Perceptions and experiences of nurses involved in quality-im… : JBI Evidence Synthesis

Introduction

Quality in health care can be described as the extent to which a service provides care within researched and established principles.1 Quality-improvement (QI) processes are integral to contemporary healthcare providers2 as a method of demonstrating organizational standards, values, and goals for consumers of the healthcare service. Quality improvement is a process that involves a continuous cycle assisting the health service to maintain evidence of compliance with quality assurance processes. According to the Australian Commission on Safety and Quality in Health Care,3 the participation of nurses in QI processes is essential, not only to patient safety but also the effectiveness of the entire healthcare system. Nurses play a significant role in assisting acute healthcare service providers to implement, monitor, and maintain QI strategies.5 As nurses are considered vital to this process, the perspectives or experiences of nurses in this context are important to consider.4,5

Quality in health care is a service-delivery goal; QI can be used as a means to achieve set goals.1,4 Quality improvement incorporates functions of quality processes in healthcare environments, including setting out the expected standard of care, and designing tools and methods for delivery and evaluation of care.4 Quality improvement functions as an operational process within health services, enabling those involved in care delivery to continuously measure and improve practice.6

Pioneers in the understanding of quality systems, such as Donabedian,2,6 Berwick,7 Juran,8 and Deming,8 identified QI as important for quality planning, improvement, control, reflection on action, and entire organizational engagement of the health service. Berwick7 proposed that training and tradition in core practices have traditionally relied on an individual practitioner’s skills to improve healthcare delivery, rather than an organizational standard to measure actual performance or outcome. Donabedian’s model illustrates how QI can be integrated into the organization and delivery of healthcare.2,6 This model considers QI as consisting of three distinct components — structure, process, and outcomes — that have often been integrated and used to develop policy. Structure describes the physical organization of healthcare services. Process is the method used by the health service to define the physical aspects of care. Outcomes are results that occur after implementing these structures and processes.2 This model is used to determine whether expected or desired outcomes can be associated with changes in structures and processes of care or policy and whether they have been achieved.9 Organizational QI processes also inform standards for the audit of compliance with regulations for healthcare services.4,9

The World Health Organization (WHO),1 for example, describes quality in relation to the requirements of provision of healthcare services. The constructs described by WHO include effectiveness, efficiency, accessibility, acceptability/patient centeredness, equitability, and safety.1

Healthcare organizations can use the WHO strategies to measure the delivery of quality processes and, in turn, assist in determining ongoing QI procedures. The WHO1 proposed that in addition to the healthcare providers ensuring QI, there should be engagement of policy makers and service users included in this entire process. Berwick7 proposed that engagement of key stakeholders in development of policy or QI processes was necessary for successful implementation, and that QI must be organizationally embraced from the perspective of management through to those involved in the hands-on delivery of front-line services. As nurses are a central element to this process, perspectives of nurses on QI processes is useful to understand.

Because nurses are key stakeholders in the implementation of QI processes, their perceptions on these processes could be linked to an ability to execute them successfully. Ott and Ross10 indicated that nurses’ input into QI processes can be used as indicators of satisfaction in their roles: “Staff nurse satisfaction is a synergistic effect of shared governance. Fulfillment and empowerment occur when job duties are defined, input is solicited, work is made easier and the staff nurses are content.”10(p.766) If nurses perceive the implementation of the QI processes as being successful, they may engage more effectively with the processes to be implemented.

As nurses are on the front line of patient service delivery, they are well placed to contribute to QI processes. Oestberg stated, “As direct caregivers, nurses spend more time with patients than most other disciplines. What nurses do has a huge impact on the care our patients receive.”5(p.46) Nursing knowledge, skills, and experience contribute to the overall quality of care; however, many variables affect that perception of quality.11 Although some studies indicate that QI requires consultation, agreement, discussion, and collaboration to achieve set goals or objectives, other studies suggest a disparity between the perceptions of management consultation versus the perceptions of nurses at the front-line level of delivery.12 Moran and Johnson wrote, “Those who perform direct services are in an excellent position to identify the need for change in service delivery processes.”13(p.45) Some research evidence appears to indicate inconsistencies in the involvement of nurses in decision making for change, which has the potential to affect integration of QI processes: “Practising nurses are often participants in studies measuring nursing care quality; however, evidence of their input into the development of measures is lacking.”14(p.1690)

A contemporary example of QI process is the use of evidence-based health care (EBHC) in acute-care facilities (where nurses are key participants).15-17 Use of EBHC is not only an example of a quality process, but assists the healthcare service in demonstrating the organizational requirements for quality standards of care. Professional standards for regulation of practice and codes of conduct for nurses are similarly used in quality processes as a method for determining quality care and as an evaluation of nursing performance.18,19 Nursing practice standards provide healthcare services, regulators, and consumers with an expectation or benchmark for the standard of care.18

As there is considerable regulation applied to local practice of nursing and quality frameworks that define nursing practice standards, it is important to collaborate with nurses5 in planning, developing, and integrating of quality standards for care, as they are key stakeholders in the delivery of healthcare practices.

Burhans and Alligood14 discussed the value of nurses being involved in development of QI strategies. They considered that engaging with nurses and understanding their experiences might expedite implementation of methods to improve quality in nursing care, and stated, “Related improvements in patient outcomes might be influenced by these changes. Nurse-valued measures can only be developed if the lived meaning of quality nursing care is clearly identified.”14(p.1691) In alignment with that view, an Australian study by Price et al.20 stated, “Integral to the success of any quality improvement process is the inclusion of views of both nurse managers and clinical nurses.”(p.43)

Preliminary searches have identified data showing that the experience of nurses in consultation of QI process continues to be overlooked. Burhans and Alligood14 identified that in the process of consulting with nurses on what quality care means, “It is notable that, with 2.6 million nurses in the USA delivering patient care, their daily evaluation of that care is done without a shared understanding of what quality nursing care really means.”(p.1690) Jakobsson and Wann-Hansson15 described the nursing perception of the process in implementation of structured care plans as a QI process and found in their study that “The implementation process of the SCP [Structured Care Plans] at the different clinics was not optimal according to the nurses.”(p.950) This suggests that contemporary health service managers of QI processes do consider that nurses’ input is necessary; however, other studies16,20,21 suggest divergent views of the extent to which nurses (particularly clinical nurses) are involved in processes associated with QI and whether engaged models of QI implementation are consistently applied. An opportunity exists to conduct a qualitative systematic review to explore themes and develop a meaningful understanding of nurse perceptions and experiences as they participate in QI processes in the acute-care environment.11,15,22

Preliminary searches of PROSPERO, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports were conducted and no current or in-progress systematic reviews on the topic were identified.

Review question

What are the experiences and perceptions of nurses who conduct and participate in QI processes in the acute-care environment?

Inclusion criteria

Participants

The reviewers will consider studies that include nurses working in acute care, sub-acute care and tertiary centers, and hospitals. Registered and enrolled nurses at all levels will be considered, including internationally equivalent roles from any geographic region.

Studies that focus solely on nursing student roles will be excluded. However, studies that include students, medical teams, and/or patients may be included where it is possible to extract the data specific to registered and enrolled nurses’ experiences, to ensure that the depth of the review is appropriate. The researchers will limit studies to those conducted in English language or translated to English, due to limitations of the researcher’s ability to overcome budgetary constraints. Some studies23 suggest that limiting studies to English language only may not necessarily impact negatively on the results.

Phenomena of interest

This review will consider studies that explore the perceptions and experiences of nurses who are involved in organizational clinical practice QI processes.

Context

This review will consider studies that have been undertaken within acute healthcare organizations, such as hospitals and sub-acute, surgical, medical, or tertiary care centers, regardless of geographic location or public or private status.

Types of studies

This review will consider qualitative data arising from study types including, but not limited to, designs such as phenomenology, discourse analysis, grounded theory, ethnography, action research, and qualitative descriptive research.

Studies published from database inception to the present will be included. Quality improvement processes, although not necessarily formally characterized, have been integral since Nightingale’s inception of the nursing role.24 Therefore, no restriction on the evidence found in terms of date will be imposed for this review.

Methods

The proposed qualitative systematic review will be conducted in accordance with the JBI methodology.25 This protocol has been registered in PROSPERO (CRD42019146833).

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of Google Scholar, PubMed, and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for PubMed (see Appendix I). The initial key words were: quality improvement, clinical competence, clinical standard, organization and administration, professional competence, and clinical governance.

The search strategy, including all identified keywords and index terms, will be adapted for each included database. The reference lists of all studies selected following critical appraisal will also be screened for additional studies.

Information sources

The databases to be searched include PubMed, CINAHL, Embase, and Scopus. The search will also include the following gray literature sources: Informit, MedNar, and ProQuest for conference papers and proceedings, dissertations, and theses.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X9.1 (Clarivate Analytics, PA, USA), and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a meta-aggregative flowchart.26

Assessment of methodological quality

Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI critical appraisal checklist for qualitative research.25 The critical appraisal tool will be used; any “yes” answers to questions specifically related to congruity between the research, researcher, methods, analysis, and culture will indicate a quality threshold in terms of dependability.27 Studies that have been allocated a “no” answer to those specific questions will be excluded.

The next step will be applying a ranking score to determine credibility. The credibility ranking will allow grading of the data in terms of high to very low, which assists in establishing confidence in the data.25,27

Authors of studies may be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table.

Data extraction

Data will be extracted from studies included in the review using the standardized JBI data extraction tool.25 The data extracted will include specific details about the populations, context, culture, geographical location, study methods, and the phenomena of interest relevant to the review objective. Findings, and their illustrations, will be extracted and assigned a level of credibility.25 Authors of papers may be contacted to request missing or additional data, where required.

Data synthesis

Qualitative research findings will be pooled using the meta-aggregative approach.26 This will involve the aggregation or synthesis of findings based upon similarity in meaning, as identified by the review author, to generate a set of statements that represent that aggregation. Findings considered similar will inform the development of categories. A category is a detailed and meaningful statement that integrates two or more findings through assembling the findings and categorizing as an interpretive process. These categories will then be subjected to a second level synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice.

Assessing confidence in the findings

The synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.25,27 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest, and context for the specific review. Each synthesized finding from the review will then be presented, along with the type of research informing it, with scores for dependability and credibility and the overall ConQual score.25,27

Acknowledgments

Ms Sandra Rennie, approved external co-supervisor by Adelaide Graduate Centre, The University of Adelaide, South Australia.

Ms Natalie Brewer, Librarian, Australian Nursing Midwifery Federation, Adelaide, South Australia.

This review contributes toward a higher degree by research for the primary reviewer (MN).