Quality in Primary Care Open Access

Keywords

Nurses, Patients, Nursing care services, Quality of nursing cares

Background

Nurses comprise the vast majority of hospital staff among the health care professionals (HCP) in hospital environment that they are legal trustful and professionally responsible for the quality of care they provide to patients.[1,2] They work at organizations such as hospitals, private practice, nursing homes, laboratories and clinics.[2] Nurses spent more time with hospitalized patients than a member of any other disciplines. They are also the frontline people that patients most likely meet up with, spend the highest amount of time with and rely upon for recovery during their hospitalization. By shifts nurses are stay in the hospital twenty four hours, seven days per week and three hundred sixty five days in a year that it implies nurses and patients are inseparable.[3,4]

Quality refers to the excellence of products or services including its attractiveness, lack of defects, reliability and longterm durability. It is also defined as the extent of resemblance between the purpose of healthcare and truly granted care.[5] Quality of care is a system approach to health services, which emphasizes both technical competence as well as interpersonal dimension of “health care giving process.[6] Quality of nursing care is nursing response to physical, psychological, social and spiritual needs of patients providing in caring matter. In hospitals, nursing care must be provided for 24 hours every day of the year. Without nursing care, neither health care consumer nor health care providers will be satisfied with service provided.[7]

The work environment factors such as lack of nursing standards, lack of appropriate policies, inadequate resources, including human and material resources in which nurses provide care to patients can affect the quality of patient care. Inappropriately designed health care facilities, inadequate patient care layout, poor technologies, fragmented and duplicated documentation, and lack of teamwork, dissatisfaction and emotional exhaustion of nurses hinder to deliver safe, efficient and effective care for patients.[8]

Nursing program of quality assurance is concerned with the quantitative assessment of nursing care as measured by proven standards of nursing practice. Quality assurance system motivates nurses strive for excellence in delivering of quality care and to be more open, flexible in experimenting with innovative ways to change the system of quality care. It is also dynamic process through which nurses assume accountability for quality of care they provide.[5]

Creating positive work environment is important to health work environment, motivated employee involvement and reinforced to produce positive patient outcome. Moreover, research has reported that a positive work environment including higher level of autonomy and is associated with nursing care.[9]

Studies of the quality of medical care are increasing in importance as a component of health care research. The consumer's opinion of services is being taken into account in assessments of quality. Thus, evaluating the quality of nursing care involves the measurement of its benefits to patients and the community at large.[10] Despite the fact, there had not been a research conducted similar study place. Therefore, this study assessed the perception of nurses and patients on quality of nursing care practice in in-patient departments of Bale Zone Hospitals, Bale Zone, Southeast Ethiopia.

Methodology

Study setting and period

This study was conducted in April 2014 in hospitals of Bale Zone, Oromiya regional state of Ethiopia. Bale zone is located at 430km Southeast of Addis Ababa and it has a total of 1,708,910 population, among this 837,366 (49%) are male and 871544 (51%) are female, Bale zone has four hospitals, namely Dellomena, Ginnir, Robe and Goba hospital. From these four hospitals of the zone two of them were selected that Robe and Goba Hospital by simple random sampling. Robe hospital was started as health center from 1978- April 2011. Then it becomes hospital comprising four wards with a total of 56 beds and 46 nurses. The nurses give care for around 270 inpatients per month within four wards. Goba hospital is one of hospitals that located in Bale zone. It first established as a small clinic in a resident house in 1955. Currently it is the hospital which has 105 beds, and it has 29 Diploma and 34 BSc nurses that providing promotive, preventive, curative and rehabilitative services for an estimated population of 845,591. The hospital also gives care to around 630 patients within four wards per months.[11-13]

Study design and participation

A descriptive facility based cross-sectional study design was conducted by employing quantitative study methods.

The source population was all nurses who were working in Bale zone hospitals and all patients who were admitted in the hospitals during data collection period. Nurses, who were working in selected Bale zone hospitals during data collection period and patients who were admitted in the inpatient departments (wards) at selected hospitals of Bale zone during data collection period were considered as study participants.

Nurses that were not present due to different reason like training, annual leave, and illness during study period as well as patients who have serious health problems that result difficulty of responding for questions were definitely excluded from the study.

Sample Size and Data Collection Methods

The sample size of the patients was determined with 5% absolute precision and 95% confidence interval. Since there is no similar study before, 50% of estimated proportion of population was considered. Non-response rate was 5%. Finally by using single population proportion formula, the final sample size were becomes 403 patients. As the nurses in the selected hospital were small in number, the whole nurses (43) who were in the ward during data collection time were included in the study. The patients (sampled) were addressed by simple random sampling.

Structured self-administered questionnaire was used to collect data from the nurses and face-to-face interviews were used to collect from in-patients. The questionnaire consisted of questions about socio-demographic characteristics of the study participants, environmental factors on a five point likert scale used and the response recorded as follows (1) = strongly disagree to (5) strongly agree, quality related items likert scale ranging from (1) = very poor to (5) excellent, and service related factors.

Data Quality Assurance

The questionnaire was adapted from relevant literatures in English and translated to Afan Oromo and Amharic language, then re-translated to English. Pretest was conducted three weeks before the actual data collection time in a sample of 5% in Goba hospital. Necessary modifications were made for the questions.[1-4,14] The data collectors and supervisor trained for two days. Five BSc candidate nurses collected the data and One MPH Supervisor supervised the data collectors while they collect the data. Daily, the principal investigators and Supervisor were checked the data for its completeness.

Data processing and Analysis

First we read the whole list of collected questionnaires and then codes were given for complete questionnaires. Data entered into Epidata version 3.1 and exported to SPSS version 16.0 for descriptive analysis to determine the magnitude for different factors that can affect quality of nursing care in patients and nurses perception. The data analyzed were summarized using percentage and frequency. The results were presented by narrative presented using tables, graphs and pie charts.

Ethical Considerations

Ethical clearance and approval was obtained from College of Medicine and Health Sciences, Community Based Education Office, Madda Walabu University. A supportive letter was given to the Hospitals. Permission was obtained from Hospital Manager to implement the study. Prior to the interview, the aims and objectives of the study were clearly explained to the participants and oral informed consent was obtained. Confidentiality and anonymity were ensured throughout the execution of the study as participants were not require to explain their name. The patients were assured that due to their idea, the services they got not compromised and the information they gave were confidential.

Results

Socio-Demographic Characteristics of Nurses

In the study, the response rate was 100% for nurse participants. Nineteen (44.2%) of nurses were male and 24 (55.8%) were female. From them 27(62.8%) of the respondents were 18 to 30 years old and 11(25.6%) were from 31-40 years. When we analyzed their ethnicity, 21(48.8%) were Oromo which was equal to that of Amhara, 21(48.8%) and only 1(2.3%) were Tigre. Majority of nurses 32 (74.4%) were married and 10(23.3%) were single. Thirty-four (79.1%) were orthodox, 5 (11.6%) were Muslim and the rest 4(9.3%) were protestants.

From the nurse respondents, 27 (62.8%) were diploma nurses and 12 (27.9 %) were degree nurses. Among the nurse respondents, majority of them 36 (83.7%) not specialized, 3 (7%) of them specialized by psychiatry and 2 (4.7%) of them specialized by ophthalmology. Again from the total nurse respondents, 15(34.9%) were assigned in medical ward, 11(25.6%) surgical ward and 9(20.9%) pediatrics ward. Of the total nurse respondents, 16(37.2%) had a work experience of ≤ 5 years and 7(16.3%) had a work experience of 16 years and above [Table1].

Some of the reasons that affect quality of nursing care practiceSome of the reasons that affect quality of nursing care practice

From the nurses that were assigned in the wards, 24(55.8%) were strongly agreed and 16(37.2%) agreed that heavy workload was the factor that affect quality of nursing care practice. Four (9.3%) of them were strongly agreed and 26(60.5%) agreed that nurse work schedule was the major factor that affect quality of nursing care. Majority of the respondents 25(58.1%) were strongly agreed and 10(23.2%) agreed that quality of nursing care was also affected due to the insufficient man power or the imbalance number of nurses available to the patients. Many of respondents, 22(51.1%) were agreed and 14(32.6%) disagreed that appreciation for achievement is the factor that affect quality of nursing care practices [Figure 1].

Figure 1: Some of the reasons that affect quality of nursing care practice in Bale Zone Hospitals, Oromiya Regional State, Southeast Ethiopia, April 2014

Some of the reasons that influence implementations of nursing roles

As majority of respondents said, the level of education could influence nursing care services implementation. Coordination of care, amount of time available for care and patient educational level and quality of communication was another influencing factor of nursing role implementations. Again, other factors were shortage of the nurses, shortage of equipments and supplies, poor nurses work conditions and lack of managerial support as possible reasons for poor state of nursing care. Finally, majority of the respondents respond that lack of teamwork, shifting of work time, interest of nurses to their professions and environmental interruptions around workplace can affect nurse to give adequate care to the patients [Table 2].

Some of the reasons that affect Quality of care during Medication Administrations and Procedures

From the respondents, 21(48.8%) strongly agreed and 11(25.6%) agreed on interruption of people to ask patient affect the quality of care. However, 14(32.6%) of nurses were strongly disagreed that bedside practicing students hinder them to give care. Twenty-four (55.8%) of nurses agreed that patient family near bedside affect them to give care in good manner [Figure 2].

Figure 2: Some of the reasons affect quality of care during medication administration and procedure in Bale Zone Hospitals, Oromiya Region, Southeast Ethiopia, April 2014

Overall Quality of nursing care in the Hospital to Patients

Majority of nurses 29(67.4%) reported the nursing care quality was good and 11(25.6%) of the nurses rated nursing care quality was very good [Figure 3].

Figure 3: Quality related items that affect quality of nursing care in Bale Zone Hospitals, Oromiya Region, Southeast Ethiopia, April 2014.

Socio-Demographic Characteristics of Patient Respondents that Admitted in Inpatient Departments of Bale Zone Hospitals

The response rate for patients was 98.5%. More than half of our respondents 211(53.1%) were females. Majority of respondents 213 (53.7 %) were fall between the age of 19 - 40 years old (old adolescent age group). On the assessment, 245(61.7%) of respondents were married. On the other side nearly half of patients 195(49.1%) were illiterate and most of them were housewives. Beside this out of all patients, 206 (51.9 %) were Muslims and most of patients had no history of previous admission 219 (55.2%) [Table 3].

Some of the reasons that influencing nursing care practice as patients responses

Shortage of nurse was complained among 75 (18.9%) of the patients came to Bale Zone Hospitals for health services. Similarly, 96 (24.2%) and 177 (44.6%) of patients rated strongly disagree and disagree about their economy causing them to not receive good nursing care respectively. Students on practice were also raised among 94 (23.7%) of the patients as students interfere quality of nursing health care they had. Two hundred eight (52.4 %) patients agreed that there was shortage of equipments and drugs. Fifty nine (14.9 %) agreed that heavy workload to nurse as a problem of getting quality nursing care [Table 4].

Patients feeling about quality of nursing care services

In this study, 360 (90.7%) of respondents rated the quality of care they were received in their assigned bed was good, very good and excellent in summation. From all respondents, 171 (43.1%), 178 (44.8%) and 17 (4.3%) of respondents rated the relation between nurses and them as good, very good and excellent respectively [Table 5]. Moreover, 358 (90.2%) of respondents, rate the overall quality of nursing care during their stay as attractive [Figure 4].

Figure 4: The perception of patients about overall quality of hospital care during their stay in Bale Zone Hospitals, Oromiya Region, Southeast Ethiopia, April 2014.

Almost all, 361 (90.9%) respondents answered as the nurses call them by their names and 359 (90.4%) respondents said that the nurses greeting them during their stay in hospital. In other dimension, 346 (87.2%) of patients answered that the nurses were polite to their requests and 343 (86.4%) responded nurses gave them chance to talk about their feeling. In the study also, 314 (79.1%) said they got information about their finding from nurses [Table 6].

Discussions

This study assessed perceived quality of nursing care practices in inpatient departments of Bale Zone Hospitals, Oromiya Regional State, Southeast Ethiopia in nurses and patients perspectives using items of quality assessment questions. As in general, majority of respondents, 29(67.4%) nurses and 358 (90.2%) of patients rated the nursing care the hospital provided to patients was good.

The study revealed that 75 (18.9 %) of patients and 37 (86%) of nurses agreed that shortage of nurses was the factor that affect nursing care. In similar, the study done in Jimma specialized hospital also showed that 56.3% of patients felt that the reason of poor state of nursing care was due to shortage of number of nurses.[15] According to the study done in Mekelle Zone, Ethiopia, the majority, 150 (75%), of the respondents said that the nurse to patient ratio was not optimal to apply the nursing process that increase quality of care delivered for the patients.[16]

In this study, 94 (23.7%) of patients and 13 (30.2%) of nurses agreed that practicing students affect the quality of care patients received, which is proportional with the study conducted in Jima specialized hospital.[15] Again, According to this study, almost half 208 (52.4%) of patients and 36 (83.7%) of nurse responded that there was shortage of equipment’s and drugs. This result is supported by the study conducted in South Africa where shortage of medication and supplies were the main problem for quality of nursing care.[17]

In this study, 59 (14.9%) of patients and 40 (93%) of nurses agreed that heavy workload to nurses was their perceived reason that affect quality of nursing care. A research shows that a heavy nursing workload, burnout and high perceived workload were adversely affects quality of nursing care. [18-20] The study conducted in Addis Ababa, Ethiopia, revealed that patients and works overload, lack of motivation including salary were the identified barriers for adequate pain management that reflects poor nursing care quality.[21]

According to the perception of patients, the technical competences of nurses while care delivering, keeping privacy of patients and giving chance to talk for patients were seen as a good, very good and excellent majorly. In similar with this findings, the study done in Amhara Region, Ethiopia reflected that Freedom, privacy given to patients and the capabilities of the nurses at their jobs were the top areas of patients have got satisfied on nursing care services delivered.[14,22]

The communication between nurses and patients were complied by nearly half of nurses, 20 (46.5%) and 58 (14.6%) of patients as other factors that affected the quality of care they received. Similarly, studies conducted in Debre Markos Hospital, Amhara Region, Ethiopia, showed that those patients who have good communication with nurses were more satisfied with the care that is one types of quality components.[23]

From the respondents, 91 (22.9%) of patients and 17 (39.5%) of nurses agreed that nurses poor working condition was also the reason in hindering quality of nursing care. Study conducted in Sidama Zone, Ethiopia, described that working environment was significant predictor of nurse satisfaction that indirectly limit the quality of nursing care. [24] The environmental interruptions in the nursing work place caused interruption in continuity of care and in consistencies in nursing assignments such as medication errors and delay in patient treatments.[25] In similar to this study finding listed above, the study conducted in Arba Minch General Hospital, Ethiopia has identified that lack of facility from organizational factors, economic status of the patient to collect material for nursing care, level of knowledge were among those factors highly affecting nursing process implementation. This factors cause poor quality of nursing care disorganized caring system, conflicting role, medication error, dissatisfaction with the care patients have received and finally mortality patients can be increased.[26]

Strength and Limitations of study

The data were collected from both nurses and patients that can increase validity of data. Data were collected by BSc candidate nurses that can decrease uncertainty while collection of the data. Since the data collectors were not from the hospital workers, the patient can talk freely what he/she felt heart fully about the quality of care without fearing for his/her future cares. The qualitative methods of data collection were not conducted. With a descriptive analysis it is difficult to identify specific factors that affect quality of nursing care. Therefore, in future it is better if both qualitative and quantitative methods of data collections will be used for further study.

Conclusions and Recommendations

According to the perceptions of both nurses and patients, the overall quality of nursing care in Bale zone hospitals was good. It was found that shortage of drugs and supplies, and environmental interruptions, nursing work overload, overcrowding due to too many practicing students, communication between nurses and patients and technical competences of nurses while care delivering were the major reasons for why quality of nursing care practice were undermined.

The hospital Managers and other stakeholders should take into consideration the above raised problems like resources allocation, arrange and follow carefully the nursing work hours, poor working conditions and nurse to patient ratio to increase quality of nursing care delivered for patients that both nurses and patients were complaining. In addition, nurse’s administrator recommended considering nurse to patient ratio to decrease work overload that can affect quality of nursing care. The nurses should have to communicate with the patients, give freedom to talk for patients and should have to be devoted for their works. The Hospitals and Madda Walabu University should have to arrange the practicing students according to the capacity of wards.

Competing interests

None of the authors has any competing interest.

Authors' contributions

BD, TL, TH, YH, ShY & MA conceived and designed the study. BD & ND analyzed the data and interpreted the results. BD prepared the manuscript & ND critically reviewed the manuscript. All authors have read and approved the manuscript.

Acknowledgments

We would like to acknowledge Madda Walabu University for supporting this study financially. Our thanks also extended to both Hospital managers and Staffs for their cooperation. In addition, our heartfelt thanks also extended to study participants and data collectors who shared their priceless time as well as for their full commitment to give information and collect that information respectively. Not the least but the last we acknowledge our families, friends and colleagues for all their supports and encouragements during conduction of this study.

References

1. Mahadeo Sh and Kavita K.  Patient’s Satisfaction with Nursing Care Provided in Selected Areas of Tertiary Care Hospital, India. International Journal of Science and Research (IJSR) 2014; 3: 2319-7064.
2. Mansoureh Z., Tafresh and Mahrnoosh p. Perspectives on quality of nursing care: a qualitative study in Iran. Intervention Journal of quality Assurance 2007; 20: 320-328.
3. Molla M, Berhe A, Shumey A. and Adama Y.  Assessment of Nursing Care Experience and Associated Factors Among Adult Inpatients in Black-Lion Hospital, Addis Ababa, Ethiopia.  An Institution-Based Cross-Sectional Study. J Nurs Care 2014; 3: 165. 
4. Wai Mun Tang, Chi-Yang Soong and Wen Chieh Lim. Patient Satisfaction with Nursing Care: A Descriptive Study Using Interaction Model of Client Health Behavior. International Journal of Nursing Science 2013; 3: 51-56.
5. Donabedian A. The quality of care. How can it be assessed 1988; 260:1743-1748.
6. Mohammad H., Rasheed H., Saeed A, Tariq S and Khalid Sh.  Patient Satisfaction with Nursing Care. Rawal Med J 2007; 32:28-30.
7. Chaka B. Adult Patient Satisfaction with Nursing Care: Addis Ababa University 2005; 24-34.
8. Rothenberg M, Abraham, Liden O. & David Rose. Improving Nurse to patient Staffing Ratios as a cost Effective Safety Intervention, 2005; 43: 785-791.
9. Donabedian A, Evaluating the quality of medical care. 1966. Milbank Q 2005; 83: 691-729.
10. Nahed S. El-Nagger, Sahar M. A. Ahmed, Lamiaa A. Elsayed, Hamdia M. A. Khamis.  Patients' Satisfaction Regarding Nursing Care Provided in Different Hospitals in Makkah AL Mukramah. Life Science Journal, 2013; 10.
11. Goba Hospital Report. Goba Referral Hospital, Bale Zone, Southeast Ethiopia. 2014.
12. Robe Hospital Report. Bale Robe District Hospital, Bale Zone, Southeast Ethiopia. 2014.
13. Bale Zone Report. Socio Demographic and Socio Economic Profile of Bale Zone, southeast Ethiopia. 2013.
14. Azanu Kibret Negash, Wubante Demilew Negussie, Amsalu Feleke Demissie. Patients’ Satisfaction and Associated Factors with Nursing Care Services in Selected Hospitals, Northwest Ethiopia. American Journal of Nursing Science 2014; 3: 34-42. 
15. Beyene W., Jira Ch. and Sudhakar M. Assessment of Quality of Health Care in Jimma Zone, Southwest Ethiopia. 2011. Ethiop J Health Sci 21: 49-57.
16. Fisseha Hagos, Fessehaye Alemseged, Fikadu Balcha, Semarya Berhe and Alemseged Aregay.  Application of Nursing Process and Its affecting Factors among Nurses Working in Mekelle Zone Hospitals,Northern Ethiopia. Nurs Res Pract 2014: 9.
17. Eygelaar JE and Stellenberg EL. Barriers to quality patient care in rural district hospitals, South Africa. 2012. Curationis 35, 36: 8 pages.
18. Lang TA, Hodge M. and Olson V. Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Adm. 2004; 34:326–37.
19. Reader and Gillespie: Patient neglect in healthcare institutions: a systematic review and conceptual model. BMC Health Services Research 2013 13:156.
20. Keers RN, Williams SD and Cooke J et al. Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study. BMJ Open 2015; 5:e005948.
21. Kassa RN and Kassa GM Nurses’ Attitude, Practice and Barriers toward Cancer Pain Management, Addis Ababa, Ethiopia, 2014. J Cancer Sci Ther 6: 483-487.
22. Abebe N, Abera H and Ayana M. The Implementation of Nursing Process and Associated Factors among Nurses Working in Debremarkos and Finoteselam Hospitals, Northwest Ethiopia 2014; J Nurs Care 3: 149.
23. Shegaw Alemu, Challi Jira, Tsion Aseffa. and Mayur M. Desa. Changes in Inpatient Satisfaction with Nursing Care and Communication at Debre Markos Hospital, Amhara Region, Ethiopia. American Journal of Health Research 2014; 2: 171-176. 
24. Asegid A, Belachew T and Yimam E. Factors Influencing Job Satisfaction and Anticipated Turnover among Nurses in Sidama Zone Public Health Facilities, South Ethiopia. Hindawi Publishing Corporation. Nursing Research and Practice 2014; 26 pages.
25. Anita L. Tucker and Steven J Spear. Operational Failures and Interruptions in Hospital Nursing. Health Research and Educational Trust.
26. Zewdu Shewangizaw, Abera Mersha. Determinants towards Implementation of Nursing Process, Arbaminch General Hospital, Ethiopia. American Journal of Nursing Science 2015; 4: 45-49.