A common opinion among participants was that indicators should incorporate both clinician and patient perspectives. Commissioners reported valuing indicators agreed after discussion and input from the providers. They felt that ownership from the provider was essential for the success of a CQUIN and that community nursing staff will be more committed and willing to implement indicators that they have helped shape. One provider business manager thought that, to promote engagement and/or ownership from the service, it could be useful to move towards standardising questions rather than answers, so that staff would be able to self-select measures appropriate for their practice.
Provider managers agreed that having informed professional input enhances the quality of any measures developed and helps to establish ownership among nursing staff. The data revealed that, in a number of the case sites, initiatives were being put in place to ensure that staff views could contribute to indicator development, and most provider managers said that staff had some input into indicator identification and selection. Nevertheless, community nurses across all five case sites refuted this view, describing the process
as‘a top-down’ approach; the general feeling expressed by the nurses was that indicators were imposed
when and if there were signs of possible problems. Many nurses were unsure who was involved in the selection process and were suspicious of QIs, feeling that they could be used punitively with staff:
Elmhampton CNFG7:I think it’s the people that put the numbers in the computers and think, ooh,
this looks a bit dodgy there, and we’ll send it down I honestly do.
Elmhampton CNFG8:Yes.
Elmhampton CNFG7:They haven’t got a clue what’s going on.
Elmhampton CNFG6:It’s probably risk assessed, isn’t it?
Elmhampton CNFG7:I think, you know, if you’ve put lots of Datix [serious incident forms; Datix Ltd,
In one site, a nurse commented on the language of‘harm-free’ care and the implication that they were otherwise treating patients in a way that was detrimental to their health:
Dogwoodheath CNFG2:So it’s meant to be a useful tool to improve care [NST], now it seems to be to find out why we’re getting . . .
Dogwoodheath CNFG1:Measuring to see how bad we are, yes.
Dogwoodheath CNFG2:I think that’s why it’s worded wrong, because it’s all about harm. So you feel
it’s negative from the start, because they’re trying to find out how much harm you’ve created.
A provider quality analyst from Beechbury who worked closely with front-line staff on quality data
reiterated the importance of the vocabulary used when talking about quality, preferring the phrase‘see
how you are doing’ to more punitive and management language about missed targets and performance.
Community nurses said their role was poorly understood by commissioners and many examples showed how their work differs from that of nurses working in hospitals. Differences include the need to factor
in time spent travelling to patients’ homes, tabling visits to fit around medication timings, connectivity
problems with mobile technology, unrecorded work necessitated by other‘missing’ services, isolation of
patients, lone working and the practicalities of working in people’s homes. These differences underpin
nurses’ views that QIs for community nursing could be made more useful and better reflect the quality of
care given if the nurses themselves played an active role in their design and analysis, rather than simply collecting the data. Nurses indicated that they would appreciate being involved in the whole process of quality assessment. When asked how quality measures could be made more meaningful for them, nurses in one site responded:
Dogwoodheath CNFG3:Maybe involving us in, you know designing the indicators, you know . . .
Dogwoodheath CNFG2:And that you saw some good come out of doing it . . .
Dogwoodheath CNFG3:And being involved in action planning to improve it when you get the results. Patients are not involved in identifying or selecting indicators generally. There was only one instance of patient involvement in the development of an indicator in the data, concerning wound care:
We surveyed about 21 patients to ask them what they want from wound healing. What’s the thing
that upsets them most about their wounds? And it talked about things like pain and healing rates, so that was a quite useful exercise.
Cedarham PM2
Some participants showed an awareness that perceptions of what makes care‘good’ may differ between
patients and professionals. Nevertheless, there was evidence of intention to tackle the issues of involving patients appropriately in indicator selection processes.
A number of commissioners thought that the future direction of travel for measuring quality will be towards outcomes-based measuring, dependent on patient input:
It might be more on the patient outcomes and I think that’s the direction that we’re going in . . .
waiting times are important because you can monitor the access but we are working more and more
on patient outcomes. So when we’re redesigning or designing from scratch a service, part of the
public engagement would be what outcome would you expect from this service and then we use them as our core qualitative measures.
Summary
The data showed that, despite stated aspirations to involve other stakeholders, particularly front-line nurses
and service users, current processes of selection largely involve a‘top-down’ process involving commissioners
and senior provider managers. The fact that the process is already very time-consuming must mitigate wider stakeholder involvement without radical restructuring and reordering of QI selection.
Nevertheless, the disadvantage of excluding community nurses from the selection process appeared to have sometimes given rise to measures which could clash with provision of patient-centred care. This situation inevitably placed nurses in an invidious position, as they were duty bound to apply the indicators while simultaneously bearing a professional obligation to deliver care in line with best clinical practice.
Despite participants’ stated concerns to select feasible indicators, the decision to extend quality measures
suitable for acute settings into the community without appropriate modification appeared to render
some quality measures as problematic from the nurses’ viewpoint. It was apparent that, where nationally
mandated indicators are concerned, this matter was out of commissioners’ hands.
The combination of all these factors implied that nurses were being placed in unnecessarily stressful situations with respect to care quality measurement. This appeared to exacerbate further the current difficulties experienced with the delivery of community nursing services, as detailed in Chapter 4.
Chapter 6 Findings 3: application
A
pplication refers to the processes around implementation of QIs in practice; that is, how selectedindicators for community nursing were introduced to the nurses, whether or not any further training was offered, how data were collected and quality assured and any resulting feedback for staff.
Identifiers for quoted excerpts from interviews and focus groups in this chapter are shown in Table 14. Excerpts from field notes recorded during observation of meetings and of front-line staff at work are labelled accordingly.
In each case, an individual participant is identified by a unique number preceded by the name of the case site (where applicable) (e.g. Beechbury CNFG1; FGP2).
Themes identified for‘application’ included QI monitoring, communication about indicators within provider
organisations, data collection processes and data quality.