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Abstract
Introduction The Australian Council on Healthcare Standards (ACHS) set criteria for the delivery of healthcare services in Australia. While a voluntary process, continual accreditation with ACHS is an expectation of, and for, Australian healthcare providers. Juxtapositioned with the ACHS, the Nursing and Midwifery Board of Australia (NMBA) set the mandatory practice requirements of, and for, Australian nurses. Despite these overarching quality and governance directives, a regional Queensland Hospital and Health Service (HHS) demonstrated deficits in the quality of nursing care. Accordingly, a HHS project was commissioned with the aim of producing a quantum shift in the quality of nursing services such that the service was ready-everyday for accreditation assessment, and nursing practice exemplified the NMBA standards.
Several barriers to achieving the aim were identified and it was considered that the implementation of critical system changes would structurally and operationally support the achievement of the aim. The system changes are pivoted around an interactive matrix that links nursing care services to the array of nursing professional and practice standards and provides real-time quantitative output measures. This paper outlines the protocol that will be used to establish, implement and evaluate the matrix.
Methods and analysis A participatory action research design with a modified Delphi methodology will be used for the development the matrix. The organisational change management around the matrix implementation will be informed by Kotter’s model and supported by the use of the McKinsey 7S. The matrix implementation phase will be conducted using a modified Promoting Action on Research Implementation in Health Services model. Quantitative and qualitative data will be collected over a 12 month pre-test/post-test design to measure the statistical significance of the matrix in supporting compliance with nursing standards and the achievement of quality nursing care. Quantitative data from quality of care assessments will be analysed using descriptive and comparative statistics. Qualitative data from staff surveys will be analysed by content analysis of the major themes (n~200).
Ethics and dissemination The project has ethics approval from a Queensland Health Human Research Ethics Committee. Results will be reported to participants and other stakeholders at seminars and conferences and through peer-reviewed publications.
- healthcare accreditation
- nursing standards
- measuring nursing care
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Strengths and limitations of this study
The methodology broadly engages nursing services and organisational leads from clinical, education, management and research domains to achieve Australian Council on Healthcare Standards accreditation.
This protocol is the first to map nursing professional and practice standards into an interactive, real-time quantitative matrix to provide a constant nursing service measure.
This protocol uses non-probability sampling, and while economically and logistically advantageous, elevates the risk of selection bias.
Introduction
In Australia, the Australian Council on Healthcare Standards (ACHS)1 has established standards for the delivery of healthcare services. Healthcare organisations voluntarily measure their achievement of the ACHS through a range of external and internal processes. The ACHS healthcare service external accreditation process is a cyclic 4-year event, with an interim review once within the 4-year period. ACHS conduct both the interim and final assessments on specified dates with specified assessors. In counterpart, the Nursing and Midwifery Board of Australia (NMBA) define the specific code of conduct and standards for nurses,2 with nurses self-auditing their practice against these standards as a component of their yearly registration renewal. At an organisational level, compliance with nursing standards is measured through a combination of internal and external methodologies and tools. As an example, in Queensland public hospitals, the yearly bedside audit (QBA)3 is the sentinel external tool which measures a range of nurse sensitive indicators (NSIs).
External and internal ACHS and nursing standard compliance assessments are intended to demonstrate the achievement of quality and safety benchmarks. An organisation’s and individual’s compliance with these benchmarks provides a level of surety for organisations around the achievement of quality and safety expectations. Moreover, the process of conducting compliance assessments and the findings provide an opportunity to bring about system and individual changes to healthcare delivery.
In 2017, the Hospital and Health Service (HHS) initiated with ACHS, Queensland Health (QHealth) and other partners, an Australian-first research project with the aim of being Accreditation Ready Everyday. The project methodology is such that an accreditation review can occur at any time and with any frequency.4 5 The initial 2017 ACHS research project assessment evidenced deficits in nursing documentation, the conduct and the quality of nursing care and the use of evidence-based nursing practice. These findings were supported by the 2017 QBA report which demonstrated concerns in the acute care areas of the two larger HHS hospitals. Further confirmation that the nursing standards were not being achieved in those areas was provided from internal NSI assessments.
The consistent downward trend in compliance achievement across several time periods and assessment methodologies was an organisational risk. It was evident that a dichotomy existed between nursing standards and patient outcomes. This separation was supported (counter-intuitively) by system-generated rote nursing processes that were not based on evidence-informed or patient-centred care delivery. That is, nursing assessment, planning, implementation and evaluation processes had become firmly standardised and scripted into large documents with numerous checklists. Nursing standards and care planning processes were being driven by the requirement to have the ‘form completed’. As a result, the patient record often contained the appropriate nursing form, however the nursing care delivery was not being completed, or to the standard required. Furthermore, the HHS’s standards compliance reports were provided only as aggregate end-of-month data. This created a time-lag between the patient experience and the individual nurse/shift/day and reduced the ability for nurse leaders to activity monitor and respond to real-time compliance achievement.
In response to the deficits in care delivery, the HHS introduced several policies and conducted a series of training sessions and focus groups with the senior nursing staff within the acute care areas at both hospitals. Evaluation of the impact of the training and group workshops on the quality of nursing care was through an external review in February and March of 2018. That review supported the previous unfavourable findings and emphasised the continued deficits in the nursing standards around the level and quality of nursing care.
Varying approaches were initiated to identify the barriers to compliance achievement. Overarchingly, as a barrier to the provision of quality nursing care, nursing staff reported that there was confusion and a knowledge gap related the large number of governance standards and professional guidelines. Augmenting the barrier, was the disparate location of standards and guidelines on HHS systems and in the nursing care areas. Furthermore, the standards and guidelines often lacked quantitative measurement criteria.
Consultation around the structures and processes to enable the acute care areas to continuously achieve nursing standards occurred with the broad stakeholder group. The group agreed on the following Ready-everyday Nursing Standards (RENS) project aim: To provide proof of concept for a method (the matrix) that articulated nursing professional standards, organisational standards and guidelines for nursing practice against measurable criteria and which could provide compliance information at any time and against any standard.
Change management framework
The establishment of the system changes (the project) and the implementation of the matrix is expected to involve major shifts in the management, planning and delivery of nursing care. Planning and implementing significant workplace change provides a milieu of complexities requiring concerted leadership and management investment. Change management research demonstrates that organisations which adopt a formal process for large-scale changes are more successful in achieving the desired change. Kotter6 articulates eight compelling change management principles, and in this project, those principles have been agreed on as the mechanism by which the stages to effective change will be undertaken. Table 1 briefly outlines the principles and their application to this project.
Kotter’s principles of leading change applied to this project
Kotter’s principles6 will be supported by the use of the McKinsey 7S framework.7 McKinsey 7S8 model is structured around seven internal focal points: strategy, structure and systems (hard elements) and shared values, skills, style and staff (soft elements). In this project, McKinsey 7S (figure 1) will be used to consider the alignment of the elements, identify the likely effects and team specific impacts of the change and determine how best to implement the proposed matrix
McKinsey 7S framework8 - project modifications.
The implementation of the matrix is expected to provide a number of challenges, accordingly the project team considered a range of theoretical and practice implementation models9–13 before selecting Promoting Action on Research Implementation in Health Services (PARiHS).14 PARiHS is generally utilised for the implementation of evidence-based guidelines, however the project team believed that a modification of this model offered a structure to support the identification and embedment of professional standards (which inform practice guidelines) into the acute care areas. The implementation structure for this project will employ the three primary PARiHS themes: (a) the evidence, (b) the context and (c) the facilitators of change.
Methods and analysis
Population, recruitment, consent and data sources
Patient and Public Involvement: Patients and the public were not actively recruited to this study, nor did they actively inform the study.
This is a mixed methods study with two cohorts. Cohort 1: This population will consist of all patients who have had an admission to the surgical and/or medical wards of the two major HHS hospitals over the past 3 years (2016 to 2019). Pre-implementation and post-implementation de-identified data will be collected from QHealth HHS reports and quality systems (listed in table 2) under a waiver of consent. No individual patient data will be collected.
Data sources and consent procedures
Cohort 2: This population will consist of the acute care nursing teams in the surgical and medical wards of the two major HHS hospitals (n~200). This population will be exposed to the new process (the matrix) as part of their standard workplace roles. In order to understand what those staff consider to be the important issues related to the achievement of quality nursing care in their unit, a pre-implementation survey will be conducted. Potential survey participants will be purposely invited to participate through a generic email to their work address. In addition, the survey will be available in the clinical areas and on the HHS website. The survey study should take less than 30 min to complete. Participants will be informed that participation in the survey is anonymous and voluntary. Completion and return of the survey to an independent third party will signify consent to participate.
Six-months post implementation of the matrix, the procedure will be repeated to obtain post-implementation survey data.
The intervention
The matrix will be developed and implemented as follows:
Phase 1
The project team will identify relevant nursing professional standards, organisational standards and guidelines. The project team will use a modified Delphi methodology to gain consensus on the standards for inclusion, exclusion and their context into the tool. The inclusion criteria will be based on the standard’s ability to influence or impact the nursing service and nursing practice. Statements without linkage to nursing and nursing practice will not be included. Standards without validated measurement criteria will have measurement criteria or indicators developed by the project team. All criteria will be expressed as single elements of a standard and written in plain English using a structured and standardised format. Clinical nursing standard criteria will follow the nursing process of assessment, planning, implementation and evaluation. The broader stakeholder team will review all standards and criteria in terms of importance to patient care, impact on nursing service or nursing care, and feasibility and viability of measurement criteria. Initially the tool will be developed as a hardcopy and online Excel tool before moving to a purpose-designed electronic application (app). The tool will be positioned on HHS computer desktops and portable devices and enable real-time data collection.
Phase 2
Using a modified PARiHS model, the matrix will be implemented into the acute care areas of the two hospitals. Participation in Phase 2 is an expectation for all nursing staff employed in the surgical and medical wards of HHS hospitals as part of a standard quality improvement activity. The Phase 2 elements are listed in the project plan outline (table 3).
Project plan outline
Data collection and analysis
Quantitative and qualitative data will be collected to measure the statistical significance of the matrix in supporting compliance with nursing standards and the achievement of quality nursing care. Table 2 lists the reports that will be used as the data sources for this project. From those reports, variables that relate to nursing services quality of care will be identified and a range of patient outcome data will be obtained. Six-months following the implementation of the matrix, post-implementation data will be obtained from the same sources (excluding a repeat external review). Included will be adverse incidents, for example the development of a pressure injury, medication errors and falls.
Pre-test and post-test statistical analysis will be used to compare the results on both the qualitative and quantitative data to determine if there has been a statistically significant improvement in the nursing standards by showing if the results can be attributed to chance variation. Quantitative data will be compiled onto Excel spreadsheets and imported into SPSS V.25.0 (IBM SPSS Statistics 25) for Windows for analysis. Validation of the data accuracy following transfer will be conducted by comparing the computed values on the Excel spreadsheets with the computed values in SPSS. Missing data will be reported but will be excluded from analysis. Outliers will be identified by the use of boxplots in SPSS. These outliers will be confirmed based on the established procedures15 and will be reported but excluded in the data analysis.
Descriptive and comparative analyses will be undertaken. Means±SD or proportions will be reported for in-group dispersion and central tendency where applicable. Continuous variables will be tested for statistically significant differences using t-test and analysis of variance, followed by appropriate post-hoc tests when required. Categorical variables will be analysed by chi-square with appropriate post-hoc tests when required. Confounders, variable modifiers and biases will be identified, eliminated were possible or appropriately dealt with. Results will be reported at alpha 0.05 and accompanied by 95% CIs.
Qualitative data will be collected from the external review and from the pre-implementation and post-implementation nursing staff surveys. Qualitative data will be analysed by content analysis of the major recurring themes and a frequency count may then be performed.
De-identified quantitative and qualitative data will be reported as aggregate data. Qualitative and quantitative analysis which shows statistically significant post-implementation results will provide proof of concept around the use of the matrix to impact the quality of nursing care.
Ethics, timelines and dissemination
HHS and an exemption from full Human Ethics Research Committee approval has been obtained for this quality improvement project (HREC/2019/QPCH/51342).
Timelines. Initial roll-out of the matrix is planned for June 2019.
Dissemination of findings. Findings, including the validated matrix, will be reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for observational studies.16 17 Participants and healthcare consumers will be informed of the project results through publication on publicly accessible websites, media and local newsletters. Additionally, HHS newsletters will contain details of the research findings and links to the journal articles. Findings will be presented at Australian and international conferences and seminars.
Conclusion
This paper describes a participatory action research project aimed at establishing a mechanism for measuring the delivery of nursing care in the acute care areas of a regional Queensland HHS against professional nursing and clinical standards. The paper identifies the theoretical frameworks for developing the implementation plan and identifies the disablers and enablers to delivering the project aim. The mixed methods approach to data collection aligns with the project aim of delivering a substantial and sustainable improvement in the delivery of nursing care and achievement of nursing standards by embedding Ready Everyday Nursing Standards into practice.
Footnotes
Contributors All authors contributed to the conception of the study protocol and the final approval of the manuscript. Study design: AP, FS. Literature search and assessment: AR. Drafting the manuscript: AR. Critical revision of the manuscript for intellectual content: AP, FS.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The project has ethics approval from a QHealth Human Research Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.