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Quality of Nursing care in the perspective of Nurses at Tertiary Care Public

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 research article

Quality of Nursing care in the perspective of Nurses at Tertiary

Care Public Hospital, Karachi.

Ameer Ullah Khan1, Sajjan A. Abstract

Halepoto1, Sineer Micah2, Sikander Quality care is essential for patient safety and positive outcomes. Nurses have a
Munir Memon1, Victoria Samar1, major contribution in patient care. Their perspective about the nursing care
Muzafar Ali1, Mehar Ali1, Imran Ali quality is of great importance. Analysis of the literature reveals that quality care is
Shah1. subjective aspects based on standards and difficult to quantify but the outcomes of
1
People’s Nursing School, quality care are patient satisfaction, safety and improvement in health status. The
LUMHS, Jamshoro. objective of the study is to explore the quality of nursing care in the perspective of
2
Sindh Government Hospital Liaquatabaad,
nurses at a tertiary care public hospital, Karachi, Pakistan. A descriptive cross
Karachi.
sectional study was conducted ata tertiary care public hospital; recruited 44
nurses, working in cardiology and cardiac surgery departments. Data were
Received: 10 October 2017 gathered through a questionnaire consisted of seven dimensions; “patient
Revised: 4 November 2017 satisfaction, health promotion, prevention of complications, well-being and
Accepted for publication 8 December 2017 self-care, functional Readaptation, nursing care organization and responsibility
Correspondence: and rigor”. Data were analyzed with STATA, version 12.1, frequency and
Afsheen Mushtaque Shah percentages were obtained. Activities in four dimensions i.e. patient satisfaction,
Institute of Biochemistry, University of prevention of complications, functional Readaptation and nursing care
Sindh, Jamshoro. organization are often or always fulfilled. Health promotion, wellbeing and
E-mail: afsheen.shah@usindh.edu.pk
self-care and responsibility and rigor are less executed. Nurses are empathetic and
show respect for patients’ desire but they did not engage them in the care process.
Policies should be designed for health promotion, patient well-being and self-care
to reduce mortality, morbidity and hospitalization.
Keywords: Nursing, Nursing care, Quality care, Standard care, Tertiary Care.

Introduction information and make critical decisions, administer

Quality of health care standards is the essential elements for
patient safety and positive outcomes. In USA, approximately
250,000 deaths per year occurred due to laps in the quality
care1. Health care quality in public hospitals of Pakistan is
considered to be much lower than standard care and
continuously a part of criticism. Most of the people of
Pakistan live in low socioeconomic conditions and visit public
hospitals but public hospitals are unable to provide better
services than private hospitals2,3. The studies conducted to
explore quality of care are based on the perspective of patients
as they are the receivers. Nurses have the key role in providing
of these services and are legally and morally responsible for
it4. It is important to know nurses perspective about the
nursing care quality5 as it is important for patient’s outcome,
safety and improvement.
Registered nurse (RN) practiced in a therapeutic and
professional relationship with individuals and their families
who may be healthy or have health problems either physically
or mentally6. They provide safe and quality care and are
responsible to perform comprehensive assessment, interpret
medications and execute other necessary interventions7. The
objective of the study was to assess quality of nursing care in
the perspective of nurses as there is strong need to quantify
the overall magnitude of this, so that policy can be
established. This will help in decreasing the negative
stereotype perception about public sector organizations. So,
in future intervention can be design for prevention of miss
care.
In study conducted in Thailand reviewed 58 articles through
concept analysis and identified attributes, antecedence,
consequences and empirical references. The attributes were
“nurse competent performance, met nursing care needs, good
experiences of care, good leadership, staff characteristics,
preconditions of care, physical environment, progress of
nursing process, and cooperation with relatives”.
Antecedences were “nurse staffing, positive practice
environment, and shortage in number of nurses”.
Consequences were “patient safety, patient satisfaction,
nursing outcomes and nurse satisfaction”8.

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Methodology Table 1: Demographic Characteristics
Descriptive cross-sectional study was conducted at tertiary
Variables Frequency %
care public hospital Karachi, Pakistan since September 2017
to December 2017.All the staff Nurses working in cardiology Age 35.36* 9.12**
and cardiac surgery departments who had spent at least three Gender
months in institution and willing to participate were included
using convenient sampling technique. Male 16 36.36
An adopted questionnaire “Nurses’ perceptions and practices: Female 28 63.64
contributions to care quality” was used for data collection. It
is a Likert scale with four options; Never, Rarely, Often and Nursing Qualification
Always, consisted of 25 items categorized in seven RN 26 59.09
dimensions; Patient satisfaction, Health promotion,
BSN 18 40.91
Prevention of complications, Well-being and self-care,
Functional re-adaptation, Nursing care organization, MSN NIL 00.00
Responsibility and rigor. The tool is valid and reliable having Department
Crohncach’s alpha of 0.9409.
Permission was taken from Chief Nursing superintendent; Cardiac ward 10 22.73
thereafter proceed to the respective participants and CICU 08 18.18
explained objectives and purpose of the study then asked to
CCU 12 27.27
give consent in written form. After it, questionnaire forms
were distributed in participants and explained each point of Cardiac Surgery Ward 06 13.64
questionnaire for minimizing the error. Each form was Cardiac Surgery ICU 08 18.18
checked at the time of collection to make sure of their
completion on spot. Statistics/Data Analysis software Designation
(STATA), version 12.1 was used for data analysis. Head Nurse 03 6.82
Staff Nurse 41 93.18
Results
A total of 44 nurses participated in the study. With regard to Total Work Experience
demographic data of participants (Table 1), the mean age Less than one Year 02 4.55
(±SD) of the participants was 35.36 (±9.12) years. Majority of
participants were female (63.64%) while male were (36.36%), 1 – 5 years 10 22.73
there is a predominance of staff nurses (93.18%) whereas head 6 – 10 years 20 45.45
nurses were (6.82%). More than half (59.09 %) of the
11 – 15 years 04 9.09
participating nurses have Three Years Registered Nurse (RN)
qualification followed by Bachelors of Science(BSN) degree 16 – 20 years 02 4.55
(40.91%). with regards to department of work, most of the 21 years and above 06 13.64
respondents were from CCU (27.27%) after that Cardiac ward
(22.73%), CICU and Cardiac Surgery ICU (18.18%) and
Cardiac Surgery Ward (13.64%). when asked for work Mean age of participants*, Standard deviation of age**
experience, there is a high proportion of nurses (45.45 %)
having experience of six to ten years, (22.73%) have one to five In the results of the scale “Nurses’ perceptions and practices
years, (9.09%) have 11 to 15 years, (13.64%) have experience that contribute to quality care, within the dimension of
of 21 years and above, two nurses have less than one year (4.55 Patient satisfaction (Table 2) most participants replied Always
%) and two have 16 to 20 years’ experience (4.55%). (72.73%), followed by Often (13.64%), Rarely (9.09%) and
Never (4.55%) in response of “Nurses show respect for the
abilities, beliefs, values and desires of individual patient while
providing nursing care.” In activity “Nurses are constantly
seeking to show empathy in interactions with the patient”
(59.09%) replied Always, (22.73%) Often and (18.18%)
Rarely. In reaction of “Nurses involve significant cohabitants
of individual patient in the nursing care process” most
participants replied Rarely (63.64%) followed by Always
(18.18%), Often (9.09%) and Never (9.09%).

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Table 2: Patient Satisfaction

Patient Satisfaction Never Rarely Often Always Total

f % f % f % f % f %
“Nurses show respect for the abilities,
beliefs, values and desires of individual 02 4.55 04 9.09 06 13.64 32 72.73 44 100.0
patient”.

“Nurses are constantly seeking to show

empathy in interactions with the 00 00 08 18.18 10 22.73 26 59.09 44 100.0
patient”

“Nurses involve cohabitants of

individual patient in the nursing care 04 9.09 28 63.64 04 9.09 08 18.18 44 100.0
process”

Within context of dimension Health Promotion (Table 3),
most participants(68.18%) replied Rarely, followed by Often
(22.73%), Always (4.55%) and Never (4.55%) in response of
“Nurses identify the health situation of the population and the
resources of patient/family and community”.
In response of activity “Nurses use the hospitalization time to
promote healthy lifestyles”, majority replied Often (50 %),
then Rarely (27.27%), Always (18.18%) and Never (4.55%).
In reply of “Nurses provide information that generates
cognitive learning and new abilities in the patient”, most
participants responded Rarely (36.36%), after that Often and
Always (27.27%) and Never (9.09%).

Table 3: Health Promotion

Health Promotion Never Rarely Often Always Total

f % f % f % f % f %
“Nurses identify the health situation of
the population and the resources of 02 4.55 30 68.18 10 22.73 02 4.55 44 100.0
patient”.

“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 04 9.09 16 36.36 12 27.27 12 27.27 44 100.0
abilities in the patient”.

Within the dimension of Prevention of Complications (Table
4), majority of participants answered Rarely (40.91%),
followed by Often and Always (22.73%) and Never (13.64%)
in response of “Nurses identify potential problems of the
patient.” In the response of “Nurses prescribe and perform
interventions to prevent complications” most respondent
reacted Often
(45.45%) followed by Always (40.91%), Never (9.09%) and
Rarely (4.55%). Most nurses replied Often (40.91%) then
Always (31.82%), Rarely (22.73%) and Never (4.55%) in reply
of “Nurses evaluate the interventions that help prevent
problems or minimize undesirable effects.”

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Table 4: Prevention of Complications

Prevention of Complications Never Rarely Often Always Total

f % f % f % f % f %
“Nurses identify potential problems of
06 13.64 18 40.91 10 22.73 10 22.73 44 100.0
the patient”.

“Nurses prescribe and perform

04 9.09 02 4.55 20 45.45 18 40.91 44 100.0
interventions to prevent complica-
tions”.

“Nurses evaluate the interventions that

02 4.55 10 22.73 18 40.91 14 31.82 44 100.0
help prevent problems or minimize
undesirable effects.”

Regarding dimension Well-being and Self-care, most
participants replied Rarely (45.45%, after that Often (36.36%),
Always (13.64%) and Never (4.55%) in reply of “Nurses
identify patient’s problems that will help improve the patient’s
well-being and daily activities”. In the reply of “Nurses
prescribe and perform interventions that will help improve
the patient’s well-being and daily activities.” Half of
respondents answered Rarely (50.00%), following Often
(36.36%), Always (9.09%) and Never (4.55%).
Table 5: Well-beingand Self-care
In the answer of “Nurses evaluate the interventions that help
improve the patient’s well-being and daily activities”, most of
the nurses respond Often (45.45%), followed by Rarely
(36.36%), Never and Always (9.09%). In the response of
activity “Nurses address problematic situations identified that
will help improve the patient’s well-being and daily activities”,
there is predominance of reply Rarely (45.45%), after that
Often (22.73%), Always (18.18%) and Never (13.64%)

Well-being and Self-care Never Rarely Often Always Total

f % f % f % f % f %
“Nurses identify patient’s problems
that will help improve the patient’s 02 4.55 20 45.45 16 36.36 06 13.64 444 100.0
well-being and daily activities.”

“Nurses prescribe and perform

interventions that will help improve 2 4.55 22 50.00 16 36.36 4 9.09 44 100.0
the patient’s well-being and daily
activities.”

“Nurses evaluate the interventions that

help improve the patient’s well-being 4 9.09 16 36.36 20 45.45 04 9.09 44 100.0
and daily activities.”

“Nurses address problematic situations

identified that will help improve the 06 13.64 20 45.45 10 22.73 08 18.18 44 100.0
patient’s well-being and daily
activities.”

In the matter of Functional Readaptation dimension, more of “Nurses plan discharge of hospitalized patients in health
than half of participants reacted Always (54.55%) followed by institutions, according to each patient’s needs andcommunity
Often (36.36%) and Rarely (9.09%) in the reply of “Nurses resources”, most of the respondent replied Always (54.55%),
ensure continuity of nursing service provision”. In the answer then Rarely (22.73%), Often (13.64%) and Never (9.09%).

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In the response of “Nurses optimize the abilities of the patient
and his/her significant cohabitants to manage the prescribed
therapy”, most of the nurses answered Often (45.45%)
following Rarely (36.36%), Never (13.64%) and Always
(4.55%). In the activity “Nurses teach, instruct and train
Table 6: FunctionalReadaptation
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patients for their individual adaptation and teach, instruct
and train patientson what is required for their functional
readaptation”, most of participants reacted Always (40.91%)
then Often (27.27%), Rarely (18.18%) and Never (13.64%).

Functional Readaptatio Never Rarely Often Always Total

f % f % f % f % f %
“Nurses ensure continuity of nursing
00 00 04 49.09 16 36.36 24 54.55 44 100.0
service provision.”

“Nurses plan discharge of patients

according to each patient’s needs and
04 9.09 10 22.73 06 13.64 24 54.55 44 100.0
community resources.”

“Nurses optimize the abilities of the

patient and his/her cohabitants to
06 13.64 16 36.36 20 45.45 02 4.55 44 100.0
manage the prescribed therapy.”

“Nurses teach, instruct and train

patients for adaptation and teach,
06 13.64 08 18.18 12 27.27 18 40.91 44 100.0
instruct and train patients what is
required for functional readaptation.”

In regard to the Nursing Care Organization, there is a Regarding activity “Nurses know the hospital’s policies”, most
predominance of nurses who replied Always (72.73%), of the participants answered Always (63.64%) after that
followed by Often and Rarely (13.64%) in the response of Rarely (18.18 %), Often ( 13.64%) and Never (4.55%).
“Nurses know how to handle the nursing record system”.

Table 7: Nursing Care Organization

Nursing Care Organization Never Rarely Often Always Total

f % f % f % f % f %
“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

About Responsibility and Rigor dimension a high number of
the participants answered Often (45.45%) followed by Always
(36.36%) and Rarely (18.18%) in the response of “Nurses
show responsibility for the decisions they make and for the
acts they perform and delegate, aiming to prevent
complications”. In the answer to “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”,
majority of respondents reacted Often and Rarely (36.36%)
after that Always (22.73%) and Never (4.55%). In the response
of “Nurses show technical/scientific rigor in the
implementation of nursing interventions aiming to prevent
complications” most of the participants replied often and
always(40.91%) followed by rarely(18.18)

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Table 8: Responsibility and Rigor

Responsibility and Rigor Never Rarely Often Always Total

f % f % f % f % f %
“Nurses show responsibility for the
decisions they make and for the acts
00 00 08 18.18 20 45.45 216 36.36 44 100.0
they perform and delegate, aiming to
prevent complications.”

“Nurses show responsibility for the

decisions they make and for the acts
2 4.55 16 36.36 16 36.36 10 22.73 44 100.0
they perform and delegate, aiming to
ensure well-being and self-care of
patients.”

“Nurses show technical/scientific rigor

in the implementation of nursing
00 00 08 18.18 18 40.91 18 40.91 44 100.0
interventions aiming to prevent
complications.”

“Nurses show technical/scientific rigor

in the implementation of nursing
02 4.55 18 40.91 18 40.91 06 13.64 44 100.0
interventions that help improve the
patient’s well-being and daily
activities.”

“Nurses refer problematic situations to

other professionals, according to the
04 9.09 08 18.18 10 22.73 22 50.00 44 100.0
social mandates.”

“Nurses supervise the activities that

support nursing interventions and the
04 9.09 16 36.36 14 31.82 10 22.73 44 100.0
activities they delegate.”

Discussion individual patient while providing nursing care.” and “Nurses

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
education10 and recommended to increase qualified nurses in
specialized care units, but Abdul Rahman et al. do not agree
with their findings11. 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
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.12 Patients’
perceived their involvement in care seemed to be associated
with their attitudes about their illnesses and recovery and
preferred shared decision making 13.
About “Health Promotion dimension”, most of the nurses
answered Rarely in the statements “Nurses identify the health
situation of the population and the resources 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 Tronchin14,
majority of nurses replied Often, which is differ from
this study while most of the participants in this study

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67

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 promotion15. 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 mostly nurses Often
perform and evaluate intervention to prevent complication
but they have rarely able to Identify potential problems of the
patient. These finding are differ from the results of the
aforementioned study. According to American Nurses
Association, nurses must increase their efforts for
development and implementation nursing actions to support
promotion of health and prevention of disease/illness and
disability7. In 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. al14. 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 Readaptation”,
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
A LUMHS
expenses16.
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 Readaptation”; 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 days17. Most of the respondents
answered Rarely in the activities “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”, “Nurses show technical/scientific rigor in the
implementation of nursing interventions that help improve
the patient’s well-being and daily activities” and “Nurses
supervise the activities that support nursing interventions
and the activities they delegate.” Even after delegating activity,
it is the responsibility of the nurses to supervise subordinates
for patient safety and prevent unwanted outcomes. Nurses are
professionally and legally responsible for providing care,
decisions taken and its consequences18.

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