Research article Quality of Nursing care in the perspective of Nurses at Tertiary Care Public Hospital, Karachi Ameer Ullah Khan1, Sajjan A. Halepoto1, Sineer Micah2, Sikander Munir Memon 1, Victoria Samar1, Muzafar Ali, Mehar Ali, Imran Ali Shah1 People’s School of Nursing, LUMHS, Jamshoro, Sindh Government Hospital Liaquatabad, Karachi Correspondance: Ameer Ullah Khan People’s School of Nursing, LUMHS, Jamshoro Received: 10 October 2019 Revised: 25 November 2019 Accepted: 2 January 2020 LMRJ.2020:2(1) Doi: 10.38106/LMRJ.2020.2.1.01 Abstract Quality care is essential for patient safety and positive outcome. Nurses have to play pivotal role in patient care. This study was aimed to explore quality of nursing care in perspective of nurses at a tertiary care public hospital Karachi, Pakistan. A descriptive cross-sectional study was conducted at a tertiary care public sector hospital. Data was collected by using a pre-defined questionnaire. Activities in four dimensions including patient satisfaction, prevention of complications, functional re-adaptation health promotion are almost always fulfilled while, well-being and self-care and responsibilities and rigor were less executed. Nurses are empathetic and show respect to the patient but not engaged in acre process. Key words: Nursing, nursing care, Quality care, standard care. Tertiary care Introduction Quality of health care standard is an essential part of patient safety and positive outcomes. In United States of America (USA) approximately 250,000 deaths account for laps in quality care1-3. Studies have been conducted to explore quality of care taking into account only patient’s perspective, though nurses have a key to play in this regard4-5. Therefore it is important to consider nurse’s perspective in quality care. Registered nurse (RN) practice in a therapeutic and professional relationship with individuals and their attendants6. Nurses provide safe and quality care and are also responsible to perform comprehensive assessment, interpret information and make critical decisions, administer medications and execute other necessary interventions7. This study was aimed to assess quality of nursing care in perspective of nurses as there is strong need to quantify overall magnitude of problem so that policy can be established. Methodology Descriptive cross-sectional study was conducted at tertiary care public hospital Karachi, Pakistan from September 2017 to December 2017. All the staff Nurses working in cardiology and cardiac surgery departments who had spent at least three months in the institution and willing to participate were included using convenient sampling technique. An adopted questionnaire “Nurses’ perceptions and practices: contributions to care quality” was used for data collection. It is a Likert scale with four options; Never, Rarely, Often and Always, consisted of 25 items categorized in seven dimensions; Patient satisfaction, Health promotion, Prevention of complications, Well-being and self-care, Functional readaptation, Nursing care organization, Responsibility and rigor. The tool is valid and reliable having Crohncach’s alpha of 0.940a. Permission was taken from Chief Nursing superintendent; thereafter proceed to the respective participants and explained objectives and purpose of the study then asked to give consent in written form. After it, questionnaire forms were distributed in participants and explained each point of questionnaire for minimizing the error. Each form was checked at the time of collection to make sure of their completion on spot. Statistics/Data Analysis software (STATA), version 12.1 was used for data analysis. Results A total of 44 nurses participated in the study with mean age of 35.36 (SD ±9.12) years. Majority of participants were female (ie 63.64%). There was a predominance of staff nurses (93.18%) while 6.82% were head nurses. More than half (59.09%) of the participating nurses have three years RN qualification followed by Bachelors of Science(BSN) degree (ie 40.91%). With regards to department of work, most of the respondents were from CCU (27.27%), followed by Cardiac ward (22.73%), CICU and Cardiac Surgery ICU (18.18%) and Cardiac Surgery Ward (13.64%). There was a high proportion of nurses (45.45 %) having experience of six to ten years (Table 1). In the results of the scale “Nurses’ perceptions and practices that contribute to quality care, within the dimension of Patient satisfaction (Table 2) most participants replied Always at the of 72.73%). Within context of dimension Health Promotion most participants (68.18%) replied Rarely (Table 3). In response to activity “Nurses use the hospitalization time to promote healthy lifestyles”, majority replied Often (50 %) (Table 4). Responses of “Well-being and Self-care” are summarized in Table 5. Responses of functional re-adaptation are summarized in Table 6. Responses of nursing care organization are given in Table 7, while responsibility and rigor was summarized in Table 8. Table 1: Demographic Characteristics Variable Frequency Percentage Age 35.36" 9.12** Gender Male 16 36.36 Female 28 63.64 Nursing Qualification RN 26 59.09 BSN 18 40.91 MSN NIL 00.00 Department Cardiac ward 10 22.73 CICU 08 18.18 CCU 12 27.27 Cardiac Surgery Ward 06 13.64 Cardiac Surgery ICU 08 18.18 Designation Head Nurse 03 6.82 StaWurse 41 93.18 Total Work Experience Less than one Year 02 4.55 1 — 5 years 10 22.73 6 — 10 years 20 45.45 11 — 15 years 04 9.09 16 — 20 years 02 4.55 21 years and above 06 13.64 Table 2: Patient Satisfaction n % n % n % n % n % “Nurses show respect for the abilities, beliefs, values and desires of individual patient”. 02 4.55 04 9.09 06 13.64 32 72.73 44 100.0 “Nurses are constantly seeking to show empathy in interactions with the patient” 00 00 08 18.18 10 22.73 26 59.09 44 100.0 “Nurses involve cohabitants of individual patient in the nursing care process” 04 9.09 28 63.64 04 9.09 08 18.18 44 100.0 Table 3: Health Promotion n % n % n % n % n % “Nurses identify the health situation of the population and the resources of patient”. 02 4.55 30 68.18 10 22.73 02 4.55 44 100.0 “Nurses use the hospitalization time to promote healthy lifestyles”. 02 4.55 12 27.27 22 50.00 08 18.18 44 100.0 “Nurses provide information that generates cognitive learning and new abilities in the patient”. 04 9.09 16 36.36 12 27.27 12 27.27 44 100.0 Table 4: Prevention of Complications n % n % n % n % n % “Nurses identify potential problems of the patient”. 06 13.64 18 40.91 10 22.73 10 22.73 44 100.0 “Nurses prescribe and perform interventions to prevent complica- tions”. 04 9.09 02 4.55 20 45.45 18 40.91 44 100.0 “Nurses evaluate the interventions that help prevent problems or minimize undesirable Acts.” 02 4.55 10 22.73 18 40.91 14 31.82 44 100.0 Table 5: Well-being and Self-care n % n % n % n % n % “Nurses identify patient’s problems that will help improve the patient’s well-being and daily activities.” 02 4.55 20 45.45 16 36.36 06 13.64 444 100.0 “Nurses prescribe and perform interventions that will help improve the patient’s well-being and daily activities.” 2 4.55 22 50.00 16 36.36 4 9.09 44 100.0 “Nurses evaluate the interventions that help improve the patient’s well-being and daily activities.” 4 9.09 16 36.36 20 45.45 04 9.09 44 100.0 “Nurses address problematic situations identified that will help improve the patient’s well-being and daily activities.” 06 13.64 20 45.45 10 22.73 08 18.18 44 100.0 Table 6: Functional Re-adaptation n % n % n % n % n % “Nurses ensure continuity of nursing service provision.” 0s 00 04 49.09 16 36.36 24 54.55 44 100.0 “Nurses plan discharge of patients according to each patient’s needs and community resources.” 04 9.09 10 22.73 06 13.64 24 54.55 44 100.0 “Nurses optimize the abilities of the patient and his/her cohabitants to manage the prescribed therapy.” 06 13.64 16 36.36 20 45.45 02 4.55 44 100.0 “Nurses teach, instruct and train patients for adaptation and teach, instruct and train patients what is required for functional readaptation'’ 06 13.64 08 18.18 12 27.27 18 40.91 44 100.0 Table 7: Nursing Care Organization n % n % n % n % n % “Nurses know how to handle the nursing record system.” 00 00 06 13.64 06 13.64 32 72.73 44 100.0 “Nurses know the hospital’s policies.” 02 4.55 08 18.18 06 13.64 28 63.64 44 100.0 Table 8: Responsibility and Rigor n % n % n % n % n % “Nurses show responsibility for the decisions they make and for the acts they perform and delegate, aiming to prevent complications.” 00 00 08 18.18 20 45.45 216 36.36 44 100.0 “Nurses show responsibility for the decisions they make and for the acts they perform and delegate, aiming to ensure well-being and self-care of patients.” 2 4.55 16 36.36 16 36.36 10 22.73 44 100.0 “Nurses show technical/scientific rigor in the implementation of nursing interventions aiming to prevent complications.” 00 00 08 18.18 18 40.91 18 40.91 44 100.0 “Nurses show technical/scientific rigor in the implementation of nursing interventions that help improve the patient’s well-being and daily activities.” 02 4.55 18 40.91 18 40.91 06 13.64 44 100.0 “Nurses refer problematic situations to other professionals, according to the social mandates.” 04 9.09 08 18.18 10 22.73 22 50.00 44 100.0 “Nurses supervise the activities that support nursing interventions and the activities they delegate.” 04 9.09 16 36.36 14 31.82 10 22.73 44 100.0 Discussion The results of demographic data of participants revealed that the mean (+SD) age of the participants was 35.36 (+9.12) years. There was majority of female (63.64%) and staff nurses (90.91%). Most of the participating nurses (59.09 %) have Three Years Registered Nurse (RN) qualification. It is matter of concern that there is no any single nurse, having Master degree in Nursing. According to Barret, there is a significant relationship between quality care and level of nurses education' and recommended to increase qualified nurses in specialized care units, but Abdul Rahman et al. do not agree with their findings“. A high percentage of nurses (45.45 %) have experience of six to ten years. Regarding the scale “Nurses’ perceptions and practices that contribute to quality care”, in the dimension “Patient Satisfaction” mostly participants replied Always in the activities “Nurses show respect for the abilities, beliefs, values and desires of individual patient while providing nursing care.” and “Nurses are constantly seeking to show empathy in interactions with the patient”. The main area of concern is most of the nurses replied Rarely (63.64%) in the activity “Nurses involve significant cohabitants of individual patient in the nursing care process.” Understanding patient’s abilities is important to involve them as a shared partner in health care.” Patients’ perceived their involvement in care seemed to be associated with their attitudes about their illnesses and recovery and preferred shared decision making " About “Health Promotion dimension”, most of the nurses answered Rarely in the statements “Nurses identify the health situation of the population and there sources of patient/family and community” and “Nurses provide information that generates cognitive learning and new abilities in the patient”. A study conducted by Ribeiro, Martins and Tronchin , majority of nurses replied often, which is differ from this study while most of the participants in this study responses Often in “Use the hospitalization time to promote healthy lifestyles”, which is in line with their study. These finding are significant for concern. Nurses are the foundation of patients’ behavioral changes by means of approaches focused on health promotion". But, the findings of this study recommend that this may not be executed by nurses in hospital setups. In the dimension Prevention of Complication, results showed that nurses often perform and evaluate intervention to prevent complication but they are rarely able to identify potential problems of the patient. These finding differ from the results of the aforementioned study. According to American Nurses Association, nurses must increase their efforts for development and implementation of nursing actions to support promotion of health and prevention of disease/ illness and disability’. With regards to dimension “Well- being and Self-care”, most of the participants replied rarely while few answered Always which are oppose to the findings of the study by Martins et al. The findings suggest that there is a strong need to focus on this domain as it is necessary for a healthy recovery. In the context of “Functional Re-adaptation”, majority of respondents answered Always in the activity Nurses ensure continuity of nursing service provision. Continuity of care insures high quality care and cost effectiveness. If care is episodic, chronically ill patients might develop adverse effects and complications; results in high expenses and poor outcome. Most of the nurses replied Always in this study for the activities “Nurses plan discharge of patients according to each patient’s needs and community resources and Teach, instruct and train patients for adaptation and teach, instruct and train patients what is required for functional Re-adaptation”; mostly answered often in the response of “Nurses optimize the abilities of the patient and his/her cohabitants to manage the prescribed therapy”. Mabire et. al. did a study and reported that discharge planning helps in transition from hospital to home care and decrease post-discharged complications and adverse events but comprehensive discharged planning did not benefit the patients results in less readiness and frequent readmission within 30 days”. 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