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This paper examines the inpatient education programme in the Coronary Care Unit (CCU) at St. Vincent's Hospital, Sydney, and discusses possible methods to determine the quality of inpatient education delivered by the nurses in this area. Patient education is an important function of nursing, the quality of which requires constant evaluation in order to effect change in nursing practice to optimise patient health. A questionnaire was developed and the data collected about the CCU in-patient education programme will be analysed and necessary changes effected.
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The Coronary Care Unit (CCU) at St. Vincent's Hospital, Sydney, is a thirty-bed unit divided into six acute beds and twenty-four sub-acute beds. There is one Nursing Unit Manager and one Clinical Nurse Educator for both areas and the nursing staff rotate through acute and sub-acute coronary care. This enables them to nurse patients from admission to discharge. The inpatient education programme was established in the Coronary Care Unit by the nursing staff some eight years ago and has not been evaluated since implementation. Although the programme is now under the auspices of a multidisciplinary health team, it was nurse-initiated and is currently nurse co-ordinated. As patient education is an extremely important component of nursing care in the CCU it is appropriate to evaluate the effectiveness of the programme.
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According to Doughty and Marsh (1984: 11), nurses need to assure themselves and their patients that they are delivering a high standard of quality nursing care. Previously the health care industry was considered above being questioned about the quality of care, but nowadays, health care is a major industry and each hospital is accountable to its consumers. The availability and quality of health care are determined by the values and expectations of the consumers.
Consumers expect value for their money and count on the existence of services when needed. More and more patients are demanding to be informed partners in decisions regarding their health, and their concerns are now directed at the whole spectrum of their care whilst in a health care institution. As Doughty and Marsh (1984: 4) emphasise, patients now complain, demand, report and sue and have realised that the quality of nursing care is an important factor in patient outcomes.
From a historical perspective, the concern for high quality health care dates back to the 5th Century BC, when Hippocrates established a code of medical ethics, obliging future doctors to swear "never to do harm to anyone". The history of quality assurance activities in nursing can be traced back to Florence Nightingale's attempts to improve the conditions of care to the soldiers of the Crimean War in 1858. Her standards to assess the care of the soldiers has been established as one of the first documented efforts of quality improvement work, and since then, assurance of quality nursing care has remained a priority for nurses throughout the world (Kahn, 987: 21). Subsequently, nursing has developed into a profession with an emerging unique body of knowledge and this has resulted in a growing interest in the improvement of quality nursing care. Whilst this may be true, Cantor (1983: 3) maintains that nurses have not traditionally concerned themselves with the problems revolving around health care delivery nor the health needs of society as a whole.
Nurses have seen their role at the bedside, dealing with the needs of the individual patient, and were unlikely to consider whether their nursing care was delivered in the most effective and efficient way with the maximum utilisation of scarce resources. Therefore it is important that nurses understand the importance of one of the underlying concepts of quality care, and that is accountability.
Bennett (1989: 155) states that to be accountable, we must be answerable for our own decisions and actions, not only to other members of the health team, but to the consumers of health care, whether individual, family or community. Donabedian's now classic work on quality assurance argues that the hospital is a major component of organised care in the health care system and therefore establishes the standards of care which safeguard the quality of care and is held responsible for the maintenance of those standards. Bennett (1989: 158) defines standards as being desirable and achievable levels of performance consistent with quality, and if we are concerned with all aspects of quality care then three dimensions can be identified: structure, process and outcome. These dimensions are central to the definition of quality assurance developed by the Royal Australian Nursing Federation (RANF, 1985: 3) "A planned systematic use of selected evaluation tools designed to measure and assess the structure, process and/or outcome of practice against an established standard, and the institution of appropriate action to achieve and maintain quality."
Peters (1991: 1) describes quality as "elusive" and cites Donabedian as writing that quality represents our concepts and values of health, our expectations of the provider-client relationship, and our view of the role of the health care system.
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According to Van Maanen (1984: 18), structure is the evaluation of the organisation of the institution delivering care; the conditions under which care is provided and its impact on quality, i.e. buildings, budget and equipment. Process concerns the evaluation of the performance of health professionals in the management of patients, and the outcome is the evaluation of the end result, observable changes in the health status of the patient. Bauman (1991: 8) stresses that in the past, health organisations have concentrated on establishing Quality Assurance (QA) programmes according to the structural standards of the particular institution. Gradually, there has been a shift to greater emphasis on the process of patient care in the areas of patient assessment, teaching and discharge planning. Additionally, documentation of each step in the process became critical evidence to the demonstration of the provision of high-quality care. However, the emphasis is now moving towards patient outcome.
Bauman (1991: 12) states that by evaluating patient outcome, health providers can determine whether the care provided has had the desired effect or result for the patient.
For example, was the health teaching presented in such a way that the patient had improved knowledge regarding the disease process and the life style changes required to obtain optimal health following discharge? A second reason to analyse patient outcome is to determine cost in relation to the provision of optimal care. In the current economic climate, health organisations experiencing Budget reductions must be able to measure the effect on the health care consumer whilst doing "more with less" (Bauman, 1992: 12). Thirdly, outcome measurement provides the nursing profession with the necessary feedback to make appropriate adjustments in nursing processes which ultimately result in long-term improvement in health of each patient.
It is the opinion of Ell (1990: 14) that we do not ask patients enough for their perception of care received. The methods of identifying problems is achieved through the tools such as patient questionnaires, interviews, surveys and observation of care whilst it is being delivered. No one technique can be used solely, since each method has strengths and weaknesses. According to Pawsey (1990: 28), patient satisfaction surveys are a common use of the survey method in QA. The Macquarie Dictionary defines survey as "to collect sample opinions, facts, figures or the like in order to estimate the total overall situation" (1981: 1739). A series of questions are formulated to collect feedback about a patient care or service. Pawsey (1990: 28) recommends a response rate of 75% and that ensuring anonymity may enhance the response rate. The design of the questionnaire is important. Boxes to tick yes/no answers make it easier to complete and data easier to interpret, although some feedback information may need open-ended questions. To avoid bias, the questions should be worded in such a way that they do not prompt a particular answer. The method of evaluation for the CCU inpatient education programme was the patient questionnaire as outlined by Pawsey (1990: 28).
The development of a unit-based QA tool for analysis of the St. Vincent's Hospital (SVH) CCU In-Patient Education Programme was prompted by a need to evaluate the effectiveness of the education programme for patients admitted to the unit with ischaemic heart disease. Patient education strategies had been implemented to ensure the continual improvement of education services provided by the nurses in the CCU. However, a meaningful and specific system to collect data to measure the success of the programme needed to be activated, and following the appointment of a QA facilitator in CCU, a questionnaire was developed. The two-page questionnaire asks the patient to complete the questions which revolve around the in-patient education programme provided by a multidisciplinary team of nurses, dietitians, pharmacists and social worker. Confidentiality is assured and emphasis is placed on the fact that the responses from the patients will assist the nursing staff to identify strengths and weaknesses of the programme and the direction the education activities may need to take for improved patient care in the future (SVH Quality Improvement Activities Log, 1991).
The goal was to develop a comprehensive QA survey of important aspects of nursing care relating to in-patient education in the CCU that could be applied to a high volume of cardiac patient. Standards of nursing practice had been formulated by the Division of Nursing which incorporated the major nursing activities conducted in the hospital. Hence a standard for patient education is now in use. A task force, at unit level then established sample size, frequency of monitoring, methods of data collection and a desirable response rate. As sample size of thirty was selected and the frequency of monitoring was identified as monthly. In terms of data collection, a patient survey in the form of a questionnaire was developed which would be given to patients pending discharge from hospital. The patients completed the questionnaire in their own time. The patients were encouraged to use the National Heart Foundation booklets, which are distributed to them as part of the education programme, in order to answer the questions.
To ensure anonymity, no names were required and the completed questionnaires were placed in a centrally located box. The distribution of questionnaires was the responsibility of the QA facilitator and the Clinical Nurse Educator whose task was explanation of the purpose of the survey and instruction to patients regarding completion of the questionnaire. Lastly, the desired response rate was specified at 75%. A unit-based committee was organised to involve the staff in QA activities, and the Clinical Nurse Specialist selected as the QA facilitator explained the aspects of the questionnaire as the data collection method. After the data is collected and analysed, problem areas will be identified and proposed corrective action to reinforce the strengths and change the weaknesses will be recommended to improve nursing practice in this area. Whilst the QA facilitator and Clinical Nurse Educator felt the questionnaire was the most effective to measure the in-patient education outcomes Masso (1991) and Pawsey (1990) caution the use of this method.
Masso (1989: 18) states that patient questionnaires do not in themselves evaluate quality of care delivered; rather they function as an indicator of quality and identify the aspects of the service that the patients are satisfied or dissatisfied with. He continues that there are many more opportunities for research into the relationship between information received by patients and satisfaction with care and how patients arrive at their assessments and why some are satisfied and some are not. The major problems with questionnaires are low response rates, problems of obtaining a representative sample, lack of specificity because the number of questions must be limited, and problems in discrimination of results due to high levels of satisfaction recorded (Pawsey 1991: 29).
Kahn (1987: 126) alludes to the methodological problems in measuring patient outcomes stating that each patient is a unique individual and may respond idiosyncratically to any given procedure. Also, the same patient may respond differently to the same procedure performed at a different time or the procedure has been inconsistently applied, poorly trained staff, inappropriate environmental conditions or lack of patient co-operation. The patient responses then may not always be the result of the "same procedure". For example the CCU staff members differ in educational skills resulting in inconsistent educational input for the patients. Realising the short-comings of questionnaires, individual interviews were also considered as a possible method of evaluation.
Interviewing is personal and elicits a feeling of special attention for the individual patient. Interviews can be guided by the nurse asking open-ended questions, or asking questions from a form listing specific questions. Interviews also allow the nurse to provide reinforcement and give feedback to the patient regarding their learning (Whitman, Graham, Gleir & Boyd 1986: 184). However, patients are unlikely to be critical of nursing care whilst still under the care of the nurses and may feel embarrassed if unable to answer questions. Interviewing can be confrontational for the patient and time consuming for the nurse which may interfere with the efficacy Of this method of evaluation. For this particular target group it was felt the interview method was unmanageable.
Interviewers cannot always be objective and interpretation of the data must be consistent and objective. Questionnaires allow the collection of information, especially opinions or feedback which are unavailable from any other source. Masso (1989: 19) concludes that there is no right way to assess quality; every methodology has its flaws and limitations and the perfect method promises to be a long way off. Although not perfect, questionnaires for this target population elicited the necessary information and was a manageable task.
Whatever the method used, the most important purpose of an evaluation method is to improve the quality of care. Evaluation can be defined as a means of obtaining the information needed to make predictions on which to base decisions about the maintenance or revision of a system, programme, or process established to achieve a specific purpose (Cantor, 1983: 7). Health care as an industry has changed and grown with quality care being recognised as a right rather than a privilege. As professionals we have the privilege and the responsibility of self-regulation through peer review. It is up to us to set our standards and assure they are met, to solve our problems and to improve our quality of care.
Quality, according to Bauman (1991: 13), does not just "happen"; it is a result of learning and changing. By analysing patient outcomes the nurse creates a feedback system, conducive to learning and effecting change to develop a high quality of patient care.
As previously stated the data collected from the CCU in-patient education programme questionnaire will be analysed and necessary changes effected.
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