of this claim needs more study through obtaining patients and other health care workers perspectives about this subject.

REFERENCES:

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2. American Society for Quality (ASQ) (2004), available at: www.asq.org/.

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Received on 07.04.2017 Modified on 11.07.2017

Int. J. of Advances in Nur. Management. 2018; 6(3): 227-230.

DOI: 10.5958/2454-2652.2018.00050.1