Assessment Of Nursing Role In Patient Management Among Nurses In OAUTHC

Assessment Of Nursing Role In Patient Management Among Nurses In OAUTHC

Abstract

It has been reported for over the last decade that the quality of nursing care provided towards patients has decreased tremendously. The literature shows the role of nursing to patients and assumes the influence of nurses’ perceptions of patient management on its delivery.

However, studies about such perceptions are still few in Nigeria.

Aim:

The purpose of this study was to explore the role of nursing care in patient management.

Methodology:

A non-experimental exploratory descriptive design which was quantitative in nature was used. A self-report questionnaire comprised items related to socio-demographic characteristics of participants, perceptions of patient management, nurses’ role in patient management and factors affecting the delivery of patient management. The sample was obtained through a purposive non-probability sampling of the nurses (n=150) who were available during data collection from 16 to 28 October 2011, with a return rate of 110 (73%) of completed questionnaires.

Results:

The findings from demographic data indicated that many of nurses were young, with 48.2% falling into the 20 to 30-year-old bracket and the majority of the participants (83.3%) were enrolled nurses. Many of the participants were new to the nursing profession, with 47.2% falling into the 6 months-5 years working experience bracket. This study suggests that nurses had an appropriate perception of patient management, as evidenced by the mean score of 4.183 (SD: .5741), related to nurses’ understanding of patient management with mean score of 4.137 (SD: .5763) for the role of patient management in patient management.

The role played by nurses in patient management was evident, but it was constrained by the factors related their nursing practice environment. In summary, this study provided insights into nurses’ perceptions of patient management, and their current ongoing endeavours to provide quality improvement in spite of challenges in their workforce environment. This study has described the challenges which interfere with the delivery of patient management that need to be addressed so that patients may benefit from evidence-based care.

Table of Content

Chapter One:

Introduction

• 1.1 Background to the Study
• 1.2. Problem Statement
• 1.4. Purpose of the Study
• 1.5. Research Objectives
• 1.6. Research Questions
• 1.7. Significance of the Study
• 1.8. Operational Definitions
• 1.9 Limitations of the Study
• 1.10 Organization of the Study
• 1.11 Summary of the Chapter

Chapter Two:

Review of Related Literature

• 2.1 Conceptual Review
• 2.2 Theoretical Review
• 2.4 Summary

Chapter Three:

Research Methodology

• 3.1. Introduction
• 3.2. Research Paradigm
• 3.3. Study Design
• 3.4. Research Settings
• 3.5. Study Population
• 3.6. Sample and Sampling
• 3.7. Data Collection Instrument
• 3.8. Data Collection Procedure
• 3.9 Reliability of the Study
• 3.10 Validity of the Study
• 3.11 Data Analysis
• 3.12 Ethical Considerations
• 3.13. Data Management
• 3.14. Dissemination of the Findings
• 3.15. Summary of the Chapter

Chapter Four:

Data Analysis and Result Presentation

• 4.1 Data Presentation
• 4.2 Summary of Findings

Chapter Five:

Discussion and Conclusion

• 5.1 Discussion
• 5.2 Conclusion
• REFERENCES
• APPENDIX

Chapter One

Introduction

1.1 Background to the Study

Exploring the nurses’ perspectives of patient management is imperative since nurses are the most appropriate persons to bring about effective changes within the health systems (Farquhar et al., 2010; Hall et al., 2008). Stichler and Weiss (2001: 60) argued that “nurses’ perceptions of patient management are based on nurse-patient relationship, collaborative teamwork, and a work environment with resources and support for nurses in their patient care role”. In a qualitative study conducted by the Ipsos MORI Social Research Institute (2010), findings showed that nurses believe that patient management means looking after the patients, and making sure that they are comfortable and happy in their environment. Along the same line of thought, the Rhode Island Department of Health (1999), in Stichler and Weiss (2001) found that 65% of nurses believe that quality of care in a hospital means treating patients well and paying attention to their personal needs. However, these nurses attributed differences in quality to levels of staff training, and experience. To this end, Murphy (2007) understands patient management as a care that is person centred and holistic, provided by knowledgeable and skilled staff who make an effort to know the patient better. Lynn and Moore (1997:188) documented the four dimensions of the nurses’ perceptions of patient management, which included: ‘developing a relationship, therapeutics (supportive and nurturing care, and nursing care using a scientific approach); unit collaboration; environment and resources’.

To explore the concept of patient management it is necessary to figure out the salient factors confronted by nurses in their daily nursing duties. Buerhaus, Donelan, Ulrich, Norman, Williams and Dittus (2005) and Teng, Hsiao and Chou (2010) conducted a survey to explore registered nurses and chief nursing officers’ perceptions and found that lack of time was the main reason for failing to maintain quality of care. Additionally, short staffing, time demands and a stressful work environment were reported by hospital nurses in Belgium and Taiwan as obstacles to providing good nursing care to patients (Ma, Lee, Yang and Chang, 2009; Milisen, Abraham, Siebens, Darras and Dierckx de Casterle, 2006).

Even although nurses are capable of bringing about change that will enhance quality of care in health care delivery, those changes cannot emerge from a vacuum. High quality patient care requires a professional nursing practice environment embedded with high quality leadership and management, good staffing, trustful and mutual nurse-physician relationships, reasonable workloads and favourable working conditions (Van Bogaert et al., 2009; Milisen et al., 2006). Apart from those factors aforementioned, it has been documented that access to quality care training, professional development, involving the nurses in the functioning of the institution and empowering them in decision-making are key elements to heightening quality care in health systems (Roche and Duffield, 2010; Aiken, Clarke, Sloane, Lake and Cheney, 2008; Lake and Friese, 2006; Lake, 2002).

The Nigerian health system is a pyramidal system comprising of the central, intermediate and operational levels. The central level comprises the central departments of the Ministry of Health (MoH) and the national reference or tertiary hospitals geared to provide specialized care. The intermediate level involves the administration of the Department of Health which facilitates and guides the process of the operational level by providing the administrative, logistical, technical and political supervision. The operational level comprises of district hospitals and health centres. This level provides primary and secondary care and is confronted with issues of poor quality of care, whereby a lack of suitably qualified health professionals limits its functionality (WHO Regional Office for Africa, 2009; Kayonga, 2007
).
According to the Ministry of Health’s (2008) annual health report, the healthcare system of Nigeria is currently facing numerous problems, including the shortage of human resources, limited material resources, inadequate infrastructure and financial constraints. These limitations are exemplified by the fact that there is only one doctor per 18 000 people, one pharmacist for 38,000 people and one nurse per 1700 people. To grasp the severity of this staff scarcity, one can contrast this situation with that of United Kingdom (UK), where there are 123 nurses and 23 doctors per 10 000 population (Roxburgh, Taylor and Murebwayire, 2009). There are 13 doctors per 10 000 population and 28 nurses per 10 000 globally (World Health Organization, 2009). The figures quoted above pertaining to Nigeria clearly point out that nurses are the main care givers in that country. However, the high nurse patient-ratio of 1:1700 reflects a serious situation where nurses are not able to respond adequately to their daily nursing duties, thus making it difficult for them to improve the quality of care they provide to patients. This is supported by Sturgeon (2010), who states that the high number of patients, which is not commensurate with the number of nursing staff, jeopardizes the confidence of the nurses, thereby hampering their ability to provide high quality care.

The lack of human and other resources is particularly relevant to Nigeria, where nurses and other health professionals are still responding to the challenges resulting from the genocide of 1994. This is illustrated by the findings of a study conducted by Kalinganire (2010),who works for Access Project in Nigeria, a project which aims at assisting some of the health centres to run more efficiently by streamlining the health-related infrastructure. In this study, it is reported that over 300, 000 people living in sectors without a health centre travel six or more hours on foot to seek care in neighbouring sectors. This author emphasized the negative impact of inaccessibility to quality care which results in the emergence of disease as well as an increase in the maternal and child mortality rate.

It has been noted that nurses in Nigeria do not always perform their required duties with some being inconsistent in taking the patients’ vital signs and others not recording children’s weight (Mote and Richard, 2010). Sturgeon (2010) ascribed these behaviours to be in relation to low staffing, inadequate equipment and lack of incentives to nurses. This was supported by Francis (2010:400) who also identified the “weak professional voice in management decisions” as a contributory factor to poor standards of care. Van Bogaert et al. (2009) suggest that managers create and support nurses’ work environment by allocating appropriate nurse staffing, adequate nurse hours per patient-day, adequate patient to nurse ratios and involving nurses in hospital and unit policies. These management interventions are presently not realistic in Nigeria owing to the above patient ratio context.

In Nigeria, a focus of the MoH is to provide ongoing strategies that will improve the quality of health care, especially nursing care. The plan to build the capacity of Human Resource for Health (HRH) is to develop the skills of the health professionals through improved preservice and in-service training, while also strengthening post-basic and post-graduate training. The plan to retain the capacity which has been created is to establish a support system to better manage health workers’ performance, provide attractive compensation packages and ensure equitable utilization across the country (Ministry of Health, 2009). Ultimately, it has been suggested that the delivery of health services be built around the core competencies of its employees, who then provide the evidence-based services desired by its patients and clients (Carney, 2009).

1.2. Problem Statement

The issue of poor quality of care is of significant concern in health care system delivery, particularly in the nursing practice environment (Hurst, 2011; Kendall-Raynor, 2011; Sturgeon, 2010). Even although the factors affecting quality of care have been highlighted by a wealth of literature, few formal studies have been conducted to explore nurses’ perceptions of patient management, especially in the district hospitals in Nigeria.

Mote and Richard (2010) reported the extent to which patient management is undermined among nurses in district hospitals and health centres in Nigeria. To illustrate this, Lee (2008), a physician who was working for Partners in Health [PIH] in Nigeria, reported that vital signs had not been taken, medications not administered and that prescribed screening tests had not been done. He also found some issues related to resources, namely inadequate staff to allow sustainable patient-to-doctor and patient-to-nurse ratios. This was supported by the WHO Regional Office for Africa (2009) reporting the insufficiency of nurses and the technical capacity of health facilities estimated to meet the minimum standards at 30%. As King (1981), referred to by Zimmerman (2007), has stated, a human being’s perceptions of objects, persons and events influence his behaviour, social interaction, and health. Similarly, Burhans (2008) maintained that the way nurses perceive patient management may influence the delivery of care rendered towards patients. Although a few studies have been carried out in the Nigerian context, they have explored the factors affecting quality of care at tertiary level, but did not explore the perceptions of patient management from the nurses’ perspectives. Therefore, such studies are needed in district hospitals where the nursing practice environment is still challenged by poor quality services delivery and working conditions.

Although the Nigerian nursing practice environment is challenged by the shortage of nurses and limited infrastructure to provide high quality care, the contribution of nurses is invaluable. Considering the impact of poor patient management on patient outcomes, it is suggested that exploring the perceptions of patient management among nurses working in two district hospitals in Nigeria will be valuable in order to inform realistic context driven patient management strategies.

1.4. Purpose of the Study

The aim of the study is to explore the perceptions of patient management among nurses working in two district hospitals in Nigeria in order to inform realistic context driven patient management strategies.

1.5. Research Objectives

The objectives of this study are:

1. To explore the nurses’ perceptions of patient management in two district hospitals;
2. To explore the nurses’ perceptions of their role in providing continuous quality improvement (CQI) in the two district hospitals; and
3. To describe the factors affecting the quality of nursing care in the two district hospitals.

1.6. Research Questions

1. What are the nurses’ perceptions of patient management in the two district hospitals?
2. What is the role of nurses in providing patient management in the two district hospitals?
3. What are the factors affecting the quality of nursing care in the two district hospitals?

1.7. Significance of the Study

The results from this study could inform patient management (CQI) strategies, current and future, not only in the two district hospitals, but could also be applied in other district hospitals in Nigeria as well. The hospital management may be informed of the factors affecting quality care enabling them to adopt new strategies for entrenching appropriate and adequate quality care in the nursing practice environment. Nurses may take cognizance of their critical role in quality improvement and this might positively influence their attitudes and perceptions towards CQI of care. Likewise, patients, family members, consumers and stakeholders could benefit from this study by receiving efficient, effective, timely and cost-effective nursing care interventions that improve health care outcomes.

The MoH and other stakeholders may be able to utilize the findings from this study to inform the development of education outcomes of interventions for further education, training and professional development for nurses and make the professional nursing practice environment in Nigeria more conducive to providing patient management to Nigerian consumers.

1.8. Operational Definitions

1.8.1. Perception

Perception is a belief or opinion, often held by many people and based on how things seem; the quality of being aware of things through the physical senses, especially sight or someone’s ability to notice and understand things that are not obvious to other people (Cambrige Advanced Learner’s Dictionary, 2008: 1054). This means that by asking nurses about their perception of nursing quality care, we are asking them to articulate what they expect or understand patient management to be.

1.8.2.Patient Management

Patient management is defined as care that is provided according to hospitals’ standards and job requirements (Grujic, O’Sullivan and Wehrmacher, 1989). In the context of this study, patient management is any nursing activity provided by nurses working in the two district hospitals to the patients in accordance with nursing standards of practice. The care rendered should be efficient, effective and cost-effective, timely and provide insight to the patient about the nursing interventions being implemented.

1.8.3. Nurse

For the purpose of this study, a nurse refers to both enrolled nurses (A2) and registered nurses (RN). An enrolled nurse is a nurse that has completed basic nursing, whereas a registered nurse is a nurse who has completed her professional courses in mental health, general nursing or midwifery. In the Nigerian context, a RN falls into three categories: advanced diploma in nursing (A1), a degree in nursing including: Bachelor, Honours or Masters (A0); and a Doctorate in nursing (PhD), according to Nigeria National Council of Nurses and Midwives (Musoni, 2009). All nurses in this study were working in two district hospitals in Nigeria.

1.8.4. Nurse Practice Environment

The construct nursing practice environment refers to the organizational characteristics of a work setting that facilitate or constrain professional nursing practice (Lake, 2002: 178). For the context of this study, the nurse practice environment is a practice setting that maximizes the health and wellbeing of nurses, quality patient outcomes and organizational performance in the two district hospitals (Pearson, Pallas, Thomson, Doucette, Tucker, Wiechula et al., 2006).

1.8.5.Patient Management

Patient management (CQI) has been defined as a method of planning and implementing ongoing improvements in systems or processes to define quality health care as reflected by improved patient outcomes (Painter, 2010: 227).

1.8.6. Quality Assurance

Quality assurance refers to all actions taken to be certain that standards and procedures are adhered to and that health services are provided for meeting the performance requirements (Manghani, 2011: 34).

1.9 Limitations of the Study

It is commonly known that any scientific investigation has its limitations, strengths and weaknesses. Hence, this study faced mainly methodological issues articulated as follows. Firstly, this study was conducted in only two of the district hospitals in the whole country and as it is not representative of the estimated 40 district hospitals in Nigeria, it therefore may not be extrapolated. Secondly, even although the researcher was not known to participants and strived to reduce desirability bias through implied consent and a data collection procedure that ensured privacy, it is likely that participants’ responses did not represent their actual perceptions.

The strength of this study was that the researcher took the initiative to conduct an investigation related to quality of care, an issue which is not only difficult to explore, but is also underexplored due to its sensitivity.
The weakness of this study was that the purposive non-probability sampling method is suggested to be a weak design in the sense that it only targets the participants who are available during data collection, which could be a source of biases in study data.

1.10 Organization of the Study

This study is divided into five chapters.

• Chapter one is introduction which consists of the background to the study, statement of problem, research questions, research hypotheses, objectives of the study, the significance of the study, the scope and limitations of the study and finally the organization of the study.
• Chapter two deals with the literature review which consists of the conceptual literature, theoretical literature, empirical literature, theoretical framework.
• Chapter three gives the research methodology including research design, population of study, sample size, sampling technique, method of data collection, instrument of data analysis, method of data analysis, validity/reliability of instrument.
• Chapter four is presentation and analysis of data, discussion of findings.
• Chapter five gives the summary, conclusion and recommendations.

1.11 Summary of the Chapter

This chapter introduced the concept of quality care in the nursing profession and the issues within the nursing practice environment that have a detrimental effect on providing such care. All the nuances that play a part in undermining quality care in nursing have received the deepest interest. The problem statement was taken up, especially in the Nigerian context, and the purpose and objectives of the study were determined. Finally, the definitions of the study’s concepts and the explanation of the conceptual model underpinning this study closed this introductory chapter. The ensuing chapter is dedicated to the literature review.

Chapter Five

Conclusion and Recommendations

5.1 Conclusion

The purpose of this study was to explore the perceptions of patient management among nurses working in two district hospitals in Nigeria in order to inform realistic context driven patient management strategies. The findings from this study suggested that nurses have an appropriate perception of the meaning of patient management, as evidenced by the mean score of 4.183 (SD: .5741) related to nurses’ understanding of patient management with mean score of 4.137 (SD: .5763) for the perceptions of the delivery of patient management. There was a significant statistical difference with respect to gender regarding the nurses’ understanding of patient management (P=.021, 95% CI: -.05 to .63). Furthermore, the role played by nurses in patient management was evident, but constrained by the factors related the nursing practice environment in which they were operating. This study suggested that the factors affecting the delivery of patient management included, amongst others, nurse understaffing, lack of time to complete nursing care, heavy workloads and few opportunities for advancement. Finally, the influence of the nursing practice environment on the delivery of patient management has been extensively discussed.

5.2. Recommendations from the Study

The recommendations of this study are made in relation to nursing administration, nursing practice, nursing education and nursing research.

5.7.1. Nursing Administration

Drawing on the findings from this study and concurrently on those from other nursing scholars who informed this study, many factors that detract from patient management have been underlined. Therefore, for nurses to be motivated and committed to patient management delivery there is a need for organizational leadership to:

1. Provide adequate time for patient care by determining rationally appropriate nursepatient ratios workloads;
2. Provide opportunities for nursing career development and advancement through continuing nursing education with a view to upgrading the level of nurses in district hospitals, taking into account that they were still predominantly at secondary level of nursing education;
3. Provide opportunities for nurse managers to develop their leadership and managerial skills, considering their role in maintaining a nursing practice environment conducive for the provision of patient management to patients;
4. Maintain adequate support by employing nurses with advanced levels of nursing training and increasing the medical staff personnel in the nursing practice environment; and
5. Promote collegial, open communication as well as professional autonomy in the nursing practice environment.

5.7.2. Nursing Practice

According to the findings from this study, optimal care was not delivered to the patients. Considering that caring is not only the essence of the nursing profession, but also essential for the delivery of patient management, the following suggestions may be helpful:

1. Implementation of daily nursing activities towards patients should be prioritized;
2. Health education and information towards patients should be encouraged to increase their health literacy resulting in positive patient outcomes;
3. Surveillance of the patients could be at the heart of nursing care with a view of providing safe and harm free nursing care towards patients; and
4. Timely care towards patients should be enhanced and made through the collaboration of nurse-physicians.

5.7.3. Nursing Education

Considering the value of managerial and leadership skills in making the nursing practice environment enticing as highlighted throughout this study, this following suggestion could be important:

Nurse Managers should be encouraged to help patients receive evidence-based nursing care by regular clinical supervision and mentorship of subordinate nurses as these strategies are regarded as the essence of quality improvement.

5.7.4. Nursing research

In this study, the current state of the utilization of the evidence-based nursing care has been proffered as it is the cornerstone of quality improvement in health care systems. Considering the value of research in refining the extent of evidence-based care, the following suggestions should be of great value:

1. Knowledge becomes obsolete when it is not updated. Therefore, it is suggested that despite their overburdened workloads, nurses take opportunities to read and partake in nursing research activities with a view of keeping themselves abreast of evidence based practice in nursing;
2. This topic has been explored using a quantitative approach. To this end, a similar study could be conducted using a qualitative research approach to uncover the meaning of the delivery of patient management from the nurses’ perspectives in relation to their workforce environment;
3. Considering the influence of the delivery nursing care models in the provision of patient management, it is suggested that other researchers could conduct investigations aimed to explore this phenomenon by finding out which model is suitable for the Nigerian context.
4. An exploration of unmet nursing care in district hospitals based on patient documentations and reports could be critical in this journey towards nursing excellence; and
5. An investigation about the exploration of the perceptions of patient management from the patients’ perspectives in district hospitals should be undertaken.

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