Quality Nursing Research Paper
JAN
JOURNAL OF ADVANCED NURSING
ORIGINAL RESEARCH
Quality nursing care in the words of nurses
Linda Maas Burhans & Martha Raile Alligood
Accepted for publication 19 March 2010
Correspondence to L.M. Burhans: e-mail: linda.burhans@gmail.com
Linda Maas Burhans PhD RN CPHQ
Associate Executive Director of Education and Practice
North Carolina Board of Nursing and
Adjunct Faculty, East Carolina University
College of Nursing, Wilson, NC, USA
Martha Raile Alligood PhD RN ANEF
Professor and Director of PhD Program
East Carolina University College of Nursing,
Greenville, NC, USA
B U R H A N S L . M . & A L L I G O O D M . R . ( 2 0 1 0 ) Quality nursing care in the words of nurses. Journal of Advanced Nursing 66(8), 1689–1697.
doi: …show more content…
10.1111/j.1365-2648.2010.05344.x
Abstract
Aim. This paper is a report of a study of the meaning of quality nursing care for practising nurses.
Background. Healthcare quality continues to be a subject of intense criticism and debate. Although quality nursing care is vital to patient outcomes and safety, meaningful improvements have been disturbingly slow. Analysis of quality care literature reveals that practising nurses are rarely involved in developing or defining improvement programs for quality nursing care. Therefore, two major study premises were that quality nursing care must be meaningful and relevant to nurses and that uncovering their meaning of quality nursing care could facilitate more effective improvement approaches.
Method. Using van Manen’s hermeneutic phenomenology, meaning was revealed through analysis of interviews to answer the research question ‘What is the lived meaning of quality nursing care for practising nurses?’ Twelve nurses practising on medical or surgical adult units at general or intermediate levels of care within acute care hospitals in the United States of America were interviewed. Emerging themes were discovered through empirical and reflective analysis of audiotapes and transcripts. The data were collected in 2008.
Findings. The revealed lived meaning of quality nursing care for practising nurses was meeting human needs through caring, empathetic, respectful interactions within which responsibility, intentionality and advocacy form an essential, integral foundation.
Conclusion. Nurse managers could develop strategies that support nurses better in identifying and delivering quality nursing care reflective of responsibility, caring, intentionality, empathy, respect and advocacy. Nurse educators could modify education curricula to model and teach students the intrinsic qualities identified within these meanings of quality nursing care.
Keywords: hermeneutic phenomenology, nursing, nursing care, qualitative, quality
Introduction
The need to address healthcare quality improvement intensified within the past decade. In 2000, the Institute of
Medicine (IOM) heralded the need patient safety and quality of care in
America (USA) with publication of
Building a Safer Healthcare System
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for improvement in the United States of
To Err Is Human:
(IOM 2000). Their
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documentation of 98,000 hospital deaths annually due to errors by healthcare providers sent shockwaves through professional and public arenas. In Crossing the Quality
Chasm: A New Health System for the 21st Century (IOM
2001), a vision for safe, high quality care that is evidencebased, patient-centred and systems-oriented was delineated.
In response to these reports, healthcare professionals were challenged to take responsibility and accountability for the quality of their practice and actively improve the quality and safety of healthcare in the USA.
In the 2004 report titled Keeping Patients Safe: Transforming the Work Environment of Nurses, the IOM validated research indicating that nursing care was directly related to improved patient outcomes and that nursing vigilance protected patients against errors (IOM 2004).
Nurses, as hands-on caregivers, make major healthcare contributions by assessing, planning, and evaluating patient care needs; delivering treatments and medications; advocating for patients; and assuring their comfort. The quality of nursing care makes a vital difference in patient outcomes and safety. Despite dissemination of numerous innovative patient safety and quality programmes in recent years, however, meaningful improvements have been disturbingly slow.
Clarke and Aiken (2006) stated that: ‘There is consensus that the goal proposed by the IOM to halve the rate of medical errors within 5 years has not yet been achieved’
(p. 3). As healthcare professionals, nurses are accountable for the quality and systematic improvement of nursing practice
(American Nurses Association 2004).
It is notable that, with 2Æ6 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. The existing literature focuses primarily on measurement of nursing care quality through patient outcomes and patient satisfaction. Whereas these data provide important information, they do not address quality nursing care specifically.
Practising nurses are often participants in studies measuring nursing care quality; however, evidence of their input into the development of measures is lacking. Furthermore, the developers and authors of the measures are often nurse leaders, managers, educators and researchers who, by virtue of their positions, are not in practising nurse care roles.
Therefore, practising nurses’ meanings of quality nursing care are not adequately represented.
We reasoned that if current outcome measures and quality criteria failed to capture the heart of nursing and the meaning of quality nursing care for practising nurses, this might be contributing to the slow pace of improvement in quality
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nursing care. Therefore we designed a study to uncover the meaning of quality nursing care as lived, understood, and articulated by practising nurses.
Background
Literature from various countries supported the need to explore the lived meaning of quality nursing care. Coulon et al. (1996) identified themes of professionalism, holistic care, practice, and humanism in Australian nurses’ quest for excellence. The importance of these elements was supported by Gunther and Alligood’s (2002) conclusion that ‘high quality nursing equates with competence in the cognitive, affective, and psychomotor domains’ (p. 357) among USA nurses. Likewise, Glen (1998) argued that high quality nursing care in British nurses ‘is influenced predominantly by values’ (p. 38) and that ‘the key to improvement in practice may be the improvement of emotional and motivational tendencies’ (p. 42). The findings of Attree (2001), Hogston
(1995) and Idvall and Rooke (1998) supported evaluation criteria indicative of both external system influences on quality nursing care and internal characteristics evident through interpersonal processes and elements of performance among British and Swedish nurses. Aiken and Patrician
(2000) reported that the presence of professional environments in the USA correlated with high quality nursing care.
Williams (1998) proposed that Australian nurses’ perceptions of quality care included themes of patient need fulfilment and therapeutic effectiveness mediated through selective focusing. Interpersonal relationship with patients and effective leadership were each identified as strong quality indicators by Redfern and Norman (1999a, 1999b). Quality nursing care in Thailand (Kunaviktikul et al. 2001) was related to the degree to which the patient’s physical, psychosocial and extra care needs were met. However, although these globally diverse researchers attempted to define quality nursing care, it is not known if or how the identified themes or elements relate to the lived meaning of quality nursing care from the perspective of practising nurses. The subjective, stakeholder-specific nature of quality (Jennings & Staggers 1999, Lang & Mitchell 2004) is evident throughout the nursing literature. Nurses evaluating quality may focus on assessment, planning, or the effectiveness and skill with which treatments and medications are delivered.
Patients, in contrast, are likely to care more about the communication, listening, kindness and responsiveness of their nurses. Meanwhile, nursing managers often favour a focus on the organizational elements of efficiency and costeffectiveness. These differences reflect the knowledge, views
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and values of differing participants in the healthcare experience.
Research related to the meaning, definition and perception of quality nursing care has been limited. The dearth of published studies addressing the unique perspective of nurses was specifically noted by Lynn et al. (2007), who observed that without knowing nurses’ perspectives, the evaluation of quality patient care is incomplete and ineffective. In fact, the definition and meaning of quality in all healthcare disciplines remains elusive, subjective, and stakeholder-specific, resulting in measurement and improvement challenges (Burhans
2007).
Anecdotally, through over 30 years experience in implementing quality improvement programmes and initiatives in acute care hospitals, practising nurses have often pointed out to researchers that nursing managers were out of touch with the demands of bedside nursing and the real needs of patients.
Our premise was that nursing care improvement strategies focused on measures valued by nurses and identified by them as the core meaning of quality nursing care might result in more rapid, effective changes and improvements in nursing quality care. 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. In the initial study reported here, we focused on practising nurses working in acute care hospitals in the USA because significant improvement efforts are currently focused in this arena.
Because the lived meaning of quality nursing care for practising nurses has not been specifically identified in the nursing literature, a new approach was proposed. An exploratory, qualitative study, using van Manen’s (1990) approach to hermeneutic phenomenology, was conducted to explore and uncover the lived meaning of quality nursing care. Pope et al. (2005) supported the use of qualitative methods as appropriate in determining what really matters to caregivers in the arena of healthcare quality. They stated that,
‘the emphasis in qualitative research on understanding meanings and experiences makes it particularly useful for quality assessment and for unpacking some of the complex issues inherent to quality improvement’ (p. 148).
The study
Aim
The aim of the study was to uncover an understanding of the meaning of quality for practising nurses. The research question was: ‘What is the lived meaning of quality nursing care for practising nurses in the USA?’
Quality nursing care
Methodology
This study was informed by van Manen’s (1990) hermeneutic phenomenological approach to human science research, designed to uncover the lived meaning of pragmatic experiences. His methodology, philosophically based in both the descriptive traditions of Husserl and the interpretive traditions of Heidegger, strives to grasp the essential meaning of an experience. Phenomenological research is: ‘the study of lived experience… the explication of phenomena as they present themselves to consciousness… the study of essences; and … the description of the experiential meanings as we live them’ (van Manen 1990, pp. 9–11). Because hermeneutic phenomenology uncovers pragmatic meaning patterns, it was an appropriate approach in this search for the lived meaning of quality nursing care for practising nurses.
In hermeneutic phenomenology the interview process is specifically used ‘as a means for exploring and gathering experiential narrative material that may serve as a resource for developing a richer and deeper understanding of a human phenomenon’ but at the same time ‘needs to be disciplined by the fundamental question’ (van Manen 1990, p. 66).
The hermeneutic phenomenological method (van Manen
1990) was used for the analysis and interpretation of descriptions of personal meanings and experiences. This approach provided: (1) a pragmatic process; (2) applicability to both the discipline and profession of nursing; and (3) a methodology that honoured the importance of nurses’ practical understanding of quality. As other researchers have noted, ‘Phenomenological research originates in practice, and through careful descriptive and interpretive scholarship, enlightens practice’ (Van der Zalm & Bergum 2000,
p. 217).
Participants
The participant selection criteria specified hospital-employed,
Registered Nurses (RNs) with a baccalaureate degree, at least
1 year’s experience and working at least 20 hours per week providing direct, hands-on, bedside, clinical patient care on adult medical and surgical units at the general or intermediate levels of care within acute care hospitals in south-eastern
USA. Nurses responded voluntarily to advertising fliers and spoke with one of the researchers to discuss their inclusion.
Those meeting all the criteria were sequentially enrolled and interviews were scheduled, forming a purposive convenience sample of practising nurses. The final sample size of 12 was determined based on data saturation.
While thematic trends and similarities began emerging after the first six interviews, a total of 12 interviews were completed to fully assure
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saturation. Participants were renamed with pseudonyms to ensure confidentiality.
All participants were female, with an average age of
37Æ5 years (range = 25–52 years). One was African American and the others were White. They had from 3 to 24 years’
(mean = 11Æ6 years) nursing experience and 1 to 12 years’
(mean = 5Æ2 years) experience in their assigned units. Seven had practised for an average of 10 years (range = 4–21 years) at the associate degree nursing (ADN) level prior to completing a Bachelor of Science in Nursing (BSN) degree.
Data collection
Data were collected through a single, tape-recorded, focused interview of approximately 40 minutes with each participant.
Interviews were conducted privately and confidentially in early 2008 by the same interviewer, either face-to-face or by telephone. The researcher (LMB) personally conducted all interviews and completed the process of
phenomenologic inquiry, including empirical and reflective methods, in seeking to uncover the lived meaning of quality nursing care for these nurses.
To elicit data, each participant was asked to respond in her own words to the following:
• Tell me about quality nursing care.
• What does quality nursing care mean to you?
• What is it like when you give quality nursing care?
• Describe an example of when you delivered quality nursing care. • What is it like when you observe another nurse giving quality nursing care?
• Describe an example of when another nurse delivered quality nursing care.
• Is there anything else I need to know about what quality nursing care is like?
If needed to elicit detail or depth, to refocus the participant’s attention on the central issue of quality nursing care, or to refocus discussion on what quality nursing care is rather than what it is not, specific probing questions were used:
• Tell me more about….
• What was that like?
• What did that look like?
• How did you feel about that?
Ethical considerations
Ethical considerations were given a high priority in the conduct of this study. The Combined Institutional Review
Board (IRB) at a university/health system approved the study.
The Chief Nursing Officers and Presidents of the study
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hospitals supported participant recruitment through the distribution of advertising fliers seeking volunteers for the study. Participants were assured of confidentiality and the opportunity to withdraw at any time and gave written informed consent prior to interview.
Data analysis
The interview data were analysed, interpreted and synthesized using van Manen’s (1990) qualitative hermeneutic phenomenological research approach that specifies six research activities. First, we ‘turned to a phenomenon which seriously interests us and commits us to the world’ (van
Manen 1990, p. 30), affirming our belief in the importance of studying the lived meaning of quality nursing care for practising nurses.
Through the second and third research activities, ‘investigating experience as we live it rather than as we conceptualize it’ and ‘reflecting on the essential themes which characterize the phenomenon’ (van Manen 1990, p. 30), we identified emerging themes within the interview audiotapes and transcripts. Combing through the data was an iterative process that moved from each whole interview, through selected excerpts, to emerging themes, back to the whole interviews, and finally led to the creation of a narrative text. We explored commonalities to uncover essential, universal elements within the interviews.
The coding process was carried out using empirical and reflective methods of transcript analysis. The initial coding identified words and phrases salient to the research question.
These were clustered into categories during a secondary coding process. Categories were combined, based on similarities, into a central theme or statement for each participant. Finally, similar elements from each participant’s central theme were combined to create overarching common themes to uncover the lived meaning of quality patient care for these nurses. Continuing the process of reflecting on the essential themes, the fourth research activity was ‘describing the phenomenon through the art of writing and rewriting’ (van
Manen 1990, p. 30). This final step in the iterative analysis process resulted in what is often considered the culmination of the interpretive analysis in hermeneutic phenomenological research – a comprehensive view of the experience of quality nursing care presented through a narrative phenomenological text called a linguistic transformation: ‘human science research is a form of writing. Creating a phenomenological text is the object of the research process’ (van Manen 1990, p.
111). Through reading the linguistic transformation narrative, others can come to understand the lived meaning of the
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Quality nursing care
phenomenon as interpreted by the author, can reflect on the lived meaning themselves, and can offer alternative interpretations.
The fifth research activity required this study to be oriented within the nursing discipline and to maintain a strong connection between theory and the real lives of practising nurses. Non-participant nurses were asked to read and validate whether the linguistic transformation described quality nursing care from their own perspectives. By producing understandings, interpretations, and formulations specific to nursing it was strong. By being concrete, the study text was rich and thick. The nurse, ‘as author, attempts to capture life experience (action or event) in anecdote or story, because the logic of the story is precisely that story retrieves what is unique, particular, and irreplaceable’ (van Manen 1990, p.
152) about the lived experience. The depth of the study text offered insight into the meaning of the lived experience, although it always remains challenging to achieve complete understanding. The steps used to assure this study’s rigor supported these characteristics.
The sixth and final research activity ‘balanced the research context by considering the parts and whole’ (van Manen
1990, p. 31). This study of the lived meaning of quality nursing care for practising nurses required mindfulness and balancing of the part-whole continuum throughout its conduct. Reflexivity, the ‘continual process of critical self-reflection on one’s personal biases, preconceived notions, assumptions, theoretical predispositions and ideological commitments’
(Powers & Knapp 2006, p. 148), was a primary strategy used to support rigor or validity. Reflexivity or reflection on reflections, characteristic of the iterative analysis processes, was used in this study by incorporating personal experiences and lived meanings rather than attempting to ‘bracket’ or set them aside. Through reflexivity, equal weight was given to participants’ voices.
The primary researcher/interviewer’s recorded reflexive field notes were used with a threefold purpose. In theoretical notes, observations were interpreted and assigned meaning.
In methodological notes, details, instructions and reminders were recorded. In personal notes, feelings, beliefs, biases and thoughts were recorded at the start of the study and throughout the research process. Ongoing dialogue with the second researcher/author, and repeatedly reflecting on the audiotapes, transcripts, and analysis documents in whole and in part further, mitigated researcher biases.
Lastly, verbatim quotes were used as low inference descriptors to allow readers ‘to experience for themselves the participants’ perspectives’ (Johnson 1999, p. 162).
Trustworthiness of the quotes was supported through direct verification of transcript accuracy by the researchers against the audiotapes and field notes.
Rigour
Findings
Rigor or trustworthiness was established in several ways.
Use of audiotapes, audited transcripts, and field notes for validation and enhancement assured data accuracy and contributed to the credibility or truth value of the research materials. The ‘phenomenological nod’ (Munhall 1994, p.
189) of agreement was obtained from three non-participant nurses, who indicated that the written interpretation of the phenomenon resonated with them, offering additional evidence of credibility. Therefore, cross-checking of information and conclusions was achieved through triangulations of multiple procedures and through independent reading and interpretation of the interviews by nurse colleagues. This dialogical interpretation established corroboration of the analysis and interpretation. This peer review auditing process was also carried out using van
Manen’s method. Participant stories, anecdotes, and examples were interpreted to create the essence that came to be understood. As in hermeneutic phenomenology, this was not a restructuring of the participants’ statements, but a new essence created and shared with non-participant nurses for validation.
Themes
We discovered six essential themes or lived meanings of quality nursing care in the words of the study participants: • Advocacy was interpreted in phrases such as: ‘look out for your patient’, ‘protecting them’, ‘calling, questioning physicians’ and ‘patient advocates all the way’.
• Caring was revealed in words and phrases such as: ‘caring’,
‘kind’, ‘a caring heart’ and ‘has aspect of caring’.
• Empathy was interpreted in phrases such as: ‘appreciating the patient’s experience’, ‘treat and view the patient as either yourself or your loved one’ and ‘being empathetic with the patient’.
• Intentionality, interpreted as the nurse’s intention to deliver quality nursing care, was revealed in phrases such as:
‘actually wanting to give that good care’, ‘giving the best I can to the patient’, ‘just day to day commitment to doing’ and ‘we know when we do it.’
• Respect was interpreted in phrases such as: ‘treat them all with respect and dignity’, ‘don’t lie to them’, ‘met patient
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choice and desire’ and ‘take that sacred trust to the bedside every time’.
• Responsibility was revealed in words and phrases such as: ‘assuming your responsibilities’, ‘make sure that things aren’t missed and omitted’, and ‘doing the right thing’. Fundamental meanings
After essential themes were interpreted and validated, we reviewed the audiotapes and transcripts again in their totality, seeking ‘what phrase may capture the fundamental meaning or main significance’ (van Manen 1990, p. 92) of each participant’s text as a whole. These verbatim examples indicated phrases most representative of the fundamental meanings of quality nursing care for each participant:
• When I give quality nursing care I’m doing what I’m supposed to do – as well as I could …and I’ve done everything I can do in the situation to support the patient and family in a difficult decision. –
capacity to provide quality nursing care. They described an intrinsic characteristic of nurses whose care reflects responsibility, caring, intentionality, empathy, respect and advocacy.
Essence
Based on the described analysis iterations and reflective insights into the thematic relationships, a succinct description of the essence of the phenomenon was developed: The lived meaning of quality nursing care for these practising nurses was interpreted and found to be meeting human needs through caring, empathetic, respectful interactions within which responsibility, intentionality and advocacy form an essential, integral foundation. This resided within nursepatient interactions that were consistently recognizable as such by nurses in their own practice and in that of their peers.
The six themes of responsibility, caring, intentionality, empathy, respect and advocacy were the essence of quality nursing care for the nurses in this study.
Breeana
• If you have a person that’s actually caring and compassionate and concerned about the welfare of that individual, it’ll take you farther than if you are an expert clinician. – Dorothy
• To be very bold in communicating … not being afraid to … be an advocate for the patient. – Lenor
• It made me remember why I do what I do. … It made me remember, we’re here for the patients. – Stacey
• We know when we do it [quality nursing care] … good care and thoughtful care. – Maryrose
The iterative process of analysing the anecdotes and stories related by nurses repeatedly uncovered the six themes of responsibility, caring, intentionality, empathy, respect and advocacy, revealing the essential components in this search for quality nursing care from the experiences and words of practising nurses. Surprisingly, their descriptions suggested that clinical nursing skills were less important as a determinant of quality nursing care: ‘the human part is bigger than the skill element … anyone can be taught to do any (skill)’ and
‘skills are critical but not as important as caring … good caring with skills is more important than skills’. Others stated that nurses ‘need some of everything but skill can come from elsewhere’, and ‘if you don’t (communicate with the patient) it doesn’t matter how good technical skills are’. Their statements suggested that their idea of quality nursing care was determined more by the manner of care delivery than by skill level. In fact, they indicated that any nurse could learn the requisite skills but nurses either had or did not have the
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Discussion
In summary, the six essential themes uncovered resided predominantly within the realm of the art of nursing.
Although some participants mentioned clinical skill, they were clear that it was not the most important indicator of quality nursing care. Instead, nursing’s oldest traditions, those of the art of nursing, resonated within the lived experiences of these nurses and thus within the lived meaning. These themes reflected the art of nursing as highly valued by practising nurses. We suggest further research to explore if the art of nursing informs a more effective application of the science.
Alligood (2002) identified a theory of the art of nursing through a hermeneutic interpretation of the writings and conceptual system of Rogers’ Science of Unitary Human
Beings:
Thus, the art of professional nursing becomes the ability to balance respect for human freedom and individual rights with responsibility for the welfare of others through knowing from the feeling attribute of empathy in the moral action that is nursing practice. (p. 58)
Responsibility, respect, and empathy in this theory of the art of nursing were identified as being related with the concept of caring. Thus, four of the six themes identified as the essence or lived meaning of quality nursing care were explained within this theory.
The understanding of quality nursing care described in our study recalls earlier literature identifying caring as a concept
‘unique to nursing’ and viewed as its ‘essence’, reported by
Morse et al. (1990). Work to reach consensus on the five
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What is already known about this topic
• Meaningful improvements in healthcare and nursing care quality are disturbingly slow and incremental, possibly related to lack of a shared understanding or definition of quality nursing care.
• Practising nurses’ meanings of quality nursing care are not adequately represented in tools used to measure it.
• Themes and elements identified by globally diverse researchers attempting to define quality nursing care may not relate to the lived meaning from the perspective of practising nurses.
What this paper adds
• Practising nurses’ lived meaning of quality nursing care was meeting human needs through caring, empathetic, respectful interactions within which responsibility, intentionality and advocacy form an essential, integral foundation. • The lived experience of quality nursing care within nurse–patient interactions was consistently recognizable as such by nurses in their own practice and in that of their peers.
• Knowledge of practising nurses’ meaning of quality nursing care may further define the discipline and facilitate practice changes, driving improvements in quality of nursing care and patient outcomes.
Implications for practice and/or policy
• Practising nurses could use these shared meanings to inform their own practice and to evaluate the quality of nursing care delivered by themselves and other nurses.
• Nurse managers could develop strategies that better support nurses in the identification and delivery of quality nursing care reflective of responsibility, caring, intentionality, empathy, respect and advocacy.
• Nurse educators could modify curricula to model and teach students the intrinsic qualities identified within these meanings of quality nursing care.
perspectives of caring; its focus, outcomes, and consequences; and the three major theories of caring reviewed by these authors continues today. That caring and related concepts identified in this earlier study constitute the contemporary practising nurses’ meaning of quality nursing care adds important knowledge for the discipline of nursing. By further defining the discipline, they may facilitate practice changes,
Quality nursing care
driving improvements in the quality of nursing care. Practising nurses, managers, educators, researchers and policymakers can use this new and important knowledge.
These findings provide beginning knowledge that the meaning of quality nursing care is shared among practising nurses. That this shared meaning is anchored in the art of nursing may be surprising to practising nurses as it contradicts the prevailing emphasis. The lived experiences of quality nursing care were centred on these nurses’ interactions with patients and were recognizable by nurses in their own practice and in that of their peers. The six essential themes of responsibility, caring, intentionality, empathy, respect and advocacy were validated as the essence of quality nursing care in the lived experience of practising nurses. These shared meanings can be used to inform practice and to evaluate the quality of nursing care being delivered. That is, nurse managers could develop strategies that support nurses better in the identification and delivery of quality nursing care reflective of the essences of responsibility, caring, intentionality, empathy, respect and advocacy. They could use these themes to evaluate the quality of nursing care delivery by observing nurses’ behaviours and interactions with patients.
Importantly, more than half of our participants described quality nursing care relative to end-of-life situations.
Research is needed to understand the meaning of this finding.
Does it reflect a hidden nursing value yet to be discovered?
Finally, will addressing the lived meaning of quality nursing care for practising nurses influence nurse satisfaction and retention? Nurse educators could use this beginning knowledge of quality nursing to identify the need for changes in nursing education curricula. Researchers could explore whether the qualities identified within this understanding of quality nursing care can be modelled and taught to nursing students.
Is the art of nursing content present in their curricula? Can it be taught? Does continuing education for practising nurses address the art of nursing?
Study limitations
As is common in qualitative methodologies, our findings are limited to the individuals interviewed and to their personal experience. Because all participants were self-selected females, educated at baccalaureate level, employed in specific hospital practice settings and located in one area of the USA, the results are not generalizable to nursing populations with differing educational preparation, in differing care delivery settings or geographic locations, nor to male nurses. Finally, the findings from hermeneutic phenomenological studies are subject to alternative interpretations.
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Conclusion
Nursing knowledge of the meaning of quality nursing care for practising nurses has potential to refine the discipline and facilitate practice changes, driving improvements in quality care and patient outcomes. Our findings suggest the need for future investigations into topics such as: (1) the lived meaning of quality nursing care for practising nurses in different acute care delivery settings and other adult medicalsurgical general and intermediate level units; (2) the lived meanings of nurses in non-acute settings and roles such as community health and other aggregate-focused care delivery settings; and (3) the lived meaning of quality nursing care among male nurses.
Funding
The study was funded in part through a grant from the East
Carolina Center for Nursing Leadership (ECCNL). ECCNL is a project within the East Carolina University College of
Nursing. There was no grant number and the amount of funding was minimal ($1000).
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
LB and MA were responsible for the study conception and design. LB performed the data collection. LB and MA performed the data analysis. LB was responsible for the drafting of the manuscript. LB and MA made critical revisions to the paper for important intellectual content. LB obtained funding. MA provided administrative, technical or material support. MA supervised the study.
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Quality nursing care
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JOURNAL OF ADVANCED NURSING
ORIGINAL RESEARCH
Quality nursing care in the words of nurses
Linda Maas Burhans & Martha Raile Alligood
Accepted for publication 19 March 2010
Correspondence to L.M. Burhans: e-mail: linda.burhans@gmail.com
Linda Maas Burhans PhD RN CPHQ
Associate Executive Director of Education and Practice
North Carolina Board of Nursing and
Adjunct Faculty, East Carolina University
College of Nursing, Wilson, NC, USA
Martha Raile Alligood PhD RN ANEF
Professor and Director of PhD Program
East Carolina University College of Nursing,
Greenville, NC, USA
B U R H A N S L . M . & A L L I G O O D M . R . ( 2 0 1 0 ) Quality nursing care in the words of nurses. Journal of Advanced Nursing 66(8), 1689–1697.
doi: …show more content…
10.1111/j.1365-2648.2010.05344.x
Abstract
Aim. This paper is a report of a study of the meaning of quality nursing care for practising nurses.
Background. Healthcare quality continues to be a subject of intense criticism and debate. Although quality nursing care is vital to patient outcomes and safety, meaningful improvements have been disturbingly slow. Analysis of quality care literature reveals that practising nurses are rarely involved in developing or defining improvement programs for quality nursing care. Therefore, two major study premises were that quality nursing care must be meaningful and relevant to nurses and that uncovering their meaning of quality nursing care could facilitate more effective improvement approaches.
Method. Using van Manen’s hermeneutic phenomenology, meaning was revealed through analysis of interviews to answer the research question ‘What is the lived meaning of quality nursing care for practising nurses?’ Twelve nurses practising on medical or surgical adult units at general or intermediate levels of care within acute care hospitals in the United States of America were interviewed. Emerging themes were discovered through empirical and reflective analysis of audiotapes and transcripts. The data were collected in 2008.
Findings. The revealed lived meaning of quality nursing care for practising nurses was meeting human needs through caring, empathetic, respectful interactions within which responsibility, intentionality and advocacy form an essential, integral foundation.
Conclusion. Nurse managers could develop strategies that support nurses better in identifying and delivering quality nursing care reflective of responsibility, caring, intentionality, empathy, respect and advocacy. Nurse educators could modify education curricula to model and teach students the intrinsic qualities identified within these meanings of quality nursing care.
Keywords: hermeneutic phenomenology, nursing, nursing care, qualitative, quality
Introduction
The need to address healthcare quality improvement intensified within the past decade. In 2000, the Institute of
Medicine (IOM) heralded the need patient safety and quality of care in
America (USA) with publication of
Building a Safer Healthcare System
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for improvement in the United States of
To Err Is Human:
(IOM 2000). Their
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documentation of 98,000 hospital deaths annually due to errors by healthcare providers sent shockwaves through professional and public arenas. In Crossing the Quality
Chasm: A New Health System for the 21st Century (IOM
2001), a vision for safe, high quality care that is evidencebased, patient-centred and systems-oriented was delineated.
In response to these reports, healthcare professionals were challenged to take responsibility and accountability for the quality of their practice and actively improve the quality and safety of healthcare in the USA.
In the 2004 report titled Keeping Patients Safe: Transforming the Work Environment of Nurses, the IOM validated research indicating that nursing care was directly related to improved patient outcomes and that nursing vigilance protected patients against errors (IOM 2004).
Nurses, as hands-on caregivers, make major healthcare contributions by assessing, planning, and evaluating patient care needs; delivering treatments and medications; advocating for patients; and assuring their comfort. The quality of nursing care makes a vital difference in patient outcomes and safety. Despite dissemination of numerous innovative patient safety and quality programmes in recent years, however, meaningful improvements have been disturbingly slow.
Clarke and Aiken (2006) stated that: ‘There is consensus that the goal proposed by the IOM to halve the rate of medical errors within 5 years has not yet been achieved’
(p. 3). As healthcare professionals, nurses are accountable for the quality and systematic improvement of nursing practice
(American Nurses Association 2004).
It is notable that, with 2Æ6 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. The existing literature focuses primarily on measurement of nursing care quality through patient outcomes and patient satisfaction. Whereas these data provide important information, they do not address quality nursing care specifically.
Practising nurses are often participants in studies measuring nursing care quality; however, evidence of their input into the development of measures is lacking. Furthermore, the developers and authors of the measures are often nurse leaders, managers, educators and researchers who, by virtue of their positions, are not in practising nurse care roles.
Therefore, practising nurses’ meanings of quality nursing care are not adequately represented.
We reasoned that if current outcome measures and quality criteria failed to capture the heart of nursing and the meaning of quality nursing care for practising nurses, this might be contributing to the slow pace of improvement in quality
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nursing care. Therefore we designed a study to uncover the meaning of quality nursing care as lived, understood, and articulated by practising nurses.
Background
Literature from various countries supported the need to explore the lived meaning of quality nursing care. Coulon et al. (1996) identified themes of professionalism, holistic care, practice, and humanism in Australian nurses’ quest for excellence. The importance of these elements was supported by Gunther and Alligood’s (2002) conclusion that ‘high quality nursing equates with competence in the cognitive, affective, and psychomotor domains’ (p. 357) among USA nurses. Likewise, Glen (1998) argued that high quality nursing care in British nurses ‘is influenced predominantly by values’ (p. 38) and that ‘the key to improvement in practice may be the improvement of emotional and motivational tendencies’ (p. 42). The findings of Attree (2001), Hogston
(1995) and Idvall and Rooke (1998) supported evaluation criteria indicative of both external system influences on quality nursing care and internal characteristics evident through interpersonal processes and elements of performance among British and Swedish nurses. Aiken and Patrician
(2000) reported that the presence of professional environments in the USA correlated with high quality nursing care.
Williams (1998) proposed that Australian nurses’ perceptions of quality care included themes of patient need fulfilment and therapeutic effectiveness mediated through selective focusing. Interpersonal relationship with patients and effective leadership were each identified as strong quality indicators by Redfern and Norman (1999a, 1999b). Quality nursing care in Thailand (Kunaviktikul et al. 2001) was related to the degree to which the patient’s physical, psychosocial and extra care needs were met. However, although these globally diverse researchers attempted to define quality nursing care, it is not known if or how the identified themes or elements relate to the lived meaning of quality nursing care from the perspective of practising nurses. The subjective, stakeholder-specific nature of quality (Jennings & Staggers 1999, Lang & Mitchell 2004) is evident throughout the nursing literature. Nurses evaluating quality may focus on assessment, planning, or the effectiveness and skill with which treatments and medications are delivered.
Patients, in contrast, are likely to care more about the communication, listening, kindness and responsiveness of their nurses. Meanwhile, nursing managers often favour a focus on the organizational elements of efficiency and costeffectiveness. These differences reflect the knowledge, views
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and values of differing participants in the healthcare experience.
Research related to the meaning, definition and perception of quality nursing care has been limited. The dearth of published studies addressing the unique perspective of nurses was specifically noted by Lynn et al. (2007), who observed that without knowing nurses’ perspectives, the evaluation of quality patient care is incomplete and ineffective. In fact, the definition and meaning of quality in all healthcare disciplines remains elusive, subjective, and stakeholder-specific, resulting in measurement and improvement challenges (Burhans
2007).
Anecdotally, through over 30 years experience in implementing quality improvement programmes and initiatives in acute care hospitals, practising nurses have often pointed out to researchers that nursing managers were out of touch with the demands of bedside nursing and the real needs of patients.
Our premise was that nursing care improvement strategies focused on measures valued by nurses and identified by them as the core meaning of quality nursing care might result in more rapid, effective changes and improvements in nursing quality care. 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. In the initial study reported here, we focused on practising nurses working in acute care hospitals in the USA because significant improvement efforts are currently focused in this arena.
Because the lived meaning of quality nursing care for practising nurses has not been specifically identified in the nursing literature, a new approach was proposed. An exploratory, qualitative study, using van Manen’s (1990) approach to hermeneutic phenomenology, was conducted to explore and uncover the lived meaning of quality nursing care. Pope et al. (2005) supported the use of qualitative methods as appropriate in determining what really matters to caregivers in the arena of healthcare quality. They stated that,
‘the emphasis in qualitative research on understanding meanings and experiences makes it particularly useful for quality assessment and for unpacking some of the complex issues inherent to quality improvement’ (p. 148).
The study
Aim
The aim of the study was to uncover an understanding of the meaning of quality for practising nurses. The research question was: ‘What is the lived meaning of quality nursing care for practising nurses in the USA?’
Quality nursing care
Methodology
This study was informed by van Manen’s (1990) hermeneutic phenomenological approach to human science research, designed to uncover the lived meaning of pragmatic experiences. His methodology, philosophically based in both the descriptive traditions of Husserl and the interpretive traditions of Heidegger, strives to grasp the essential meaning of an experience. Phenomenological research is: ‘the study of lived experience… the explication of phenomena as they present themselves to consciousness… the study of essences; and … the description of the experiential meanings as we live them’ (van Manen 1990, pp. 9–11). Because hermeneutic phenomenology uncovers pragmatic meaning patterns, it was an appropriate approach in this search for the lived meaning of quality nursing care for practising nurses.
In hermeneutic phenomenology the interview process is specifically used ‘as a means for exploring and gathering experiential narrative material that may serve as a resource for developing a richer and deeper understanding of a human phenomenon’ but at the same time ‘needs to be disciplined by the fundamental question’ (van Manen 1990, p. 66).
The hermeneutic phenomenological method (van Manen
1990) was used for the analysis and interpretation of descriptions of personal meanings and experiences. This approach provided: (1) a pragmatic process; (2) applicability to both the discipline and profession of nursing; and (3) a methodology that honoured the importance of nurses’ practical understanding of quality. As other researchers have noted, ‘Phenomenological research originates in practice, and through careful descriptive and interpretive scholarship, enlightens practice’ (Van der Zalm & Bergum 2000,
p. 217).
Participants
The participant selection criteria specified hospital-employed,
Registered Nurses (RNs) with a baccalaureate degree, at least
1 year’s experience and working at least 20 hours per week providing direct, hands-on, bedside, clinical patient care on adult medical and surgical units at the general or intermediate levels of care within acute care hospitals in south-eastern
USA. Nurses responded voluntarily to advertising fliers and spoke with one of the researchers to discuss their inclusion.
Those meeting all the criteria were sequentially enrolled and interviews were scheduled, forming a purposive convenience sample of practising nurses. The final sample size of 12 was determined based on data saturation.
While thematic trends and similarities began emerging after the first six interviews, a total of 12 interviews were completed to fully assure
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saturation. Participants were renamed with pseudonyms to ensure confidentiality.
All participants were female, with an average age of
37Æ5 years (range = 25–52 years). One was African American and the others were White. They had from 3 to 24 years’
(mean = 11Æ6 years) nursing experience and 1 to 12 years’
(mean = 5Æ2 years) experience in their assigned units. Seven had practised for an average of 10 years (range = 4–21 years) at the associate degree nursing (ADN) level prior to completing a Bachelor of Science in Nursing (BSN) degree.
Data collection
Data were collected through a single, tape-recorded, focused interview of approximately 40 minutes with each participant.
Interviews were conducted privately and confidentially in early 2008 by the same interviewer, either face-to-face or by telephone. The researcher (LMB) personally conducted all interviews and completed the process of
phenomenologic inquiry, including empirical and reflective methods, in seeking to uncover the lived meaning of quality nursing care for these nurses.
To elicit data, each participant was asked to respond in her own words to the following:
• Tell me about quality nursing care.
• What does quality nursing care mean to you?
• What is it like when you give quality nursing care?
• Describe an example of when you delivered quality nursing care. • What is it like when you observe another nurse giving quality nursing care?
• Describe an example of when another nurse delivered quality nursing care.
• Is there anything else I need to know about what quality nursing care is like?
If needed to elicit detail or depth, to refocus the participant’s attention on the central issue of quality nursing care, or to refocus discussion on what quality nursing care is rather than what it is not, specific probing questions were used:
• Tell me more about….
• What was that like?
• What did that look like?
• How did you feel about that?
Ethical considerations
Ethical considerations were given a high priority in the conduct of this study. The Combined Institutional Review
Board (IRB) at a university/health system approved the study.
The Chief Nursing Officers and Presidents of the study
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hospitals supported participant recruitment through the distribution of advertising fliers seeking volunteers for the study. Participants were assured of confidentiality and the opportunity to withdraw at any time and gave written informed consent prior to interview.
Data analysis
The interview data were analysed, interpreted and synthesized using van Manen’s (1990) qualitative hermeneutic phenomenological research approach that specifies six research activities. First, we ‘turned to a phenomenon which seriously interests us and commits us to the world’ (van
Manen 1990, p. 30), affirming our belief in the importance of studying the lived meaning of quality nursing care for practising nurses.
Through the second and third research activities, ‘investigating experience as we live it rather than as we conceptualize it’ and ‘reflecting on the essential themes which characterize the phenomenon’ (van Manen 1990, p. 30), we identified emerging themes within the interview audiotapes and transcripts. Combing through the data was an iterative process that moved from each whole interview, through selected excerpts, to emerging themes, back to the whole interviews, and finally led to the creation of a narrative text. We explored commonalities to uncover essential, universal elements within the interviews.
The coding process was carried out using empirical and reflective methods of transcript analysis. The initial coding identified words and phrases salient to the research question.
These were clustered into categories during a secondary coding process. Categories were combined, based on similarities, into a central theme or statement for each participant. Finally, similar elements from each participant’s central theme were combined to create overarching common themes to uncover the lived meaning of quality patient care for these nurses. Continuing the process of reflecting on the essential themes, the fourth research activity was ‘describing the phenomenon through the art of writing and rewriting’ (van
Manen 1990, p. 30). This final step in the iterative analysis process resulted in what is often considered the culmination of the interpretive analysis in hermeneutic phenomenological research – a comprehensive view of the experience of quality nursing care presented through a narrative phenomenological text called a linguistic transformation: ‘human science research is a form of writing. Creating a phenomenological text is the object of the research process’ (van Manen 1990, p.
111). Through reading the linguistic transformation narrative, others can come to understand the lived meaning of the
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Quality nursing care
phenomenon as interpreted by the author, can reflect on the lived meaning themselves, and can offer alternative interpretations.
The fifth research activity required this study to be oriented within the nursing discipline and to maintain a strong connection between theory and the real lives of practising nurses. Non-participant nurses were asked to read and validate whether the linguistic transformation described quality nursing care from their own perspectives. By producing understandings, interpretations, and formulations specific to nursing it was strong. By being concrete, the study text was rich and thick. The nurse, ‘as author, attempts to capture life experience (action or event) in anecdote or story, because the logic of the story is precisely that story retrieves what is unique, particular, and irreplaceable’ (van Manen 1990, p.
152) about the lived experience. The depth of the study text offered insight into the meaning of the lived experience, although it always remains challenging to achieve complete understanding. The steps used to assure this study’s rigor supported these characteristics.
The sixth and final research activity ‘balanced the research context by considering the parts and whole’ (van Manen
1990, p. 31). This study of the lived meaning of quality nursing care for practising nurses required mindfulness and balancing of the part-whole continuum throughout its conduct. Reflexivity, the ‘continual process of critical self-reflection on one’s personal biases, preconceived notions, assumptions, theoretical predispositions and ideological commitments’
(Powers & Knapp 2006, p. 148), was a primary strategy used to support rigor or validity. Reflexivity or reflection on reflections, characteristic of the iterative analysis processes, was used in this study by incorporating personal experiences and lived meanings rather than attempting to ‘bracket’ or set them aside. Through reflexivity, equal weight was given to participants’ voices.
The primary researcher/interviewer’s recorded reflexive field notes were used with a threefold purpose. In theoretical notes, observations were interpreted and assigned meaning.
In methodological notes, details, instructions and reminders were recorded. In personal notes, feelings, beliefs, biases and thoughts were recorded at the start of the study and throughout the research process. Ongoing dialogue with the second researcher/author, and repeatedly reflecting on the audiotapes, transcripts, and analysis documents in whole and in part further, mitigated researcher biases.
Lastly, verbatim quotes were used as low inference descriptors to allow readers ‘to experience for themselves the participants’ perspectives’ (Johnson 1999, p. 162).
Trustworthiness of the quotes was supported through direct verification of transcript accuracy by the researchers against the audiotapes and field notes.
Rigour
Findings
Rigor or trustworthiness was established in several ways.
Use of audiotapes, audited transcripts, and field notes for validation and enhancement assured data accuracy and contributed to the credibility or truth value of the research materials. The ‘phenomenological nod’ (Munhall 1994, p.
189) of agreement was obtained from three non-participant nurses, who indicated that the written interpretation of the phenomenon resonated with them, offering additional evidence of credibility. Therefore, cross-checking of information and conclusions was achieved through triangulations of multiple procedures and through independent reading and interpretation of the interviews by nurse colleagues. This dialogical interpretation established corroboration of the analysis and interpretation. This peer review auditing process was also carried out using van
Manen’s method. Participant stories, anecdotes, and examples were interpreted to create the essence that came to be understood. As in hermeneutic phenomenology, this was not a restructuring of the participants’ statements, but a new essence created and shared with non-participant nurses for validation.
Themes
We discovered six essential themes or lived meanings of quality nursing care in the words of the study participants: • Advocacy was interpreted in phrases such as: ‘look out for your patient’, ‘protecting them’, ‘calling, questioning physicians’ and ‘patient advocates all the way’.
• Caring was revealed in words and phrases such as: ‘caring’,
‘kind’, ‘a caring heart’ and ‘has aspect of caring’.
• Empathy was interpreted in phrases such as: ‘appreciating the patient’s experience’, ‘treat and view the patient as either yourself or your loved one’ and ‘being empathetic with the patient’.
• Intentionality, interpreted as the nurse’s intention to deliver quality nursing care, was revealed in phrases such as:
‘actually wanting to give that good care’, ‘giving the best I can to the patient’, ‘just day to day commitment to doing’ and ‘we know when we do it.’
• Respect was interpreted in phrases such as: ‘treat them all with respect and dignity’, ‘don’t lie to them’, ‘met patient
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choice and desire’ and ‘take that sacred trust to the bedside every time’.
• Responsibility was revealed in words and phrases such as: ‘assuming your responsibilities’, ‘make sure that things aren’t missed and omitted’, and ‘doing the right thing’. Fundamental meanings
After essential themes were interpreted and validated, we reviewed the audiotapes and transcripts again in their totality, seeking ‘what phrase may capture the fundamental meaning or main significance’ (van Manen 1990, p. 92) of each participant’s text as a whole. These verbatim examples indicated phrases most representative of the fundamental meanings of quality nursing care for each participant:
• When I give quality nursing care I’m doing what I’m supposed to do – as well as I could …and I’ve done everything I can do in the situation to support the patient and family in a difficult decision. –
capacity to provide quality nursing care. They described an intrinsic characteristic of nurses whose care reflects responsibility, caring, intentionality, empathy, respect and advocacy.
Essence
Based on the described analysis iterations and reflective insights into the thematic relationships, a succinct description of the essence of the phenomenon was developed: The lived meaning of quality nursing care for these practising nurses was interpreted and found to be meeting human needs through caring, empathetic, respectful interactions within which responsibility, intentionality and advocacy form an essential, integral foundation. This resided within nursepatient interactions that were consistently recognizable as such by nurses in their own practice and in that of their peers.
The six themes of responsibility, caring, intentionality, empathy, respect and advocacy were the essence of quality nursing care for the nurses in this study.
Breeana
• If you have a person that’s actually caring and compassionate and concerned about the welfare of that individual, it’ll take you farther than if you are an expert clinician. – Dorothy
• To be very bold in communicating … not being afraid to … be an advocate for the patient. – Lenor
• It made me remember why I do what I do. … It made me remember, we’re here for the patients. – Stacey
• We know when we do it [quality nursing care] … good care and thoughtful care. – Maryrose
The iterative process of analysing the anecdotes and stories related by nurses repeatedly uncovered the six themes of responsibility, caring, intentionality, empathy, respect and advocacy, revealing the essential components in this search for quality nursing care from the experiences and words of practising nurses. Surprisingly, their descriptions suggested that clinical nursing skills were less important as a determinant of quality nursing care: ‘the human part is bigger than the skill element … anyone can be taught to do any (skill)’ and
‘skills are critical but not as important as caring … good caring with skills is more important than skills’. Others stated that nurses ‘need some of everything but skill can come from elsewhere’, and ‘if you don’t (communicate with the patient) it doesn’t matter how good technical skills are’. Their statements suggested that their idea of quality nursing care was determined more by the manner of care delivery than by skill level. In fact, they indicated that any nurse could learn the requisite skills but nurses either had or did not have the
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Discussion
In summary, the six essential themes uncovered resided predominantly within the realm of the art of nursing.
Although some participants mentioned clinical skill, they were clear that it was not the most important indicator of quality nursing care. Instead, nursing’s oldest traditions, those of the art of nursing, resonated within the lived experiences of these nurses and thus within the lived meaning. These themes reflected the art of nursing as highly valued by practising nurses. We suggest further research to explore if the art of nursing informs a more effective application of the science.
Alligood (2002) identified a theory of the art of nursing through a hermeneutic interpretation of the writings and conceptual system of Rogers’ Science of Unitary Human
Beings:
Thus, the art of professional nursing becomes the ability to balance respect for human freedom and individual rights with responsibility for the welfare of others through knowing from the feeling attribute of empathy in the moral action that is nursing practice. (p. 58)
Responsibility, respect, and empathy in this theory of the art of nursing were identified as being related with the concept of caring. Thus, four of the six themes identified as the essence or lived meaning of quality nursing care were explained within this theory.
The understanding of quality nursing care described in our study recalls earlier literature identifying caring as a concept
‘unique to nursing’ and viewed as its ‘essence’, reported by
Morse et al. (1990). Work to reach consensus on the five
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What is already known about this topic
• Meaningful improvements in healthcare and nursing care quality are disturbingly slow and incremental, possibly related to lack of a shared understanding or definition of quality nursing care.
• Practising nurses’ meanings of quality nursing care are not adequately represented in tools used to measure it.
• Themes and elements identified by globally diverse researchers attempting to define quality nursing care may not relate to the lived meaning from the perspective of practising nurses.
What this paper adds
• Practising nurses’ lived meaning of quality nursing care was meeting human needs through caring, empathetic, respectful interactions within which responsibility, intentionality and advocacy form an essential, integral foundation. • The lived experience of quality nursing care within nurse–patient interactions was consistently recognizable as such by nurses in their own practice and in that of their peers.
• Knowledge of practising nurses’ meaning of quality nursing care may further define the discipline and facilitate practice changes, driving improvements in quality of nursing care and patient outcomes.
Implications for practice and/or policy
• Practising nurses could use these shared meanings to inform their own practice and to evaluate the quality of nursing care delivered by themselves and other nurses.
• Nurse managers could develop strategies that better support nurses in the identification and delivery of quality nursing care reflective of responsibility, caring, intentionality, empathy, respect and advocacy.
• Nurse educators could modify curricula to model and teach students the intrinsic qualities identified within these meanings of quality nursing care.
perspectives of caring; its focus, outcomes, and consequences; and the three major theories of caring reviewed by these authors continues today. That caring and related concepts identified in this earlier study constitute the contemporary practising nurses’ meaning of quality nursing care adds important knowledge for the discipline of nursing. By further defining the discipline, they may facilitate practice changes,
Quality nursing care
driving improvements in the quality of nursing care. Practising nurses, managers, educators, researchers and policymakers can use this new and important knowledge.
These findings provide beginning knowledge that the meaning of quality nursing care is shared among practising nurses. That this shared meaning is anchored in the art of nursing may be surprising to practising nurses as it contradicts the prevailing emphasis. The lived experiences of quality nursing care were centred on these nurses’ interactions with patients and were recognizable by nurses in their own practice and in that of their peers. The six essential themes of responsibility, caring, intentionality, empathy, respect and advocacy were validated as the essence of quality nursing care in the lived experience of practising nurses. These shared meanings can be used to inform practice and to evaluate the quality of nursing care being delivered. That is, nurse managers could develop strategies that support nurses better in the identification and delivery of quality nursing care reflective of the essences of responsibility, caring, intentionality, empathy, respect and advocacy. They could use these themes to evaluate the quality of nursing care delivery by observing nurses’ behaviours and interactions with patients.
Importantly, more than half of our participants described quality nursing care relative to end-of-life situations.
Research is needed to understand the meaning of this finding.
Does it reflect a hidden nursing value yet to be discovered?
Finally, will addressing the lived meaning of quality nursing care for practising nurses influence nurse satisfaction and retention? Nurse educators could use this beginning knowledge of quality nursing to identify the need for changes in nursing education curricula. Researchers could explore whether the qualities identified within this understanding of quality nursing care can be modelled and taught to nursing students.
Is the art of nursing content present in their curricula? Can it be taught? Does continuing education for practising nurses address the art of nursing?
Study limitations
As is common in qualitative methodologies, our findings are limited to the individuals interviewed and to their personal experience. Because all participants were self-selected females, educated at baccalaureate level, employed in specific hospital practice settings and located in one area of the USA, the results are not generalizable to nursing populations with differing educational preparation, in differing care delivery settings or geographic locations, nor to male nurses. Finally, the findings from hermeneutic phenomenological studies are subject to alternative interpretations.
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Conclusion
Nursing knowledge of the meaning of quality nursing care for practising nurses has potential to refine the discipline and facilitate practice changes, driving improvements in quality care and patient outcomes. Our findings suggest the need for future investigations into topics such as: (1) the lived meaning of quality nursing care for practising nurses in different acute care delivery settings and other adult medicalsurgical general and intermediate level units; (2) the lived meanings of nurses in non-acute settings and roles such as community health and other aggregate-focused care delivery settings; and (3) the lived meaning of quality nursing care among male nurses.
Funding
The study was funded in part through a grant from the East
Carolina Center for Nursing Leadership (ECCNL). ECCNL is a project within the East Carolina University College of
Nursing. There was no grant number and the amount of funding was minimal ($1000).
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
LB and MA were responsible for the study conception and design. LB performed the data collection. LB and MA performed the data analysis. LB was responsible for the drafting of the manuscript. LB and MA made critical revisions to the paper for important intellectual content. LB obtained funding. MA provided administrative, technical or material support. MA supervised the study.
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