Quality in Health Care 1992;1 Supplement:S15-S16 15

Qual Health Care: first published as 10.1136/qshc.1.Suppl.15 on 1 September 1992. Downloaded from http://qualitysafety.bmj.com/ on 31 July 2018 by guest. Protected by copyright.
Continuous quality improvement in nursing

Jennifer Hunt

Most people have an image of what nurses are related to internal factors and pressures, such
and what they do. In most instances this as shortages of nursing staff, and which fades
reflects a combination of historical stereotypes when the problem is resolved or is superseded.
and those induced by the media. At different As a result there has in the past been more talk
periods and in different health care institutions and more theory than either action or
nurses have done, and indeed still do, work implementation.
which could be considered the province of In their work relating to quality nurses have
many other staff: cleaners, porters, taken various approaches; these fall into four
receptionists, technicians, managers, and categories: (a) describing quality, (b)
doctors. Nursing - that is, the work nurses do measuring quality, (c) comparing outcomes, or
- is in fact a complex and demanding activity. (d) any combination of these. The most recent
It involves assessing patients' nursing developments, although incorporating these
requirements; planning and implementing approaches, can be subdivided into generic
nursing care; carrying out medical orders; audit and standard setting.
teaching staff (nursing and non-nursing) and
patients' relatives; managing, organising, and Generic audit
coordinating services; and researching and Unlike medicine, nursing in Britain at least,
evaluating the effectiveness of the nursing care has frequently opted for developing a generic
provided. Nurses therefore need to be audit tool - that is, trying to get an overall
knowledgeable and skilled and, of course, measure of qualify for a ward, department, or
caring. Nursing too is the patient care service hospital. Such measures include tools such as
in hospitals which is provided continuously 24 Monitor and Qualpacs. An additional
hours a day, seven days a week, 52 weeks of dimension with Monitor, for example, is the
the year. Nurses therefore spend more time link with staffing (both numbers and grade
with their patients than other health care mix) and patient dependency, which gives it a
professionals, which provides them with a strong management focus. The general nature
unique opportunity really to know and of this approach limits the usefulness of these
understand patients' needs and wishes. More instruments, but, even so, the implementation
importantly, research is showing that skilled of such a system has often proved helpful and
nursing affects patient outcomes. Assuring the led to further quality initiatives as long as
provision of good nursing care is therefore not nursing staff caring for patients were fully
a luxury but an essential component of involved and they were not merely driven by
effective patient care and of patient management from the top down. One further
satisfaction. problem is that evidence suggests that these
During the past thirty years there have been different audit instruments give different
two previous peaks of interest in quality results even when used in the same settings
improvement, the first in the late 1960s and and with the same group of patients. In other
the second in the early 1980s. We now have a words, they are measuring different aspects of
third and much more sustained period dating quality or the same aspects but from different
from, and stimulated by, the implementation perspectives.
of the Griffiths report' and maintained by a
continuing focus on the need for quality by Standard setting
government, management, professionals, and The idea of setting standards is well
consumers. Unlike the previous initiatives, established. Standards range from very broad,
nurses are now part of a multidisciplinary almost philosophical, statements to very
effort, which means that the outcomes are detailed protocols and procedures. Measuring
likely to be more significant and more long the effect that the implementation of such
lasting, particularly as health service standards has on patient care and patient
organizations at all levels move into total outcomes has received less attention and of
quality management. course is more difficult. In the United
Kingdom a major development has been the
Theory setting up of the Royal College of Nursing
Although the nursing literature is large it does dynamic standard setting system as part of its
not show any coherent pattern, rather a great programme on standards of care, which has
Royal Brompton deal of duplication and reinventing of the given nurses at ward level and in the
National Heart and wheel. Three main reasons account for this: community a flexible yet organised system that
Lung Hospital, firstly, the unstable, changing nature of they can work with locally and which also has
London SW3 6NP
Jennifer Hunt, definitions of quality; secondly, interest being a nationwide network of users and national
chief nurse intermittent; and, thirdly, interest often being leadership.
16 Hunt

(1) To establish the direction and practices of Chief nurse/director of quality

the nursing quality assurance programme
and to monitor and review its progress
(2) To approve all standards, policies, and
protocols
(3) To approve action plans implemented to
resolve problems
Box I Terms of reference of Nursing Quality Assurance
Committee
Qual Health Care: first published as 10.1136/qshc.1.Suppl.15 on 1 September 1992. Downloaded from http://qualitysafety.bmj.com/ on 31 July 2018 by guest. Protected by copyright.
Directors of nursing services
Director of education
Quality assurance coordinator
Nurse practice advisers
Coordinators of subgroups (nursing audit,
standards, and policies and procedures)
Box 2 Membership of Nursing Quality Assurance
Committee

Integrating theory with practice (5) Agreeing an appropriate action plan

What is happening to achieve integration of (6) Reauditing perhaps six months later or
theory with practice and to ensure that so.

standards affect nurses' behaviour and Already many topics have been addressed in
performance all day every day? Before 1989 this way - for example, management of
several quality initiatives were under way postoperative pain in adult cardiothoracic and
within the special health authority for cardiovascular surgical patients and discharge
-

example, several quality circles had been set planning for all inpatients. More are being
up and a patient satisfaction questionnaire had added all the time. The advantage of this
been developed and was administered approach is that it really involves the nursing
regularly. However, it became clear that these staff so that they "own" the process and the
initiatives needed better coordination so the results. A further benefit has been the growth
Nursing Quality Assurance Committee was set of interest of other professional staff in this
up to provide overall direction and leadership system, with the result that they are applying
(box 1). Its membership includes all the key it to their own practice - for example,
professional leaders in the special health occupational therapy - and joining with nurses
authority as well as nurses engaged daily in to develop multidisciplinary standards such as
quality activities (box 2). Meeting four times a that on discharge planning.
year, the committee devolves the work down
to the grass roots through three subgroups Conclusion
(box 2) which arrange and organise their own If quality and standards are going to become
meetings. This structure is not seen as set in realities then there has to be a mutually top
stone, rather it is an attempt to: down and bottom up initiative. Without
* Cover a wide range of quality assurance leadership from the top from those with
activities authority change is more difficult for staff;
* Involve nurses at all levels in quality without the involvement and commitment of
assurance practitioners exhortation from the top will
* Provide opportunities for learning and sound impressive but achieve little. There is
practising different skills and techniques still a need to incorporate other quality
* Enable nursing quality assurance activities activities into this framework and especially to
to be coordinated and monitored. relate them to the quality strategy of the
All of the groups have developed an active special health authority and its quality
programme. That of the standards group is the directional plan, with its focus on
most well developed because the work on implementing a total quality system. However,
standard setting using the dynamic standard we believe that we have achieved a flexible yet
setting system had begun in 1990. Its coordinated approach which involves nurses
achievements show how improvements can be from every level and specialty within our
made and maintained. The process consists special health authority, which encompasses
of: multidisciplinary work, and which we believe
(1) Setting the standard will indeed ensure a continuous improvement
(2) Auditing current practice in nursing.
(3) Implementing the standard
(4) Reauditing practice and identifying NHS Management Inquiry. Report. London: Department
1
deficiencies of Health and Social Security, 1983. (Griffiths report.)