EXPLORING THE PERCEPTIONS OF QUALITY NURSING CARE AMONG NURSES WORKING IN TWO DISTRICT HOSPITALS IN RWANDA. Purpose: The purpose of this study was to explore the perception of quality nursing care among nurses working in two district hospitals in Rwanda.
INTRODUCTION
Therefore, with a view to the ongoing maintenance of quality nursing care, it is important to consider the different views held by major healthcare stakeholders (patients, providers, payers and the public) while defining quality of care (Huycke and Anita, 2000). . To monitor quality nursing care it is important to put quality assurance strategies in place (Manghani, 2011).
BACKGROUND TO THE STUDY
The central level consists of the central departments of the Ministry of Health (MoH) and the national referral or tertiary hospitals geared to provide specialized care. In Rwanda, a focus of the MoH is to provide ongoing strategies that will improve the quality of health care, especially nursing care.
PROBLEM STATEMENT
The plan to build Human Resources for Health (HRH) capacity is to develop the skills of health professionals through improving pre-service and in-service training, while also strengthening post-basic and postgraduate training. Considering the impact of poor quality nursing care on patient outcomes, it is suggested that exploring perceptions of quality nursing care among nurses working in two district hospitals in Rwanda will be valuable to inform continuous quality improvement strategies , driven by the real context.
PURPOSE OF THE STUDY
Therefore, such studies are needed in district hospitals, where the nursing practice environment is still challenged by poor quality services and working conditions. Although the Rwandan nursing environment is challenged by the shortage of nurses and limited infrastructure to deliver high-quality care, the contribution of nurses is invaluable.
RESEARCH OBJECTIVES
RESEARCH QUESTIONS
SIGNIFICANCE OF THE STUDY
OPERATIONAL DEFINITIONS
- Perception
- Quality nursing care
- Nurse
- Nurse practice environment
- Continuous quality improvement
- Quality assurance
For the purpose of this study, nurse refers to both registered nurses (A2) and registered nurses (RN). The constructive nursing environment refers to the organizational characteristics of the work environment that facilitate or limit professional nursing practice (Lake.
CONCEPTUAL FRAMEWORK
Process of Care and Outcomes Model
- Care environment
- Process of care
- Patient demographics
- Outcomes
It is worth noting that the Process of Care and Outcome Model was developed based on the Quality Health Outcomes Model (QHOM), developed by the American Academy of Nursing (Lucero et al., 2009). The care environment, patient factors and the care process have a direct relationship with outcomes (Lucero et al., 2009).
SUMMARY OF THE CHAPTER
INTRODUCTION
CONCEPTUALISATION OF QUALITY NURSING CARE
Quality of care
Acceptability of services refers to a rational response to the expectations of the patient, family members, community, provider and funders. Continuous quality improvement implies that organizational transformation has taken place or that capacity building or empowerment of the individual, group, as well as the organization in terms of the full cycle and process of quality improvement, has been achieved in that specific healthcare organization (Lynn), Baily, Bottrell, Jennings, Levine, Davidoff et al., 2007; Booyens, 1998).
Quality of nursing care
The focus is on patient needs and it is also characterized by participatory decision-making of all relevant players. Research into the nature of quality nursing care constitutes an ontological and epistemological enterprise, as it is the study of the nature of nursing and nursing knowledge (Gunther and Alligood, 2002).
OVERVIEW OF QUALITY NURSING CARE
Domains of learning in nursing
- Cognitive domain
- Psychomotor domain
- Affective domain
The psychomotor domain is concerned with physical actions or skills, including the performance derived from these motor skills (Castle, 2003). In order to incorporate the psychomotor domain into nursing practice, Miller (2010) divided psychomotor skills into two types, namely technical skills such as giving an injection or dressing and the more personal skills of helping a patient to bathe or cleaning their teeth (Gunther and Alligood, 2002).
High quality nursing care
- Succinct description of nursing care activities
- Nursing models for organization of nursing staff for patient care
- Nursing interventions
Quality nursing care also involves the acquisition of theoretical knowledge related to the care of the patient (Cowan, Norman and Coopamah, 2005). Therefore, effective decision-making skills are required for nurses to deliver safe nursing care (Paul, 1993).
Nursing practice environment
- Nurse-Physician relationships in the delivery of nursing care
- Leadership in clinical nursing practice
- Value of autonomy in clinical nursing practice
- Participation of nurses in hospital affairs
- Staffing and resources in the delivery of health services
To be a good leader in the nursing practice environment, one must be equipped with many skills and the ability to balance the needs of multiple constituencies to satisfy the demands of the nursing staff and also meet the needs of the patients (Houser, 2003). Furthermore, appointing an accessible nurse manager in the organization's top management structure has been reported to strengthen nursing practice as these representatives have the opportunity to influence.
DETERMINANTS OF QUALITY NURSING CARE
In support of this, Graven and DuHamel (2003) argued that professional development is critical to the delivery of high-quality nursing care because nurses are not only kept informed of evidence-based practice regarding new technology in the delivery of high-quality nursing care. care and practice standards. , but is also considered a strategy to retain experienced healthcare professionals. This professional development could therefore be carried out through continuing education, distance learning, further training, mentoring and clinical supervision (Gould et al., 2007; Mensah et al., 2007; Wallen, Mitchell et al., 2010; . Bondas, 2010 ; Brunero and Stein-Parbury, 2008).
FACTORS AFFECTING QUALITY NURSING CARE
QUALITY IMPROVEMENT IN CLINICAL PRACTICE
Standards and criteria
In other words, a health standard is a description of a desired level of performance for judging the quality of health care. However, the criteria are linked to the standard as they serve as detailed indicators of the standards and thus enable the standard to work.
Nursing clinical indicators
Arries goes on to state that standards are cardinal in the delivery of quality nursing care, as within them emerge criteria against which various aspects in the delivery of care are measured for quality improvement. First, the clinical nursing indicators that fall under the structural standards are the ratio of nursing staff per patient, RN and nursing staff, RN staff qualifications, total nursing hours per provided per patient, staff continuity, RN overtime, and nursing staff injury.
Strategies for fostering nursing continuous quality improvement
The South African Department of Health (2008) outlined some strategies for improving quality nursing care, which involved appropriate workloads, professional leadership and clinical support, continuing professional education, career mobility and career ladders, and good salaries. In Rwanda, Muller, Murenzi, Mathenge, Munana and Courtright (2010) documented an emphasis on training nurses in good patient interaction skills and providing adequate material, monitoring and evaluation of health services.
NURSES’ ROLE IN CONTINOUS QUALITY IMPROVEMENT
According to Bjorvell (2003), in their daily nursing activities, nurses are required to use care planning as it is essential to document care and to communicate the current status of individual patient needs and response to care. Also, nurses are suggested to increase the health education of patients through health education, so that the latter have knowledge of their role in disease management (Lamiani and Furey, 2009; Freda, 2004).
SUMMARY OF THE CHAPTER
In this regard, Murphy (2007) continues to emphasize the value of care planning in that it helps patients meet their individual physical, psychological, spiritual and social needs. Similarly, Sprinks (2011) found that nurses are responsible for treating all people as individuals and respecting their dignity and making them feel comfortable in their environment.
INTRODUCTION
RESEARCH PARADIGM
STUDY DESIGN
RESEARCH SETTINGS
The hospital consists of 11 services: emergency, pediatric, radiology, surgery, internal medicine, laboratory, nutrition, mental health, physiotherapy, ophthalmology, obstetrics and dentistry. This hospital consists of 3 departments including: Gynecology, Pediatrics and VCT/ARV and has 7 units including Radiology, Physiotherapy, Dentistry, Dermatology, Mental Health, Nutrition and Laboratory.
STUDY POPULATION
SAMPLE AND SAMPLING
Inclusion criteria
Exclusion criteria
DATA COLLECTION INSTRUMENT
The third is known as the Practice Environment Scale of the Revised Nursing Work Index and was developed by several scholars (Aiken, Clarke, and Sloane, 2002a; Lake, 2002; Aiken, Havens, and Sloane, 2000) at the Center for Health Outcomes and Policy Research, University of Pennsylvania, to measure the quality of the nursing practice environment. In terms of translation, Sections A and B of this instrument were translated by the researcher and verified by the Language Department of the University of KwaZulu-Natal (see Appendix 5.5: 131).
DATA COLLECTION PROCEDURE
The higher scores heralded agreement on the subject's existence in the work environment (see additional Appendix 1.1: 114; Appendix 1.2: 120). Section C, the BERNCA instrument, was designed and translated by the researchers (Schubert et al., 2007), and while the PES-NWI-R in Section D was designed in English by Aiken et al., at the Center for Health Outcomes and Policy Research , University of Pennsylvania, USA, it was translated into French by the University of Basel, Switzerland, (2009).
VALIDITY AND RELIABILITY
Second, the BERNCA, which was used as part C of this instrument, has demonstrated its validity and reliability in two previous studies (Schubert et al., 2008; Schubert et al., 2007). It is worth noting that this instrument has been adopted in the United States as a measure of the quality of nursing care in organizations (National Quality Forum, 2004).
DATA ANALYSIS
Spearman's rho correlation was used to test whether there is any linear relationship between years of experience and perceptions of quality nursing care (Pallant, 2007).
ETHICAL CONSIDERATIONS
DATA MANAGEMENT
DISSEMINATION OF THE FINDINGS
SUMMARY OF THE CHAPTER
INTRODUCTION
DEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE
Age and gender
Highest professional nursing qualification of the participants
Nursing work experience of the participants
The findings showed that the majority of the participants had an average of 7.7 years of work experience with a median of 6 years. n=5) had work experience of more than 21 years. According to gender distribution, 43 women and 8 men fell in the category of 6 months to 5 years, 31 women and 6 men fell in the category of 6 to 10 years, 11 women and 4 men fell in the category of 11 to 20 years . , while only 5 females with 0 males were in the category of more than 21 years.
THE NURSES’ PERCEPTIONS OF QUALITY NURSING CARE
Nurses’ understanding of quality nursing care
The majority of participants 92.4% (n= 97) agreed that good nursing care is well coordinated, while 7.7% (n=8) indicated that it was not important to the patient. A large number of participants (91.5%, n=97) agreed that good nursing care is based on respect for the patient, while 8.4% (n=8) believed that it is not important.
Nurses’ perceptions of the delivery of quality nursing care
Maintaining patients' independence: 65.8% (n=71) of participants agreed that this was an aspect of quality nursing, while 34.2% (n=37) disagreed. Composite score for nurses' perception of quality nursing care 4.3.3.1.Score for nurses' perception of quality nursing care.
Composite score for nurses’ perceptions of quality nursing care
- Score for nurses’ understanding of quality nursing care
- Score for nurses’ perceptions of the delivery of quality nursing care
The scoring of the questionnaire is structured so that higher scores indicate better perception of the delivery of quality nursing care, as shown in Table 4.7. Measures of the central tendency of the total scores for the nurses' perceptions of the delivery of quality nursing care were calculated and are displayed in Table 4.8.
NURSES’ ROLE IN THE DELIVERY OF QUALITY NURSING CARE
There was negative skewness as evidenced by the skewness statistic (-.761) which was twice the standard error of skewness (.233). There was a negative skew as shown by the skewness statistic (-.304) which was twice as large as the Standard Error of Skewness (.233).
FACTORS AFFECTING THE DELIVERY OF QUALITY NURSE CARE IN NURSING
Associations using an independent-samples t-test
An independent samples t-test was conducted to compare the participants' understanding of quality nursing scores for men and women. An independent samples t-test was conducted to compare the participants' perceptions of the delivery of quality nursing scores for men and women.
Associations using a one way analysis of variance
- ANOVA between age and understanding quality nursing care score
- ANOVA between the age and the delivery of quality nursing care score
- ANOVA between work experience and understanding of quality nursing care
- ANOVA between the work experience and the delivery of quality nursing care
An independent sample t-test was conducted to compare the participants' perceptions of the delivery of quality nursing care scores for enrolled nurses and registered nurses. ANOVA between the work experience and the delivery of quality nursing care A one-way analysis of variance between groups was performed to explore the impact of work A one-way analysis of variance between groups was performed to explore the impact of work experience on the delivery of quality nursing care.
Associations using Spearman’s rho correlation
- Correlation between participants’ age and understanding of quality nursing care
- Correlation between participants’ age and delivery of quality nursing care
- Correlation between participants’ work experience and understanding of quality
The relationship between the age of the participants and the provision of quality nursing care was also measured using a scatter plot. However, there were no linear relationships between demographic variables and participants' perceptions of quality nursing care.
INTRODUCTION
STUDY DEMOGRAPHIC DATA
This may be due to the fact that before 2007, most Rwandan nurses were trained at secondary level to be recognized as registered nurses, with few registered nurses trained at diploma level at Kigali Health Institute. However, there can be no doubt that nurses' experience and knowledge of nursing is essential for the delivery of quality nursing care (Sorrell, 2010; Paganin et al., 2008).
NURSES PERCEPTIONS OF QUALITY NURSING CARE
Nurses’ understanding of quality nursing care
In this study, the majority of participants (87.7%, n=92) believed that quality nursing care should be based on the nurse-patient relationship. It is documented in the nursing literature that the competence and technical knowledge of nurses in the delivery of quality nursing care is not only an indicator of professionalism, but is.
Nurses’ perceptions of the delivery of quality nursing care
In this study, approximately 85.1% (n=86) of participants considered meeting the physical needs of the patients as a quality nursing care delivery to patients. Advocacy for the patient as delivery of quality nursing care was supported by the majority of participants (82.2%, n=83).
ROLE OF NURSES IN CONTINUOUS QUALITY IMPROVEMENT
In this study, about 47.2% (n=50) of participants revealed that they had educated patients and their care providers. Findings from this study revealed that only 37.8% (n=39) of participants reported monitoring patients as recommended by physicians.
FACTORS AFFECTING QUALITY NURSING CARE
- Nurse participation in hospital affairs
- Nursing foundation of quality of care
- Manager ability, leadership, and support of nurses
- Staffing and resources adequacy
- Nurse-physician relationships
Based on the findings from this study, the majority of participants (74.3%, n=78) agreed that there was an active quality assurance program. In this study, the majority of participants (76.4%, n=81) agreed that there was a patient care task that promotes continuity of care.
LIMITATIONS OF THE STUDY
In this study, the majority of participants (65.5%, n=69) agreed that doctors respected nurses as professionals. This concern is also reported by Street and Cossman (2010) claiming that doctors are sometimes reluctant to allow nurses to practice independently.
RECOMMENDATIONS FROM THE STUDY
Nursing administration
Manojlovich and Antonakos (2008) argued that this issue of respect may be related to the subordinate role that nurses have played in the nursing profession in the past. Maintaining adequate support by hiring nurses with advanced levels of nursing training and increasing the staffing of medical staff in the nursing practice environment; and.
Nursing practice
Provide opportunities for career development and advancement in nursing through continuing education in nursing with the aim of upgrading the level of nurses in district hospitals, taking into account that they are still predominantly at the intermediate level of nursing education; Provide opportunities for nurse managers to develop their leadership and management skills, taking into account their role in maintaining a nursing environment conducive to providing quality nursing care to patients;
Nursing education
Nurse managers should be encouraged to help patients receive evidence-based nursing care with regular clinical supervision and mentoring of subordinate nurses, as these strategies are considered the core of quality improvement.
Nursing research
Finally, the influence of the nursing practice environment on the delivery of quality nursing care has been discussed in detail. Delivering quality nursing care: a grounded theoretical study from the nurse's perspective Journal of Advanced Nursing.
CONCLUSION
