THE STRUCTURE
5.2 The Structure
5.2.2 Confirmation from facility record
Three of the ReFs had many checklists and protocols to guide their caring activities, but one of them did not have any written document. The RN-in-charge said that caring comes from the heart and does not require any formula. This is sometimes true, but the South African Department of Health (DOH) (2000) has emphasized that clinical practice guidelines are based on research and expert opinion for patient care in specifically identified areas needing clinical intervention in ReFs and other health facilities. They are helpful in directing care processes and guiding people in making personal evaluations of specific facilitities. In one study, Singh (2010) emphasized that using guidelines in ReFs is considered a first step toward ensuring quality nursing care. Thus standardized clinical practice guidelines can be integrated with assessment and care plans to improve care delivery in ReFs (Singh, 2010). The above statement is in line with the findings of the study, which also suggests the need for those ReFs that did not have protocols or guidelines to procure and use practice guideline as they are useful in the care of the elderly in ReFs.
The four ReFs have their own constitution, which are compiled by the board of directors and periodically reviewed by the same body. Documents that were available in ease One, Two and Four, included admission checklist, protocols for infection control, informed consent, death and burial procedure, transfer, referral and discharge, as well as various clinical procedures. These documents were compiled and regularly maintained by the unit managers and registered nurses (RNs) of each ReF. In ease Four, meal and medication schedule as well as social outings, religious meetings and bed time were displayed on the
wall of the nurses' station. These documents were generally for running the ReF, and not just for the care of the elderly.
In contrast, ease Three did not have any document or checklist for care of their residents.
According to the RN in charge, the care provided to the frail elderly is based on their presenting symptoms and does not require a formula. Moreover, the researcher did not observe the nursing staff using any checklist or protocols in all the ReFs. However, most of the required procedures were carried out according to what was written. Based upon that, the researcher became convinced that with constant use, the staff had mastered those documents so well that they no longer had to constantly refer to them. The government of South Africa (SA DOH, 2000) has developed a policy on quality in health care in order to translate the constitutional rights and aspirations of all citizens into a strategic framework for practical action. The main objectives of the framework are to assure quality in health care and continuously improve the care that is being provided.
This document is relevant for the care of the elderly in ReFs since it became evident that the residents were provided accommodation in safe and a supportive environment that promotes and safeguards their well being and interest at all times. This is in keeping with the following key aims of the above policy:
• Addressing access to health care;
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Increasing patients' participation and the dignity afforded to them;
Reducing underlying causes of illness, injury, and disability;
• Expanding research on treatments specific to the needs of South Africa and on evidence of effectiveness;
• Ensuring the appropriate use of health care services; and
• Reducing health care errors (SA DOH, 2000)
In the four ReFs, there were no formal quality indicators in place. When the researcher
asked one of the administrators about quality indicators, she was told that there was only daily staff supervision by senior and experienced RNs. The administrators as well as the RNs did not understand the word, "quality indicators" and they did not know anything about their usefulness. Quality indicators (Qls) are markers of potentially poor or excellent health care quality. Nursing facility quality is multidimensional, encompassing clinical, functional, psychosocial and other aspects of residents' health and well being.
According to Zimmerman (1997), multidimensional quality factors make it unlikely that a single measure would be capable of capturing every facet or change in the quality of services provided by a nursing home. They may include such elements as staff-resident ratio, mortality rates, avoidable complications, and various health care processes such as implementation of effective treatment protocols. In contrast, there were no observable quality indicators in this study. However, literature suggests that there are quality indicators in ReFs in some places overseas (Zimmerman, 1997; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000). Moreover, the South African Department of Health (2000) had also endorsed quality indicators as useful in determining shortcomings in health care systems that could endanger the health and lives of all patients as well as residents in ReFs. Hence the health department proposes that the critical area of need
now is a national commitment to measure, improve, and maintain quality care for all its citizens (SA DOH, 2000).