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QUALITY ASSURANCE: AN
EVALUATION OF THEQUALITY OF NURSING CARE
IN SWAZILANDBy: DR. N. T. SHONGWE
SWAZILAND
At the Ecsacon 6th Scientific Conference
Dar-es Saalam August 2002
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Problem Identification The reported dissatisfaction with
the nursing care expressed by
patients/clients, the general public,other health professionals andMOHSW was the rationale forchoosing quality nursing asproblem.
By virtue of its position in society,the nursing profession owes thepublic high quality nursing care.
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Problem identification
contd..
The nursing profession has a social obligation tomonitor and evaluate the care provided topatients/clients and communities. There is a
social contract between the nursing professionand society. Thus the nursing profession isexpected to be mindful of societys trust and actin a respectful, responsible and accountablemanner. In review of this expected responsibility,
respect and accountability, the nursing professionhas an obligation of self-regulation, whereby thenurses determine whether their services are still inline with the social contract entered into with the
society.
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Problem identification
contd...
To ensure that there is delivery of quality health
services, it is mandatory to emphasize the nursing
care aspect. According to Papps(1994) good
nursing care is a critical facet of health care and
has an impact on all the business aspects of
hospital and community care. In hospitals nursing
care must be provided for 24 hours every day ofthe year. Without nursing care neither patients
nor other health professionals will be satisfied
with services provided.
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Problem identification contd...
Although there is increasing interest in evaluating
nursing/health services, historically nurses have
also been committed to the evaluation of the care
they provided to patients/clients. Schroeder(1991: 7) refers to this as a commitment to
Quality Assurance. An example of this
commitment was the introduction of standards of
infection control by Florence Nightingale duringthe Crimean war, which resulted in a decline in
the mortality rate of soldiers from 42% to 2%.
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Problem Identification Contd...
There should be evaluation of that care sothat strategies for improvement are
scientifically based.
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Purpose of The Study
To provide information to be utilized for
the improvement of the quality of nursing
care in Swaziland, through the
identification of areas that needed to becorrected or changed.
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Research Questions
Is the clinical practice environment in
medical and surgical wards and ruralclinics conducive to the provision of
quality nursing care?
What are the lodgers and patients/clientsopinions, as well as those of the nurses
about the quality of nursing care
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Definition of Concepts
Quality: Degree of excellence
Quality Assurance: A process ofestablishing a specified degree of
excellence to ensure that each patient/clientreceives the agreed level of care. It relatesdirectly to identification of criteria andstandards, and the construction of tools toassess whether or not the standards havebeen achieved. It leads to action promotingachievement of agreed standards (Pearson
1991: 7)
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Definition ofConcepts Contd... Quality Nursing Care: Is an acceptable degree of
nursing services (based on standards) provided to
patients/clients, families and communities. NB:.
These standards of nursing are developed by the
profession and serve as a basis for evaluation. Lodgers: Patients relatives or guardians who stay
in hospitals looking after their sick relatives.
Nurse: Is a profession/registered nurse or nurse
midwife working in medical and surgical wards
of the four selected regional hospitals and rural
clinics and is authorized by the Swaziland
Nursing Council to practice as a registered nurse.
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Definitions from Uganda
Quality: Doing the right thing, the right
way at the right time.
Quality assurance closes the gap between
what is being achieved and what can beachieved with the same resources
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Conceptual Framework
Donabedians structure, process andoutcome approach to quality was utilized in
conjunction with developed nursing
practice standards (1999) and Attrees
attributes of quality nursing care.
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Methodology
Exploratory study where both qualitativeand quantitative methods were used
Research instruments: Data was collected
using the following: Observation checklist for the environment
(ward)
Questionnaire: to determine nurses opinion
on QNC
Focus group interviews: to determine
lodgers, clients and patients opinions of the
quality of nursing care.
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Target population
Nurses in medical and surgical wards of thefour regional hospitals: 103 (81 %)
Lodgers in the medical and surgical wardsof the four regional hospitals: 88
Patients/clients in the selected clinics: 71
Total respondents: 262
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Process Followed
Quality assurance process Identification of values
Identification of standards:
Structure
Process
Outcome
Securing measurement instruments and
data collection Data analysis= Triangulation of
quantitative and qualitative data (Note:Data analysis approach)
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Data analysis: Outline ofData
Grouping Factors
Factor analysis of the quantitative data (SPSS )was utilized for grouping of the data as follows:
Professionalism
Resources
Management
Basic Nursing Care
Nursing process
Caring Quality nursing care
Education: Nurses, Lodgers, patients
Long waiting time
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Data Analysis cont.
Qualitative data was grouped into thematiccatagories
Triangulation of both qualitative data was
done under the factor analysis grouping.
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Summary of Findings The general quality of nursing care was found to
be unsatisfactory.
The majority of nurses (75 % ), lodgers andclients/patients concurred that the quality ofnursing care was not at the acceptable level andthey called for improvement of that care
The nurse purceived severe shortage ofnurses,equipment as well as medical supplies andnurses poor working conditions to be the mainproblems underlying the poor quality of nursing
care.
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Summary of Findings Contd..
y The lodgers and patients/clients view pointwas that the general uncaring attitude and lackof respect of the nurses and the lack of propersupervision was the reason for the poor state of
affairs. y The lodgers and patients emphasized
individual differences among nurses (good nursesand those who are not so good i.e. Caring and
uncaring nurses). Two wards in one hospital weresingled out as having very good nurses and goodsupervisors
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Summary of Findings Contd..
The lodgers and patients/clients ascribed
non-nursing problems to nurses,
particularly, the alleged poor quality care,e.g. problems about doctors, laboratory
personnel, orderlies, cleaners and high
health care costs.
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Summary of Findings Contd..
There is evidence of inadequate resources
e.g
shortage of nurses (R/N) resulted in situation
where nursing assistants were sometimes leftalone to man a ward.
Medical equipment and supplies were
wanting. In some instances, even life saving
equipment were lacking ( e.g. suctionmachine, oxygen apparatus)
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Summary of Findings Contd..
Nursing standards which form a base forevaluation of quality nursing care wasfound in only 52% of the wards. In 71% of
the wards where some nursing standardswere found, some nurses were not sureabout their existence and had to look forthem in the files. This indicated that the
existing standards were not fully utilized inthe care of the patients. Yet 99% of thenurses agreed that nursing standards formthe basis of quality nursing care.
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Summary of Findings Contd..
There was inadequate documentation,
particularly in the use of nursing process.Sixty five (65) % of the nurses said lack of
management support for nursing process
makes utilization thereof difficult.
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Overall Outcome of the Study
Values
Philosophy Mission
Scope of practice
Nursing practice standards Quality of Nursing care status
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Recommendations
Develop a national QA programme(Institutionalize QA)
Create culture of quality
Facilitate ownership of programme and teamwork for all health workers
Conduct nursing audit/evaluation onregular basis
Develop/strengthen and utilize qualityperformance indicators
Continuing education to be structured and
continuous (e.g. QA principles)
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Recommendations Contd...
Review and organize requisitioning of
equipment
Strengthen legislation and regulations forfacilitating nurses professional conduct,
performance and efficiency
Review/upgrade emergency referral system Ensure coordination and integrated
management: all health workers should be
involved in quality assurance activities
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Conclusions
The study indicated dissatisfaction about the thequality of nursing care.
Both consumers and nurses concured that thequality of nursing care was unacceptable.
Causes For the unacceptable levels of qualitywas multifactoral and included non nursingproblems, inadequate resources, lack ofsupervision and uncaring attitude as well as lack
of respect of the nurse. Overal outcome of the study included
development of nursing values, philosophy,mission statement, scope of practice, nursing
practice standards and the quality of nursing care
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Conclusions contd Consumers recognize that nursing tasks were
difficult and emotion-laden, thus they
recommended some form of counselling ormental health services for nurses.
The dynamism in the health care delivery systemdemands on-going evaluation of the quality of
nursing care, to ensure that the care is continuallyimproved to meet the ever-changing consumersexpectation and needs.
Quality insurance activities/programs are a must
in todays health care delivery system.
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THANK YOU
ASANTESANA