Thesis structure

The thesis is presented in nine chapters. In this first chapter, the research problem has been described and a background to the problem provided. The significance of the research was discussed, providing a context for the value of the research program. The chapter also included a review of the expectations for quality and safety outcomes specified by specialist critical care nursing

bodies, the evidence for outcomes of postgraduate education, and a summary of possible influencing factors on postgraduate course outcomes. This review informed the research purpose and aims.

In Chapter 2, the first aim of the thesis is addressed. The systematic search used to develop the conceptual model for nurses’ responsibilities in quality healthcare is described. The model is developed from a narrative review

33 of existing literature and provides the conceptual framework for the thesis. The specific research objectives were to:

a) Determine through narrative synthesis of the literature the domains of quality that encompass nurses’ professional responsibilities for high quality care.

b) Identify elements of practice that describe nurses’ responsibilities within each domain of healthcare quality through a review of validated

instruments used to measure nurse competence in the different domains.

In Chapter 3, the research objectives for each aim are specified, the methods used to collect and analyse the data are explained, and further detail is provided about the thesis structure. In Chapter 4 and Chapter 5, the second aim of the study is addressed. This includes the steps taken to develop a valid, reliable survey instrument to measure nurses’ perceptions of their roles and responsibilities across all the domains of healthcare quality. In Chapters 6 – 8, results pertaining to the third aim of the study are presented. Chapter 6 includes an analysis of nurses’ understanding of the domains of healthcare quality, a factor that may influence role perceptions. In Chapter 7, analyses related to students’ course aims/motivations and expectations, learning readiness, perceived patient safety competency, and beliefs about PFCC practices are presented. In Chapter 8, extrinsic factors that may be associated with nurses’ perceptions of their roles are discussed (workplace safety and PFCC practices). Finally, an integrated discussion of findings, implications of the findings,

34 strengths and limitations of the study, and conclusions are presented in Chapter 9.

35 Chapter 2: Literature Review and Development of the Conceptual

Model

Nurses have a key role to play in improving practice and preventing error within the systems and processes that ensure quality in healthcare. Postgraduate education is an opportunity for nurses to further develop and accelerate acquisition of the knowledge, skills and behaviours required to maintain and improve the quality of healthcare. Whether nurses undertaking specialist postgraduate education develop in their perceptions of their roles and responsibilities for healthcare care quality is not known. Nor is it clear which domains of quality are subject to development. In this chapter, the processes and outcomes of the first aim and associated research objectives of the research program are outlined and discussed.

Aim 1: To develop the conceptual model of nurses’ roles and responsibilities in maintaining and improving the quality of healthcare.

Research objectives:

a) Determine through narrative synthesis of the literature the domains of quality that encompass nurses’ professional responsibilities for high quality care.

b) Identify elements of practice that describe nurses’ responsibilities within each domain of healthcare quality through a review of validated instruments used to measure nurse competence in the different domains.

The four-stage process taken to fulfil these objectives comprised: 1. A literature review to identify an appropriate existing conceptual

36 2. A narrative synthesis of the literature to determine the domains of

quality nurses need to address to meet professional expectations for safe and high quality care;

3. Description of the conceptual framework for nurses’ responsibilities for healthcare quality; and,

4. A literature review to identify elements of practice that describe nurses’ responsibilities within each domain of healthcare quality.

2.1. Identifying and developing a model for nurses’ responsibilities for healthcare quality

To be useful, a model or framework for nurses’ responsibilities in healthcare quality needs to encompass the critical contribution of nursing to patient safety and quality. It should reflect the multiple dimensions of quality in which nurses engage. As nursing is a practice-based discipline, the model should be grounded in nurses’ scope of practice, regardless of practice context. In essence, what is required, is a model of practice-based domains of quality that are both discipline specific and achievable, identifying the broad integrative responsibilities nurses have for healthcare quality rather than just quality outcomes, measures, characteristics or competencies. The following sections describe the literature search undertaken to inform such a model, and the narrative review conducted to develop a comprehensive model.

2.1.1. Stage 1 methods.

The aim of Stage 1 was to locate a model for nurses’ roles and responsibilities for healthcare quality in the peer-reviewed literature. This

37 stage consisted of searching for key domains of quality expressed as

models, conceptual frameworks, or competencies for health professionals’ responsibilities in healthcare quality. Manuscripts or documents were

included if quality healthcare was discussed in a way that was transferable or relevant to nurses’ roles or responsibilities.

Database searches of the Cumulative Index to Nursing and Allied Health Literature (CINAHL complete) and Medline Complete were conducted separately. These two databases provide the broadest coverage of nursing literature. Manuscripts were limited to English language and peer-reviewed articles, and restricted to publications within and including January 2000 to April 2014 to capture contemporary perspectives of healthcare quality. To screen literature for its relevance to nurses’ responsibilities in healthcare quality, broad search terms such as ‘health professional’ were used, rather than restricting the search to ‘nurses’. Five key concepts were identified to structure the search terms. Alternate terms were used in combinations and using Boolean operators, to represent each key concept of interest (see Table 2.1). Reference lists from the full text articles assessed for eligibility were checked manually to identify other relevant articles before the final articles included in the synthesis were selected. The search strategy strings used for this stage are located in Appendix A.

38 Table 2.1 Search terms for Stages 1 and 2

Concept Terms used in search strategy

Quality quality, quality and safety, quality care, quality healthcare Healthcare health care, healthcare, care

Nurse nurse, health professional, healthcare professional, clinician

Responsibilities responsibility, role, competence

Model framework, policy, standard, guideline, model, curriculum, practice, educational outcome

2.1.2. Stage 2 methods.

The aim of Stage 2 was to identify the scope of healthcare quality as described in seminal policy and guideline documents from three key areas: (a) national and international frameworks, strategies and policies for quality and safety in healthcare (inclusive of all levels of healthcare workers); (b) national and international health professional safety and quality curricula – knowledge, skills and attitudes; and (c) professional nursing peak body performance standards. Google Advanced searches were used to identify key, publically available, grey literature. Broad internet searches of peak body sites were also conducted. Dates were restricted to January 2000 to April 2014, however known seminal sources outside of these dates were included in the final selection. Key ‘safety’ frameworks were included as ‘safety’ is often used interchangeably with ‘quality’ and is a core component of quality healthcare. Australian national frameworks and professional nursing peak bodies, including critical care and emergency nurse professional bodies, were a particular focus as the ultimate aim was to develop a conceptual model that would have specific relevance to Australian nurses, particularly critical care nurses, and provide useful guidance across broader contexts.

39 Australian state and regional sources were excluded because they were based on national frameworks and therefore did not make a unique contribution. Documents that addressed focused aspects of quality, for example frameworks and models for patient-centered care or evidence- based practice, were not included in this stage as the purpose was to develop a model that encompassed broad integrative responsibilities for quality. These more focused documents were, however, accessed for Stage 4. The five key concepts identified in Stage 1 also informed the Stage 2 search. Search strings used for this stage are provided in Appendix B.

2.1.3. Stage 1 results: Absence of an appropriate model.

Figure 2.1 provides a summary of the process of article (manuscript) selection. After removing duplicates, 1176 articles were screened for

suitability by title and abstract. For inclusion, articles needed to contribute to a discussion about a framework or conceptual model for quality that could inform a model specifically for nurses’ responsibilities in healthcare quality. Articles were excluded if they discussed nurses’ roles in specific disease management programs, advanced practice roles, nurse sensitive indicators, the nature of nursing, nursing curricula without a clear focus on quality domains, or did not meet the inclusion criteria as specified above. After review of the full text of the remaining 45 articles, and a further eight articles identified in the reference lists of the 45 articles, 13 were considered to make a contribution to the aim of Stage 1. Conceptual models specifically

addressing nurses’ roles and responsibilities in healthcare were not found in the Stage 1 search.

40 Healthcare quality as a concept or framework, its dimensions, or how it can be measured was addressed in six articles (Campbell, Roland, & Buetow, 2000; Donabedian, 1966, 1969, 1988; Goldenberg, 2012;

Mosadeghrad, 2012). Nurse competencies required for quality healthcare were discussed in four articles (Cronenwett et al., 2007; 2009; Hall, Moore, & Barnsteiner, 2008; Sherwood & Zomorodi, 2014) and nurses’ roles in quality were the focus in a further three (Hines & Yu, 2009; Irvine, Sidani, & Hall, 1998; Scott, Matthews, & Kirwan, 2014). The detailed findings of the Stage 1 and Stage 2 reviews are summarised in Table 2.2. The narrative synthesis of the literature identified in Stages 1 and 2 informed the proposed conceptual model in Stage 3 (see Figure 2.2).

41 Figure 2.1 Flow chart of article selection in Stage 1

2.1.4. Stage 2 results: Identifying domains of healthcare quality. Thirty-two key documents that contributed to the aims of Stage 2 were identified. These documents considered healthcare quality from three

dominant perspectives: (a) defining, conceptualising and measuring healthcare quality; (b) the knowledge, skills and attitudes (competencies) required for healthcare quality (quality and safety curricula guides or reports);

42 and (c) nursing roles and responsibilities in healthcare quality as defined by the nursing practice standards of several key national and international peak critical care nursing bodies. The practice standards of countries with similar demographic characteristics, healthcare environment and nursing workforce, and were freely available on the internet, were selected for review. They provide a framework to guide critical care nurses in the knowledge, skills, behaviours and attitudes required to practice safely and deliver quality patient-focused care and outcomes.

Results are summarised in Table 2.2. Further detail of the frameworks, domains, characteristics, performance dimensions or professional practice standards is available in Appendix C.

43 Table 2.2 Perspectives on healthcare quality - Synthesis of findings from Stages 1 and 2 of the literature review.

Stage Key area  Source Synthesis of findings

Perspective on healthcare quality: DEFINING, CONCEPTUALISING AND MEASURING QUALITY Stage 1 Peer-reviewed

literature  Donabedian (1966, 1969, 1988) Defining quality and approaches to its assessment Quality healthcare is care that is:  safe

 effective/evidence-

based/driven by information  appropriate

 patient centred/person- centred/patient and family centred/consumer centred/responsive  timely  efficient  equitable  measurable  Campbell, Roland and Buetow (2000) Defining quality of care

 Goldenberg (2012) Defining ‘quality of care’ persuasively  Mosadeghrad (2012) A conceptual framework for quality care Stage 2 Key national and

international frameworks, strategies and policies for quality and safety in healthcare

 Institute of Medicine (2001) Crossing the quality chasm. A new health system for the 21st century

 World Health Organisation (2006) Quality of care: a process for making strategic choices in health systems

 Organisation for Economic Co-operation and Development, Conceptual framework for the OECD health care quality indicators project (Arah et al., 2006; Kelley & Hurst, 2006)  Australian Commission on Safety and Quality in Health Care:

o Australian safety and quality framework for health care (2011)

o Australian safety and quality goals for health care (2012a) o National safety and quality health service standards

(2012b)

o Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (2012c)

 National Health Service, England (2014a) What do we mean by high quality care?

44 Perspective on healthcare quality: KNOWLEDGE, SKILLS AND ATTITUDES (COMPETENCIES) REQUIRED FOR HEALTHCARE

QUALITY

Stage 1 Peer-reviewed

literature  Cronenwett et al. (2007) Quality and safety education for nurses For quality healthcare, health professionals should demonstrate competency in:

 patient/family/person-centred care

 teamwork and collaboration  optimising human and environment factors  evidence-based practice  quality improvement and clinical governance to improve care

 safety

 discipline and context specific knowledge and skill  health informatics

 Cronenwett, Sherwood and Gelmon (2009) Improving quality and safety education: The QSEN Learning Collaborative

 Hall, Moore and Barnsteiner (2008) Quality and nursing: moving from a concept to a core competency

 Sherwood and Zomorodi (2014) A New Mindset for Quality and Safety: The QSEN Competencies Redefine Nurses' Roles in Practice

Stage 2 National and international health professional safety and quality curricula and reports

 Institute for Healthcare Improvement (1998) Knowledge domains for health professional students seeking competency in the continual improvement and innovation of health care

 Institute of Medicine (2003) Health Professions Education: A Bridge to Quality

 Australian Council for Safety and Quality in Health (2005) The Australian Patient Safety Education Framework

 The Lancet Commissions: Health professionals for a new

century: transforming education to strengthen health systems in an interdependent world (Frenk et al., 2010).

 Carnegie Foundation report, Educating nurses: a call for radical transformation (Benner & Shulman, 2010)

 Prime Minister’s Commission report, Front line care: the future of nursing and midwifery in England (Prime Minister’s Commission on the Future of Nursing and Midwifery in England, 2010)

 Institute of Medicine report, The Future of Nursing - Leading Change, Advancing Health (Institute of Medicine, 2010)

45  Canadian Patient Safety Institute (Frank & Brien, 2008) The

Safety Competencies: Enhancing Patient Safety Across the Health Professions

 World Health Organisation Core Team (2011) World Health Organisation Patient Safety Curriculum Guide: Multi-professional edition

 American Association of Colleges of Nursing - Quality and Safety Education for Nurses Consortium (2012) Quality and Safety Education for Nurses

 Health Workforce Australia (2012) National Common Health Capability Resource: shared activities and behaviours in the Australian health workforce

Perspective on healthcare quality: NURSING ROLES AND RESPONSIBILITIES IN HEALTHCARE QUALITY Stage 1 Peer-reviewed

literature  Hines and Yu (2009) The changing reimbursement landscape: nurses' role in quality and operational excellence To ensure healthcare quality, nurses have a responsibility to:

 act professionally, ethically and morally, promoting the safety and dignity of both recipients and providers of healthcare

 embrace their roles and responsibilities in the delivery and evaluation of healthcare quality

 operate within their scope of practice and at levels

consistent with established  Irvine, Sidani and Hall (1998) Linking outcomes to nurses' roles in

health care

 Scott, Mathews and Kirwan (2014) What is nursing in the 21st century and what does the 21st century health system require of nursing? Stage 2 Professional nursing peak body performance standards and competencies

 International Council of Nurses (ICN) Position Statements:  B05: Nursing research (2007)

 D04: Participation of nurses in health services decision making and policy development (2008)

 D05: Patient safety (2012b)

 B03: Cultural and Linguistic Competence (2013a)  The ICN Code of Ethics for Nurses (2012a)  Nursing and Midwifery Board of Australia (NMBA)

46  National competency standards for the registered nurse (2006)

 Code of Professional Conduct for Nurses in Australia (2008)

performance standards for their role and position  NMBA, the Australian College of Nursing, and the Australian

Nursing and Midwifery Federation, Code of Ethics for Nurses in Australia (NMBA 2008)

 Australian College of Critical Care Nurses (2002), Competency Standards for Specialist Critical Care Nurses

 College of Emergency Nursing Australasia (2013), Practice Standards for the Emergency Nursing Specialist

 European federation of Critical Care Nursing associations (EfCCNa) EfCCNa Competencies for European Critical Care Nurses (2013)

 Critical Care National Network Nurse Leads Forum (CC3N) (2013), National Competency Framework for Adult Critical Care Nurses

 Critical Care Nurses Section, NZNO. (2014), New Zealand Standards for Critical Care Nursing Practice

47 2.1.5. Stage 3: Conceptual model for nurses’ responsibilities in

healthcare quality.

While the quantity of literature addressing quality and safety in

healthcare is vast, and efforts have been made to elucidate quality domains or frameworks, no single framework or conceptualisation of domains found in this literature review provided a comprehensive frame of reference in the context of nurses’ roles and responsibilities for quality healthcare. Thus, in the absence of a unified framework for describing the roles and

responsibilities of nurses in maintaining and improving healthcare quality systems and processes, a systematic approach has been used to identify and synthesise relevant literature (Stages 1 and 2) to produce a

comprehensive and pragmatic conceptual model (Stage 3). Thematic

analysis was used to produce a rudimentary synthesis of findings across the included sources. According to Mays, Pope and Popay (2005, p. S1:12) this approach seeks “to identify and bring together the main, recurrent or most important issues or themes arising from a body of literature”.

This analysis identified that nurses’ responsibilities fall within seven constructs or domains of quality: (a) Management of the Environment; (b) Promotion of Safety; (c) Evidence Based Practice; (d) Medical and Technical Competence; (e) Person Centred Care; (f) Positive Interpersonal Behaviours; and (g) Clinical Leadership and Governance (Figure 2.2). This synthesis indicates nurses should demonstrate appropriate knowledge, skills and attitudes or behaviours in each of these domains, depending on their role, experience and qualifications.

48 Figure 2.2 Conceptual model - Domains of healthcare quality

The model, derived from the literature, identifies a core set of domains of quality in healthcare relevant to registered nurses’ roles and

responsibilities and scope of practice. Detailed definitions for each of these domains of responsibility are provided in Table 2.3. Understanding these domains provides the means for healthcare and education providers within a variety of contexts to describe, understand and evaluate nurses’ perceptions of their responsibilities in healthcare quality and to support them to fulfil these roles. Development of the model addressed the first overall research aim of the study (Chapter 1, section 1.4).

49 Table 2.3 Conceptual model domain definitions

Domain Broad definition of domain

Management of the Environment

 Encapsulates nurses’ responsibilities to maintain an appropriate, healing physical space in which a health care service is delivered.

Promotion of Safety  Refers to nurses’ responsibility to provide care that minimizes risks and harm to themselves and service users. It avoids injuries to

patients from the care that is intended to help them (IOM 2001; WHO 2006).

Evidence Based Practice  Involves giving consideration to the best available evidence; the context in which the care is delivered; client preference; and the professional judgement of the health professional (Pearson, Wiechula, Court, & Lockwood, 2005; Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996).

Medical / Technical Competence

 Refers to the discipline and context specific knowledge and psychomotor skills registered nurses need to provide quality healthcare. Person Centred Care  Nursing care that takes into account the

preferences and cultures of individual service users and their communities. Nurses have a responsibility to respect and respond to individual needs (ACSQHC 2014b; Institute for Patient and Family-Centered Care, 2010; IOM 2001; WHO 2006).

Positive Interpersonal Behaviours

 Refers to the communication skills, team behaviours and personal attributes that promote safe and quality healthcare. Clinical Leadership and

Governance

 Refers to registered nurses’ behaviours that provide direction and support to clients and the healthcare team in the delivery of patient care (Patrick et al., 2011). Nurses have a role to play in clinical governance, sharing responsibility and accountability with the governing body, managers, other clinicians and staff for quality improvement, minimising risks, and fostering an environment of

excellence in care for clients and their families (Department of Health and Ageing, 2010).

50 The purpose of constructing the model was to inform the development of an instrument that could be used to measure nurses’ perceptions of their

In document Measurement of nurses\u27 perceived responsibilities and skills for healthcare quality (Page 61-158)