University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA, LEGON COLLEGE OF HEALTH SCIENCES SCHOOL OF NURSING FACTORS AFFECTING QUALITY NURSING CARE DELIVERY AT RIDGE HOSPITAL: PERSPECTIVES OF NURSES MICHAEL BOUR (10293447) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF SCIENCE DEGREE IN NURSING DECEMBER, 2014 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Mchael Bour do hereby declare that this dissertation is my original work under the supervision of Mrs. Adzo Kwashie. It is being submitted in partial fulfilment of the requirement for the award of Master of Science degree in Nursing. References made from other articles have been duly acknowledged. I further declare that this work has not been submitted either in part or wholly for the award of any degree in this or any other university. Michael Bour Date Student Adzo K washie (Mrs) Date Supervisor University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to my wife, parents, lecturers and colleagues for their love, encouragement and support during the study. 11 University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I am most grateful to the Almighty God for His guidance, protection and the strength He granted me to carry out this study. My appreciation also goes to all the nurses at Ridge Hospital who took part in this study. My heart-felt gratitude also goes to my supervisor Mrs. Adzo Kwashie of School of Nursing, University of Ghana, for her supervision, encouragement and constructive criticism which enabled me to finish this work. My appreciation also goes to Dr. Lydia Aziato for her constant inspiring words during my study. Special thanks goes to the Dean and the staff of School of Nursing for the diverse roles played in ensuring that this work was completed and submitted on time. 111 University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS ITEM PAGE Declaration Dedication 11 Acknowledgement 111 Table of Contents IV List of figures V111 List of tables IX List of abbreviations X Abstract Xl Chapter One: Introduction 1 1.1 Background 1 1.2 Problem Statement 3 1.3 Purpose of the Study 4 1.4 Research Objectives 5 1.5 Research Questions 5 1.6 Significance of the Study 5 1.7 Definition of Terms 5 2.0 Chapter Two: Theoretical FrameworklLiterature Review 7 2.1 Theoretical framework: Donabedian's model of quality care 7 2.1.1 Application of Donab edi an' s model to nursing care 9 2.2 Literature Review 11 2.2.1 Quality Nursing Care 11 IV University of Ghana http://ugspace.ug.edu.gh 2.2.2 Structures which affect quality nursing care 12 2.2.3 Processes involved in Nursing Care 16 2.2.4 Nursing Care Outcomes 19 2.3 Measures to ensure nursing care 20 2.4 Summary 21 3.0 Chapter Three: Methodology 22 3.1 Research Design 22 3.2 Research Setting 22 3.3 Target Population 23 3.4 Sample Size and Sampling Technique 23 3.5 Data Collection Instrument 24 3.6 Pre-testing of Research Instrument 24 3.7 Data gathering Procedure 25 3.8 Data Analysis 26 3.9 Data Management 27 3.10 Methodological Rigour 27 3.11 Ethical Considerations 28 4.0 Chapter Four: Findings 29 4.1 Demographic data of participants 29 4.2 Themes and subthemes 30 4.2.1 Quality nursing care 32 4.2.2 Structural factors affecting nursing care 33 4.2.3 Process of nursing care 40 v University of Ghana http://ugspace.ug.edu.gh 4.2.4 Outcomes of Nursing Care 46 4.3 Summary 48 5.0 Chapter Five: Discussion 49 5.1 Meaning of quality nursing care to nurses 49 5.2 Structural factors affecting quality nursing care delivery 50 5.3 Processes involved in caring for patients 53 5.4 Outcomes of nursing care 56 Chapter Six: Summary, Implications, Limitations, Conclusion and Recommendations 57 6.1 Summary 57 6.2 Implication for Nursing 59 6.2.1 Nursing Practice 59 6.2.2 Nursing Education 60 6.2.3 Nursing Research 60 6.3 Limitations of the study 60 6.4 Conclusion 61 6.5 Recommendations 61 REFERENCES 63 APPENDICES Appendix A-Consent form 70 Appendix B- Interview Guide 74 Appendix C-SON approval letter 76 Appendix D-Ethical clearance from NMIMR 77 Appendix E-Ethical approval from GHS 78 VI University of Ghana http://ugspace.ug.edu.gh Appendix F -Permission from RHD-GARIRidge Hospital 79 Vll University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Donabedian's model of quality care 9 V111 University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Demographic characteristics of Participants 30 Table 2: Themes and subthemes 31 IX University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS AACN American Association of Critical-Care Nurses GAR Greater Accra Region GHS Ghana Health Service ICN International Confederation of Nurses 10M Institute of Medicine MOH Ministry of Health NHIS National Health Insurance Scheme NMIMR Noguchi Memorial Institute for Medical Research OPD Outpatient Department RHD Regional Health Directorate SON School of Nursing USA United States of America VALCO Volta Aluminium Company Limited x University of Ghana http://ugspace.ug.edu.gh ABSTRACT The factors affecting quality nursing care delivery from the perspective of nurses were explored at the Ridge Hospital. Ten nurses with two to fifteen years of working experiences were purposively sampled from the medical and surgical wards and interviewed using a semI structured interview guide after informed consent had been obtained from them. The interviews were audio tape recorded and transcribed verbatim. Additionally, data collected from participants were analysed using thematic content analysis approach adopting Donabedian's model of quality care as a framework. Quality nursing care was perceived by the nurses to mean care which is holistic, individualized and tailored to meet specific needs of patients. Findings of the study revealed that nurses in the hospital perform various activities; some of which include admission of patients, assessment of patients, educating patients on health matters, assisting patients with activities of daily living and communicating with colleagues and patients about patients' care. Nevertheless, it was observed that these nurses could not do much for patients because of several factors such as inadequate human resources, material resources and lack of motivational packages. It was therefore recommended that management should ensure that material and human resources are adequately available to facilitate quality nursing care delivery in the hospital. Also, clinical supervision in the hospital must be strengthened to ensure all round provision of quality nursing care. Xl University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION This chapter provides background information for the study, describes the purpose and the objectives of the study and outlines the research questions used in achieving the objectives of the study. It also discusses the significance of the study and defines the operational terms used in the study. 1.1 Background Nursing care, although vital in ensuring better patients' outcomes, is associated with many challenges (Ebrahimi, Namdar & Vahidi, 2012). An examination of the current health care system in the world reveals that nursing care in various health facilities is still not timely, efficient, and equitable to meet the complex and demanding needs of patients. Furthermore, health care errors continue to be at alarming rates, with almost 3 to 4 percent of in-patients suffering adversely as a result of poor nursing care (Hall, Moore & Barnsteiner, 2008). Healthcare quality in the United States of America (USA) for instance has in recent times been the subject of massive criticism. The Institute of Medicine (10M) in 2001 emphasized the need for improvement in patient safety and care quality. This was as a result of their research findings indicating that 98,000 hospital deaths occur annually in USA due to errors by health care providers (including nurses). They indicated that nursing care was directly related to improved patient outcomes and that nursing vigilance or nursing care quality always protected patients against health care errors (Burhans, 2008). In Ghana, anecdotal report has it that nursing care in various hospitals in the country continues to face some challenges irrespective of the consistent efforts by Ministry of Health 1 University of Ghana http://ugspace.ug.edu.gh and Ghana Health Service to ensure that quality care is not compromised. Quality nursing care delivery, according to some stakeholders, is sparsely rendered to patients with nurses citing the huge numbers of patients they have to take care of and unavailability of equipment as an excuse to deny them quality care. Some nurses also have the impression that quality nursing care is expensive and as such patients who demand more from them are either left ajar or abused verbally on the ward (Bannerman, Offei & Kyeremeh, 2004). Hughes (2008) contends that nurses behave this way because of poor leadership, failed standard operating procedures, breakdowns in communication among nurses and other health care providers, overlooking or ignoring individual fallibility, and losing track of objectives by nurse leaders. Molazem, Ahmadi, Mohammadi and Bolandparvaz (2011) are also of the view that nurses do not give out their best in caring for patients anymore due to poor working conditions, inadequate remuneration, poor recognition from management, and lack of required equipment in providing the necessary care to patients. Similarly, Rafii, Oskouie and Nikravesh (2007) believe that poor staffing and heavy workload results in decreased quality of nursing care and dissatisfaction of patients. They further assert that sometimes nurses' religious beliefs such as fear of divine retribution influence their caring behaviours in the presence of organizational pressures and cultural limitations; therefore it is important to carefully resolve the above mentioned problems if patients are to receive better care from nurses. Burhans and Alligood (2010) assert that although nurses spend more time with patients and provide care to them every day, their daily evaluation of this care is done without an understanding of what quality nursing care really means. They emphasized that 2 University of Ghana http://ugspace.ug.edu.gh patient care outcomes can only improve when quality nursing care becomes meaningful and relevant to nurses. It is therefore important to appreciate the effect of nursing interventions on the quality care processes and on patient outcomes so that evidence-based staffing plans and patient care outcomes can be optimized. Additionally, Draper, Felland, Liebhaber and Melichar (2008) in their study also concluded that gaining a more in-depth understanding of the role nurses play in quality improvement and the challenges they face can provide important insights about how hospitals can optimize resources to improve patient care quality. Lynn, McMillen and Sidani (2007) on the other hand believe that without knowing nurses' perspectives of the factors affecting quality care, care delivered to patients will always be incomplete and ineffective. Available data on the internet and in reviewed journals indicate that no study in Ghana has ever evaluated factors affecting quality nursing care from the perspectives of nurses. Most of the studies assessing quality nursing care in the country are all on patients' perspectives. It is therefore against this background that this study seeks to explore the factors affecting quality nursing care delivery at the Ridge Hospital from the perspectives of nurses using Donabedian's model of quality care as an organizing framework. 1.2 Problem statement Despite all the efforts by the Ministry of Health (MOH), Ghana Health Service (GHS), donor funding agencies and all other stakeholders of health to improve quality health care delivery in Ghana, it is perceived by the public that services rendered in the country by nurses in areas of care and treatment is unsatisfactory (Donkor & Andrews, 2011). Additionally, nurses in the country are perceived by the public as being incompetent and unfriendly as much as patient care is concerned. This perception however, is carried on 3 University of Ghana http://ugspace.ug.edu.gh various media platforms such as radio and television almost on daily basis. Bannerman, Offei and Kyeremeh (2004) contend that the delivery of poor nursing care or the display of unprofessional attitude by some nurses have caused patients to lose trust in the entire nursing profession in Ghana and as such do not appreciate the efforts of hardworking ones. This perceived unprofessional conduct by some nurses was also confirmed by Anas Aremeyaw (an investigative journalist) in an investigative exercise carried out at the Accra Psychiatric Hospital in 2009. In his report, he indicated that some nurses left the wards unceremoniously to attend to their own personal needs and never bothered so much about the needs of patients. Besides, items meant for the up keep of patients in the hospital were taken and used by these nurses without the patients benefiting from them. Anas further indicated that some of the nurses yelled at patients in their distressful moments; causing these patients more discomfort. He admitted that although the attitude of some patients were not the best, the nurses who were on the various wards of the hospital could not do much for the patients due to unavailability of the requisite resources needed to care for these patients. These issues above therefore prompted this study to ascertain from nurses the factors affecting quality nursing care delivery at the Ridge Hospital. 1.3 Purpose of Study The purpose of this study was to explore and describe the factors which affect quality nursing care delivery at Ridge Hospital from the perspective of nurses. 4 University of Ghana http://ugspace.ug.edu.gh 1.4 Research Objectives The objectives of the study were to: 1. Ascertain what quality nursing care means to nurses in the hospital. 2. Describe the structural factors which affect quality nursing care provision in the hospital. 3. Identify the processes involved in caring for patients in the hospital. 4. Describe the outcomes of the nursing care provided to patients. 1.5 Research Questions 1. What does quality nursing care mean to nurses? 2. What are the processes involved in caring for patients in the hospital? 3. What are the outcomes of the nursing care given to patients? 4. What are the structural factors which affect quality nursing care provIsIon in the hospital? 1.6 Significance of the Study Knowledge of the factors affecting quality nursing care may potentially further define the nursing discipline, facilitate practice changes and ensure better care to patients by nurses. Furthermore, nurses may be able to use findings of this study to inform their own practice and in evaluating the quality of nursing care delivered by themselves to patients at all times. Findings may also encourage policy makers in the establishment of effective quality improvement programs for nursing care in various hospitals in the country. 1. 7 Definition of terms Factors: These refer to structural, procedural and outcome elements within the hospital which impact on the care of patients. 5 University of Ghana http://ugspace.ug.edu.gh Nurse: A Registered General Nurse licensed by the Nursing and Midwifery Council of Ghana to practise nursing. Perception: This refers to the views and experiences of nurses. 6 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO THEORETICAL FRAMEWORKILITERATURE REVIEW This chapter contains reviewed literature on the research topic. It further gives an account of Donab ed ian's model of quality care which was adopted and used as an organizing framework for this study. 2.1 Theoretical Framework: Donabedian's Model of Quality Care Donabedian's model of quality care was introduced in 1966 and has since been a leading conceptual framework in the evaluation of health care quality in various health care settings (IsseI & Bekemeier, 2010). According to the model, one could assess whether quality care is delivered in hospitals by examining the structure of the setting in which care is provided, by measuring the actual process of care, and or by assessing what the outcomes of care are (Donabedian, 1966). Donabedian defined structure as "the adequacy of facilities and equipment; the qualifications of the providers of care and their organization; the administrative structure and operations of programs and institutions providing care; fiscal organization, and the like" (Donabedian, 2005, p. 695). According to the model, the concept of structure includes the human, physical, and financial resources that are needed to provide medical care. The term also encompasses the number, distribution, and qualifications of professional personnel; the available equipment and technology; and the geographic location of the facility (Donabedian, 1980). Structure also includes the various modes through which people access care in a community. 7 University of Ghana http://ugspace.ug.edu.gh Care processes are activities that occur within and between health care practitioners and the target population they serve (Donabedian, 1980). Donabedian defined care processes as "the appropriateness, completeness, and redundancy of information obtained through clinical history, physical examination, and diagnostic tests; justification of diagnosis and therapy; technical competence in the performance of diagnostic and therapeutic procedures, including surgery; evidence of preventive management in health and illness; coordination and continuity of care; acceptability of care to the recipient and so on" (Donabedian, 2005, p. 694). Outcomes on the other hand, are changes in the health, knowledge, behavior, and satisfaction of the target population that can be attributed to antecedent health care (Donabedian, 1980). They are the definitive validator of the effectiveness and quality of health care, which may include improvements in social, physical, and psychological function; patient attitudes and satisfaction; and health-related behavioral change (Donabedian, 2005). The model (as shown in figure 1 on page 2) shows that structures, processes and outcomes are interdependent. In other words, there is a causal connection between the three components of his model and each dimension has to be linked together in order to understand the concept of quality nursing care (Donabedian, 2005). 8 University of Ghana http://ugspace.ug.edu.gh Figure 1: Donabedian's model of quality care STRUCTURE PROCESS OUTCOME Things that have to be Activities that occur within and End result of care. available for care to be between health care practitioners • Patient satisfaction provided. and patients. • Death Hospital setting or design • Providing care • Quality of life Human resource • Communication • Readmission to hospital Financial resource • Exchange of information • Adverse events Material and Equipment • Health education Incentives • Display of competency and Protocols and operating skills by the care provider standards Organizational structure 2.1.1 Application of Donabedian model to nursing care Donabedian's model, according to Kunaviktikul, Anders, Srisuphan, Chontawan, Nuntasupawat and Purnarpom (2001), has been used in many of quality improvement studies and has gained a lot of recognition for its three concepts of structure, process and outcome and how these relate to nursing care. Structure deals with all the things which must be in place for nurses to render care to patients. This includes adequate equipment and material resources (such as sphygmomanometer, thermometers, glucometer, forceps, syringes, gauze cotton wool and others), human resource (adequate nursing staff and staff mix), positive hospital environment, clinical protocols or procedure manuals, better conditions of service packages (incentives, opportunity for professional development, good remuneration and 9 University of Ghana http://ugspace.ug.edu.gh others) and effective and efficient nursing management system (Kunaviktikul et aI, (2001) and Sibotshiwe, 2009). Katz and Green (1997) define process as what nurses do and how these impact on the health of patients. The Institute of Medicine (2001) believe that nurses make major health care contributions by assessing, planning, and evaluating patient care needs; delivering treatments and medications; advocating for patients; and assuring their comfort. Similarly, Gordon and Nelson (2005) believe that nurses are responsible for protecting patients from the risks and consequences of illness, disability, and infirmity, as well as from the risks and consequences of the treatment of illness. Nurses are responsible for assisting patients with activities of daily living and strive to achieve the best possible quality of life for their patients, regardless of disease or disability and are central when it comes to patients' care. Kunaviktikul et aI, (2001) also contend that the nursing care process entails the usage of nursing care plan, nursing practice, completion of incident reports, human relationship and communication skills, and competency. Process also entails documentation of nursing activities (Sibotshiwe, 2009). According to Kunaviktikul et aI, (2001), outcome refers to the effects of nursing care on patients' health which could either be positive or negative. Some of the positive nursing care outcomes include patient recovery and patient satisfaction. Negative nursing care outcomes also include death of patients and complications such as would infections. 10 University of Ghana http://ugspace.ug.edu.gh 2.2 Review of Literature 2.2.1 Quality Nursing Care According to Burhans and Alligood (2010), knowledge of the meaning of quality nursing care is essential in refining the discipline of nursing and to facilitate practice changes; driving improvements in quality care and patient outcomes. They added that quality nursing care is the degree of health outcomes by delivery of efficient, effective and cost benefit health services to patients. A study by Kunaviktikul et al (2001) indicated that quality nursing care is how nurses respond to the physical, psychological, social, emotional and spiritual needs of the patients. Patients always see care which is not in line with their needs as not being of quality. Hall, Moore and Barnsteiner (2008) believe that meeting the needs of patients should be one of the key objectives of nurses since patients are always and more concerned about their needs. Kapborg and Bertero (2003) also argued that when nurses show empathy, understand and are available to listen to patients, the patients felt cared for. They added that quality care was seen as showing concern for patients' individual needs. Asadi-Lari, Packham and Gray (2003) equally indicated that understanding the needs of patients and meeting them is one of the major objectives of nursing profession for achieving efficient care for the patients. The Institute of Medicine (2001) views quality nursing care as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent professional standard. Charalambous and Papastavrou (2006) indicated that quality nursing care is the provision of holistic care to patients with the appropriate means from skillful and experienced nurses in a way that patients feel secure and their dignity is protected. 11 University of Ghana http://ugspace.ug.edu.gh 2.2.2 Structures that affect quality nursing care Donabedian (2005) believed strongly in the importance of health-care structure, seeing it as a driving force for later care processes and ultimately for health outcomes. He saw structure to be the things which must be in place for care to be rendered. According to him structure includes the human, physical, and financial resources that are needed to provide medical care. He added that it also entails the care settings and the availability of equipment and technology to care for the sick. According to Donabedian effective organizational capabilities, such as leadership, human capital, information management systems and group dynamics (such as culture and incentive systems), are essential structural elements of quality improvement in a health-care organization and serve as the primary catalysts for process change. Miller and Haleem (2008) assert that conflicting values, staff shortage resulting in undesirable nurse-to-patient ratios, role ambiguity, lack of recognition from management and society, limited equipment and medications, and poor professional relationships among nurses and other health care providers affect the delivery of quality nursing care to patients. The unavailability of these structures makes it difficult for nurses to carry out their professional mandates. The first structure to consider is the care setting. An organized delivery systems according to Shortell and Hull (1996), provide more cost-effective, more accessible and quality care. They are associated with increased organizational performance and higher levels of inpatient productivity and greater total system revenue and cash flow. They added that the nursing practice environment is seen as an organizational characteristic that can either facilitate or constrain professional nursing practice. Changes to the nurses' work environment need to focus on enabling and supporting nurses to provide high-quality and safe care. Aiken 12 University of Ghana http://ugspace.ug.edu.gh and Patrician (2000) similarly reported that the presence of professional environment IS linked with high quality nursing care. Finfgeld-Connett (2008) also indicated that a work environment conducive for caring is vital in nursing patients. Heath, Johnson and Blake (2004) added that in healthy work environments, nurses feel valued by their organization, have standardized processes in place, have staff empowerment, have strong leadership, feel a sense of community, and recognize that strategic decision-making authority influence how their units run and how scarce resources are disseminated. Healthy work environments are places where safe and high-quality nursing care is expected and rewarded. Healthy work environments also foster effective communication, collaborative relationships, and promote decision making among all nurses. Unhealthy work environments on the other hand can have adverse consequences on the quality of care delivered as well as nurses' intention to leave the profession. A positive work environment is one that supports nurses' autonomy and control over the work environment, including shared governance or decision making. It is an environment with strong and visible nursing leadership, organizational support, peer support, and positive physician collaboration (Kramer, Schmalenberg, & Maguire, 2004). It is believed that lack of appropriate relationship between nurses and physicians brings about unhealthy work environments and poor outcomes for patients (Larson, 1999: Molazem, Ahmadi, Mohammadi & Bolandparvaz, 2011). Lake (2002) also indicated that nurses expenence greater professional fulfillment when strategies are implemented to promote autonomous practice environments, provide financial incentives, and recognize their professional status. Additionally, Aiken, Clarke, Sloane, Lake and Cheney (2008) believe care environment 13 University of Ghana http://ugspace.ug.edu.gh elements must be optimized alongside nurse staffing and education to achieve high quality of care. Another important structure to be considered is the nurse managers' leadership style in the hospitals. This is believed to have a significant impact on the performance outcomes of junior nurses. According to Booyens (2008), leadership competencies include the ability to build staff s capacity to perform at a high level through constructive feedback and development. Roussel and Swansburg (2009) also indicated that monitoring of performance by management is a good leadership quality which enhances commitment and productivity. Best and Thurston (2004) reported that when nurses have limited say in patient care they feel their expertise is not valued and this in tum lowers their commitment in caring for patients in their charge. According to Hagbaghery, Salsali and Ahmadi (2004), most nurses lack power to make decisions regarding care and as a result medical doctors have capitalized on this weakness of nurses to assume lead roles when it comes to patients care. Involvement of nurses in improvement efforts may lead to a more positive perception of their work environment and may also lead to higher levels of patient satisfaction. They believe that improvement of care systems by nurses satisfies their natural desire to feel useful and creative, and to work as part of a team contributing to a larger purpose (Hall, Moore, & Bamsteiner, 2008). This was confirmed by Kroposki and Alexander (2006) who also reported that higher patient satisfaction scores were more likely in health facilities where nurses and their leaders have good working relationships; opportunity for shared decision making is present and formalization of organizational and professional guidelines exist. 14 University of Ghana http://ugspace.ug.edu.gh Human resource is also one of the structural factors perceived to affect quality care delivery. According to Tourangeau, Cranle and Jeffs (2006), adequate staffing and staff mix is associated with fewer complications and lower mortality. Consequently, staffing shortages increase nurses' stress, increases their workload, and adversely impact patient outcomes (The American Association of Critical-Care Nurses-AACCN, 2005). According to Irurita (1999), most public hospitals tend to have high patient tum overs with limited number of nurses and as such these nurses are unable to provide the needs of their patients. Irurita added further that being short staffed inhibits the quality of care given to patients. It also limits the availability of time for nurses to care for each patient. Although health aides are on the ward to assist nurses, they are less knowledge and cannot easily understand and meet the current demands of patients (Aiken, Clarke, Cheung, Sloane and Silber, 2003). Availability of nursing care protocols is another structural factor deemed to affect the delivery of quality nursing care in various health institutions. Nursing care protocols are rules that specifically guide nurses on how to carry out various activities which impact on the health of patients (Katz & Green 1997). These protocols clarify the way procedures are to be carried out by clearly defining requirements so that desired outcomes are achieved. They help nurses to provide care exactly as they are expected to do. It is believed that nursing care protocols or standards helps to demarcate the scope and content of quality care and provide a benchmark for assessing the quality of care. The availability of material and equipment is also an important structural factor in the delivery of quality care. The International Confederation of Nurses (2006) believes that when organisations fail to provide nurses with essential equipment, they are unable to accomplish their jobs for reasons beyond their control. Additionally, institutional deficiencies in supplies 15 University of Ghana http://ugspace.ug.edu.gh and suitable maintenance of equipment lead to progressive deterioration of health services and create work dissatisfaction among nurses which impacts on patients care. Meessen, Kashala and Musango (2007) also argue further that unavailability of equipment, searching for supplies and having to wait for medications are performance barriers which delay nursing care provision, hence resulting in poor nursing care outcomes. Availability of motivational packages for nurses is one essential structure to help nurses care adequately for patients. According to Ngussie (2012), the effectiveness of health quality is dependent upon the motivation of nurses by management. This assertion was also confirmed by the International Confederation of Nurses (2006). They added that worker performance clearly depends on the level of motivation. Availability of motivational packages stimulates nurses to come to work regularly, work diligently, be flexible and be willing to carry out tasks essential in patient recovery. Awases (2006) also observed that motivation such as recognition for nurses by hospital management and better remuneration seriously affected the performance of nurses in Namibia. She added that when nurses are duly recognized for their efforts, they are encouraged to do more for patients. 2.2.3. Processes involved in Nursing Care Donabedian (2005) argues that a variety of factors affect the processes of care and as such these factors together with the structural factors will indirectly result in the outcome of the care and service offered. As indicated earlier, process refers to the various activities by nurses which impact on patients' health (Katz & Green 1997). Nurses assess, plan and evaluate patients' care needs. They also deliver treatments and medications; advocate for patients, educate them on their 16 University of Ghana http://ugspace.ug.edu.gh disease conditions and ensure their comfort (Institute of Medicine, 2001). They are also responsible for assisting patients with activities of daily living and strive to achieve the best possible quality of life for their patients, regardless of disease and are central when it comes to patient's care (Gordon & Nelson, 2005). Procedures which require co-ordinated muscular action or psychomotor skills like wound dressing, lifting or turning patients are part of the process of nursing care. However, prioritizing of procedures according to patients' needs as well as listening to patients and communicating professionally with colleagues, other health care providers, patients and their relations are all important processes in the care of patients (Sibotshiwe, 2009). Ballard (2003) asserts that being able to identify the problems of patients is important m ensuring that patients receive necessary care for better outcomes. Similarly, Florin, Ehrenberg and Ehnfors (2005) also believe that the ability of a nurse to identify patients' problems accurately is an important prerequisite for planning and implementing individualized high quality nursing care. Nurses are also involved in the admission process of patients. Lane, Jackson, Odom, Cannella and Hinshaw (2009) observed in their study that a quality admission process is essential for safe and comprehensive care whereas delays in admission process of a patient leads to delay implementation of treatment and hence affect patients care outcomes. According to Rankin, Stallings and London (2005), it is the responsibility of nurses to educate their patients on their health. This patient's education is necessary to ensure improved understanding of medical condition, diagnosis, disease, or disability and is also vital in ensuring compliance or patients' motivation to comply with treatment regime and 17 University of Ghana http://ugspace.ug.edu.gh better patient outcomes. Besides, when patients are educated on their conditions, they are able to participate in their own treatment, improve outcomes, help identify errors before they occur, and reduce their length of stay on the ward. Rankin and his friends believe that lack of patient education leads to poor compliance and treatment failures. Korsah (2011) in a qualitative study of the interaction between nurses and patients using a semi-structured interview of nurses in a faith-based primary care hospital found out that communication mishaps affect the care given to patients by nurses. He argued that when nurses do not understand the language of the patient, it makes it quite difficult to understand certain things that the patient may wish to communicate to the nurse. As a result, the patient is unable to communicate her needs appropriately to the nurses for them to be addressed. According to Costa (2001), sometimes family caregivers may lose their temper and utter uncomfortable words to nurses owing to their (family caregivers) responsibility to the patient lying in the hospital. When this happens some nurses become offended and retract in caring for the patients. On the contrary, when nurses are spoken to calmly, they tend to pay enough attention to the needs of patients. Studies have also shown that a lack of appropriate relationship and communication between nurses and medical officers on the ward bring about unhealthy work environment and poor outcomes for patients (Larson, 1999: Molazem, Ahmadi, Mohammadi & Bolandparvaz, 2011). Documentation of nursing activities is also another activity performed by nurses. Good nursing documentation provides an accurate and honest account of what and when events occurred, as well as identify who provided the care. Documentation facilitates communication of patients' needs and care among nurses and ensures that nurses perform their duties accordingly (Perry & Porter, 2010). 18 University of Ghana http://ugspace.ug.edu.gh Letvak and Buck (2008) however believe that an increase in workload for nurses in various facilities result in increased absenteeism and a decrease in quality of care. According to Weisman (2007), a 10% increase in the number of patients assigned to a nurse leads to a 28% increase in adverse events such as infections, medication errors, and other injuries International Confederation of Nurses (2006) also argue further that a high percentages of nurses in Canada, the United States of America, the United Kingdom, and Sweden perceive excess workload for nurses or work pressures to be severe enough to affect patient care. According to them, in such circumstances nurses are unable to plan patients' care effectively and also are unable to meet all the needs of their patients. Malvarez and Siantz de Leon (2008) added further that the higher the workload on nurses the less quality the care will be because of the inadequate workforce. Lower nurse to patient ratios lead to complications and poorer patient outcomes since nurses may not be able to meet the needs of patients. A lack of fit between the work demand of nurses and what they can reasonably provide threatens their health and puts patients at risk. 2.2.4 Nursing Care Outcomes Nursing care outcome is the end-result of nursing care. Nursing care outcomes can either be positive or negative as perceived by nurses (Kunaviktikul et aI, 2001). Positive outcomes of nursing care include client satisfaction with total nursing care, patient comfort and safety, reduction in anxiety level, and patient recovery which enables him or her to carry out activities which hitherto could not be performed (Sibotshiwe, 2009). Negative nursing care outcomes on the other hand include falls of patients on the ward, medication errors resulting in adverse effects, death, and development of pressure sores as a result of nurses failing to turn patients in bed periodically (Dunton, Gajewski, Taunton, & Moore 2004). 19 University of Ghana http://ugspace.ug.edu.gh Hall, Moore, and Barnsteiner (2008) contend that when patients recover from ill- health, nurses become proud of themselves and are willing to do more. They indicated that patient care outcomes can improve through conscientious use of evidence-based practice guidelines, which include daily assessment of patients. They added further that by applying evidence-based therapies, nurses create safer environments with less risk or better outcome for patients. 2.3 Measures to ensure quality nursing care Attree (2001) believes that improving the quality of nursing care can change the public's image of nurses and their role in the delivery of care. To facilitate effective care, Burton, Fisher and Green (2009) suggest the promotion of teamwork which requires both appropriate organizational structures and processes but more importantly opportunities for development. The Institute of Medicine (2001) also believe that the safety and quality of care can improve by holding systems accountable, redesigning systems and processes to mitigate the effects of human factors, and using strategic improvements. Adequate and periodic supervision by nurse managers is vital to ensure that nurses do not do what they want. Nurses who are seen abusing the ethical code of the profession should be sanctioned accordingly. There should be an award scheme to encourage nurses to give their best for patients. Nurses ought to be given the opportunity to develop themselves academically and all equipment needed by nurses to work must also be provided. Regular in- service training is vital in bringing to remembrance the duties of nurses and rights of patients (Bannerman, Offei & Kyeremeh 2004). 20 University of Ghana http://ugspace.ug.edu.gh 2.4 Summary In summary quality nursing care is the responsibility of all nurses and it is vital in ensuring better patient outcome. Kramer and Schmalenbberg (2007) argue that the quality of nursing care meted out to patients in various hospitals is associated with various factors within systems, organizations, and work environments. These include environmental factors, human factors, social factors and psychological factors. Some stakeholders however are of the view that nurses can provide quality care if they have adequate knowledge and skills, enough resources (staff, drugs, supplies, equipment, transport and others), safe and as well as clean workplace among better conditions of work and recognition from management. They can do better if there is the opportunity to regularly improve themselves and are well rewarded for good work. 21 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY This chapter deals with the methodological approach used in meeting the objectives of the study. The scope of the methodology used in this research encompasses the design of the research study, research setting, target population, sample and sampling technique. It also includes data gathering tools, data gathering procedure, ethical clearance, and data analysis. 3.1 Research Design This study used a phenomenological approach. Phenomenology is the study of the essence of lived experiences. Phenomenological study attempts to discover and describe the lived experiences as explained by the person who has lived that phenomenon and usually relies on very small sample size; usually 10 or lesser (Carpenter, 2011). This study design was used because of the nature of the research question of interest to the researcher. Phenomenological explorative descriptive was considered more appropriate for this study since it enables a researcher to gain a richer understanding of, and insight into, a relatively new phenomenon, for which little or no research has been done (Brink & Wood, 2001). Additionally, the design was used since little is known about the perception of nurses on factors affecting quality nursing care in Ghana. 3.2 Research Setting The study area was Ridge Hospital. It is located along the castle road. It occupies a total land area of about 15.65 acres and falls within the Osu Clottey sub metro of the Greater Accra Region. The hospital includes the old district hospital opposite the Volta Aluminum Company Limited (V ALCO) Trust House in Accra and the Adabraka Polyclinic. It is a Ghana Health Service level 'A' facility and serves as a referral point for all district hospitals 22 University of Ghana http://ugspace.ug.edu.gh in the Greater Accra region. Additionally, it is a specialist hospital. It has 240 beds and its immediate catchments area includes Nima, Maamobi, Kanda, Accra New Town, Kotobabi, Osu, La, Adabraka, Achimota and Central Accra. The hospital has 479 nurses with qualifications in different specialties and provide a whole range of general and specialist services to people within and beyond its catchment area. The hospital provides both out- patient and in-patient services, however majority of the out-patient cases are seen at the Adabraka Polyclinic which is part of the hospital. It has a Computed Tomography Scan machine and other basic equipment necessary for providing care for all patients. An average of about 600 cases are seen every day at the Out Patients Department (OPD) in the hospital and out of these, some clients are admitted to the medical ward, surgical ward, paediatric ward, female ward, postnatal ward and maternity ward. The medical and surgical wards were used for the study because both wards receive and attend to more patients in the hospital. Moreover, both wards are closer to each other in terms of their location within the hospital. 3.3 Target Population The population for this study consisted of nurses working at Ridge Hospital. Inclusion Criteria: The inclusion criterion was nurses working on the medical and surgical wards with at least two years working experience at the hospital. Exclusion Criteria: The exclusion criteria were nurses who were on leave and those with less than two years working experience. Nurses who do not work on the medical and surgical wards were also excluded. 3.4 Sample size and sampling technique Nurses on the surgical and medical wards were selected purposively for the study and data saturation was achieved with the tenth (lOth) participant interviewed. A purposive 23 University of Ghana http://ugspace.ug.edu.gh sampling technique was used to select participants to satisfy the researcher's interest and to obtain answers for the specific objectives set for this study. According to Po lit and Hungler (1995), a purposive sampling technique facilitates the selection of appropriate participants with adequate information and exposure to the phenomenon under study to help answer the research questions for the study. It is useful for situations where sampling for proportionality is not the main concern. The study sought to elicit responses from nurses who work on medical and surgical wards and have been working in the hospital for at least two (2) years. This is because it is believed that nurses who have worked in the hospital for such number of years have adequate experience with patients' care. 3.5 Data Collection Instrument Research Instruments are measurement tools designed to obtain data on a topic of interest from research subjects. These tools include questionnaires and interview guide. Based on the qualitative nature of this study, a semi structured interview guide developed in accordance with the objectives of the study was used for the data collection. This was used as a guide to help the researcher know what question to ask and the sequence to ask these questions. The semi structured interview guide used for the study was made up of two parts. Part A dealt with the demographics of participants whereas part B contained the guiding questions. Appendix B gives details of the semi structured interview guide used for the study. The interview guide also had probes to ensure that the objectives of the study were fully covered. 3.6 Pre-testing of Research Instrument The interview guide was pre-tested using two nurses from the Adabraka Polyclinic. The polyclinic is part of Ridge Hospital and has a high turnover of patients. The pre-testing 24 University of Ghana http://ugspace.ug.edu.gh was necessary to help the researcher validate the various questions and to also make it more reliable and useful in obtaining the required responses in answering the research questions. The results of the pre-testing exercise helped the researcher and the researcher's supervisor to make necessary corrections to the initial interview guide. 3.7 Data Gathering Procedure Following clearance to conduct the study from the Institutional Review Board of the Noguchi Memorial Institute of the University of Ghana, Ghana Health Service Ethical Review Committee and the management of Ridge Hospital (as included in the appendix D, E and F respectively), the researcher went ahead to collect data. Participants for the study were approached individually and those who accepted to participate voluntarily had the nature and purpose of the study as well as confidentiality and right of withdrawal explained to them. Those who voluntarily accepted to partake in the study were also given a consent form to sign to confirm their participation in the study. Suitable date and time for the interview were sought from these participants and a face to face interview carried out accordingly with them. Each interview lasted between 16 and 45 minutes. A semi structured interview guide was used for all the interviews and the interview conducted by the researcher himself. The researcher listened attentively with keen interest and interrupted only when it was necessary in order to focus the attention of the participant on the phenomenon of interest. Participants' nonverbal communication and other behaviours were carefully documented as field notes. The data collection continued until saturation was attained. Recording of interview between the researcher and participants were also done using an audiotape with 25 University of Ghana http://ugspace.ug.edu.gh participants' consent. To ensure confidentiality and anonymity, no names or identifying information of the participants were written on the interview guide. 3.8 Data analysis The interviews were transcribed verbatim immediately after each interview and analysed concurrently with data collection. The data was analysed using thematic content analysis approach taking into consideration the research objectives and various components of Donabedian' s model of quality care. Content analysis is the analysis of the manifest and latent content of a body of communicated material (as a book or interviews) through a classification, tabulation, and evaluation of its key symbols and themes in order to ascertain its meaning and probable effect (Weber, 1985). The idea of the analysis is to classify words into much fewer content categories. The analysis started by identifying the units of meanings that could be extracted from the statements that are necessary to describe participants' experiences. Transcripts were read several times to make meaning out of the accounts rendered by the participants. Coding was then carried out and summarizing of various concepts also done. Codes with similar meanings were categorized, and a label chosen for each category. The transcripts were reviewed to validate the codes and categories. Analysis was finalized by identifying several themes which emerged to describe the factors affecting quality nursing care at Ridge hospital. The analysis was also supplemented by field notes which were taken during the interviews with participants. 26 University of Ghana http://ugspace.ug.edu.gh 3.9 Data Management Each participant's interview was kept in separate folders on researcher's laptop to facilitate easy retrieval by researcher. A password was also put on the researcher's computer and other electronic storage devices to ensure that no one accesses participants' details. Signed consent forms, field notes and recording tapes were kept under lock and key hoping to destroy them after five years. 3.10 Methodological Rigour In satisfying reliability of study, Issues such as credibility, dependability and confirmability were ensured. Credibility poses the questions of whether the explanation fits the description given by participants and whether the description is credible (Babbie, 2005). Credibility is demonstrated through a number of strategies. For example, member checks, peer debriefing, prolonged engagement, persistent observation and audit trails. Participants were contacted after data analysis and then given a full transcript of their respective coded interviews with a summary of the emergent themes to determine whether the codes and themes match their experiences. Prolonged engagement with the participants within the research field was undertaken to help the researcher to obtain the participants' trust and a better understanding of the study. Dependability on the other hand was achieved through a process of auditing. As a result, an audit trail was kept. Researcher ensured that the process of research was logical, traceable and clearly documented. 27 University of Ghana http://ugspace.ug.edu.gh Confirmability is concerned with establishing that data and interpretations of the findings are not as a result of the researcher's imagination, but are clearly derived from the data (Babbie, 2005). The data collected from the participants were transcribed verbatim and respondents contacted for further clarifications on statements which were not clear to the researcher. 3.11 Ethical Considerations Ethical approval was sought from the Institutional Review Board of the Noguchi Memorial Institute of the University of Ghana. Permission from Ghana Health Service and the management of Ridge Hospital was also sought after which participants were approached and the nature and purpose of the study as well as confidentiality and right of withdrawal were explained to them. Participants were informed about the fact the participation in the research is voluntary and they can also withdraw at any time. Those who voluntarily accepted to partake in the study were given a consent form to sign to confirm their participation in the study. The participants were assured of no harm associated with the study and all information collected was treated with utmost level of confidentially. To ensure anonymity, no names or identifying information of the participants were written on the interview guide. 28 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR FINDINGS This chapter presents the findings of the study carried out at the Ridge Hospital to answers the research questions. Following the analysis of data collected from ten interviews, a number of themes emerged. The chapter begins with the demographic data of participants and then findings under varying themes and subthemes. 4.1 Demographic data of participants The nurses involved in the study comprised nine (9) female nurses and one (1) male nurse aged between 24 years and 40 years. All the ten participants had clinical experience ranging from two (2) to fifteen (15) years. Nurses selected for the study included 4 Staff Nurses, 4 Senior Staff Nurses, 1 Nursing Officer and 1 Senior Nursing Officer. Please refer to table 1 on page 30 for details of the demographic data of participants. 29 University of Ghana http://ugspace.ug.edu.gh Table 1: Demographic data of participants Participant Ward Rank Years of working Sex experience 1 Surgical Staff Nurse 3 Female 2 Surgical Senior Staff Nurse 4 Female 3 Surgical Staff Nurse 3 Female 4 Surgical Staff Nurse 2 Female 5 Surgical Senior Staff Nurse 5 Male 6 Medical Nursing Officer 10 Female 7 Medical Staff Nurse 5 Female 8 Medical Senior Staff Nurse 6 Female 9 Medical Senior Staff Nurse 5 Female 10 Medical Senior Nursing 15 Female Officer Source: Researcher's field work, 2014 4.2 Themes The purpose of this research was to ascertain from the nurses at Ridge Hospital factors affecting quality nursing care provision. Analysis of the data collected was done taking into consideration the components of Donab ed ian's model of quality care: structure of nursing care, process of nursing care and outcomes of nursing care. The themes and subthemes which emerged can be seen in table 2: 30 University of Ghana http://ugspace.ug.edu.gh Table 2: Themes and Subthemes No. Theme Subtheme 1 Quality nursmg • Meeting the needs of patients care • Identifying the problems of patients and addressing them 2 Structural factors • Nurse staffing affecting care • Availability of equipment and material resources • Availability of motivational packages for nurses • Availability of care protocols • Layout or set up of the hospital 3 Processes of • Assessment of patients nursmg care • Admission of patients • Planning patients' care • Assisting patients with the performance of activities of daily living • Providing health education to patients • Communication 4 Outcomes of • Positive nursing care outcomes nursmg care • Negative nursing care outcomes Source: Researcher's field work, 2014 31 University of Ghana http://ugspace.ug.edu.gh 4.2.1 QUALITY NURSING CARE The nurses were asked to state what quality nursing care means to them. They gave various explanations of what they believe constitute quality nursing care. The subthemes which emerged were 'meeting the needs ofp atients' and 'identifYing the problems ofp atients and addressing them' . Meeting the needs ofp atients Meeting patients' needs according to participants involves paying attention to what it is that the patient needs. The nurses expressed the fact that each person is a unique individual and therefore differs from another person. Quality nursing care is therefore provided when a nurse is able to identify specifically what a patient needs and is able to meet these needs; be it physical, psychological, social or spiritual needs. Two of the nurses expressed it as follows: "Quality nursing care is providing total care to meet the needs ofp atients. It is that care which meets the physical, psychological, emotional and social needs oft he patients" P 1. "Quality nursing care ensues when the physical, psychological, social and spiritual needs of patients are met using available resources" P8. IdentifYing patients' problems and addressing them Identifying patients' problems and addressing them was another attribute of quality nursing care expressed by the nurses. They reported that patients most of the time have 32 University of Ghana http://ugspace.ug.edu.gh problems and as such a nurse who is able to identify these problems and address them following laid down procedure is seen as providing quality nursing care. P6 and P3 clearly described quality nursing care in the following statements: "Quality nursing care is about finding out what problems the patient has and putting necessary measures in place to make him or her comfortable" P6. "Quality nursing care is provided when patients' problems are solved correctly at all times by ensuring that laid down evidenced based procedures are followed correctly" P3. 4.2.2 STRUCTURAL FACTORS AFFECTING NURSING CARE According to Donabedian's model of quality care, the structure deals with the things which must be available in a hospital before nurses can render quality care to patients. The nurses were asked to identify structural factors or things in their care settings which affect the care they give to patients. After analyzing the data collected from these nurses, the subthemes which emerged included nurse staffing, availability of equipment and material resources, availability of motivational packages for nurses, availability of protocols, and layout or set up of hospital. 33 University of Ghana http://ugspace.ug.edu.gh Nurse staffing One essential structural factor reported by the nurses to be affecting quality nursing care delivery in the hospital is nurse staffing. Participants reported that the number of nurses on the ward could have a positive or negative effect on the care provided to patients. The participants indicated that due to the introduction of the national health insurance scheme, the number of patients seeking care in the hospital and those who are admitted to the ward have gone up considerably. This has therefore made it difficult to care for patients since the number of nurses on the ward is inadequate to meet demands of this increasingly patient population. They added that they are unable to sometimes carry out basic nursing task for patients because of the increasingly patient population with limited nursing staff. They added that anytime, there are sufficient nurses to care for patients on the ward, they are able to do more for patients. The nurses also indicated that although there are health assistants on the ward to help them in caring for patients, they (health aides) do not have the requisite knowledge and skills needed to care for the patients and as such are unable to help meet the demands of patients. The nurses however indicated that the presence of adequate staff is important in providing quality care. Here are some comments from the participants: "So many people are admitted to the ward nowadays because of the introduction of the national health insurance scheme but we are unable to care for them since we are not many" PI "We are not many and as such are not able to monitor patients' vital signs consistently or give 34 University of Ghana http://ugspace.ug.edu.gh treatments on time. Anytime we have few patients on the ward, we are able to do more for them" P6. "We have health assistants who help us in caring for patients on the wards but they are unable to do much because of their level of knowledge" P8. "We can do better than we do now for patients if the number ofn urses is increased "PI O. Availability ofe quipment and material resources Another structural factor which participants perceived to affect nursing care delivery in the hospital is the availability of equipment and material resources. The participants asserted that things to care for patients on the ward are not available and as such they are unable to carry out some nursing responsibilities effectively. Some of the nurses reported that they sometimes have to borrow items from other wards to take care of patients. Other participants also indicated that sometimes patients' relations have to buy these items outside the hospital before treatment could commence. They added further that the unavailability of these items delay care, hence resulting in poor care outcome. Here are some of the statements of the participants: "Patients come to the OPD and are sometimes nursed on benches and in wheel chairs because of lack of trolleys and beds. 35 University of Ghana http://ugspace.ug.edu.gh Also, screens used to ensure privacy of patients are not available "P7. "We do not have suction machine, face mask, body thermometers, sphygmomanometers and oxygen so we sometimes go and borrow from other wards to take care ofp atients" P 2 " ... the things are not there to care for patients; therefore we have no choice than to wait for patients and their relations to buy them before they are used on them. Treatment starts early anytime things to care for patients are available" P8. Availability ofm otivational packages for nurses Another structural factor perceived by the participants to affect quality nursing care delivery is the availability of motivational packages for nurses. Participants acknowledged that motivation such as recognition of their effort of by management; provision of free medical care and opportunity for career advancement is necessary to encourage nurses to do more for patients. They added that unavailability of these motivational packages at Ridge hospital makes it difficult to give their best. Some also added that due to the unavailability of these packages, most of the nurses have left the hospital mounting more pressure on the very few nurses who have to struggle in caring for the huge patient population. These are what some nurses had to say: 36 University of Ghana http://ugspace.ug.edu.gh "There is no recognition from management when we peiform well, as a result many nurses have left Ridge Hospitaf' P 1. "We spend so much time to care for all these patients but when we fall sick management hardly visit us. Also, you are to pay for your own hospital bills if you have no NHIS card. How can we do more for patients when management cares less about us?" P4 "Obtaining study leave to upgrade one's self is a problem in the hospital and how can we perform well when our career advancement is a problem?" P8. Participants however indicated that they are on the ward to care for the sick because their reward is from God. "We are motivated by the fact that it is God who watches what we do and rewards us" P2 said. "Although people do not see and appreciate what we do, God sees it and rewards us" P7 added. 37 University of Ghana http://ugspace.ug.edu.gh Availability of care protocols Another structural factor which was elicited during the study is the availability of care protocols and institutional discipline. Nurses indicated that having a standard of care or protocols for caring for patients is important in ensuring that things are done rightly for patients. They nurses indicated that protocols for postoperative wound care, sugar control, hand washing, universal precautions and management of certain disease conditions are on the wards to guide nurses in what they do. According to the participants some of these protocols are in the form of books whereas other are written on card boards and pasted at the nurses' station. Here are some comments from some nurses: "We have a protocol for postoperative wound care on the ward and as such know exactly what to do for patients after surgery .... some of these protocols are in the form of books whereas others are written on card boards and pasted on the ward" P 1. "We know what we have to do or give when a patient reacts during blood transfusion. It is clearly pasted on the wall so that all can see" P5. "There is a sliding scale on the ward for managing blood sugars of patients on the ward ... this therefore helps us to know the 38 University of Ghana http://ugspace.ug.edu.gh amount of insulin to give at a particular times" P7. Layout or set up oft he hospital The study also revealed that the design of the wards and the hospital as a whole affect the care given to patients. It was reported by the nurses that the hospital and its wards are well-designed and makes it easier to locate the various units. This therefore saves nurses the frustration of moving from one place to the other caring for patients. Participants 7 and 10 had these to say: "The ward has two sides; female and wards units .... the treatment room is clearly marked and changing room for staff is also available. These make it easier for us to change, locate our patients and to move around freely whiles caring for our patients" P7. "The lab, x'ray unit and the pharmacy are close to the OPD so it is easy to move patients to these places for investigations requested and to also pick up patients' medications before they are moved to the ward" PI O. 39 University of Ghana http://ugspace.ug.edu.gh 4.2.3 PROCESS OF NURSING CARE According to the Donabedian's model, the process of nursing care deals with what nurses do. Nurses generally perform various activities in the hospital; however, after analyzing the data collected from participants, it was realized that nurses are involved in the assessment of patients, admission of patients, planning of patients' care, assisting patients in the performance of activities of daily living, providing health education for patients and communicating among themselves and between doctors and patients' relations about patients' care. Activities carried out by these nurses may either result in positive or negative care outcome. The nurses indicated that assessment of patients for example helps them to ascertain patients' problems and then plan their care accordingly. Planning of patients care also helps these nurses to perform nursing activities effectively; leading to better care outcomes. Assessment ofp atients According to the nurses, assessment of patients is done every day to ascertain their problems and also plan their care. It is done through observation, asking patients questions, physical examination and checking vital signs of patients. This is what some participants had to say: "Daily assessment of patients is done by asking patients questions or by observing them and this helps to identifY their day to day problems" P2. 40 University of Ghana http://ugspace.ug.edu.gh "Checking of patients' vital signs help us to know the initial status of our patients and also plan their care accordingly. .. " P8. Admission ofp atients As part of the process of providing nursing care to patients, nurses have to admit patients to the ward for treatment. The study revealed that nurses are involved actively in the admission process of patients by providing further explanation on the entire admission process and ensuring that all necessary items needed to make patients comfortable on the ward are in place. This is what some nurses had to say: "When a patient is to be admitted to the ward the nurse at the OPD first informs or explains the admission process to the patient so that the patient can take a decision "P2. "The doctor sees the patient in the consulting room and then writes requests for laboratory investigations. If the results of test demands admission, the admission procedure is explained to the patient before he or she is admitted to the ward .... the details of the patient with respect to age, sex and diagnosis are communicated to nurses on the ward so that the needed items are put in place to attend to the patient immediately and accordingly" P5. 41 University of Ghana http://ugspace.ug.edu.gh Planning patients' care Another activity performed by nurses in the process of caring for patients is planning patients' care. According to the nurses, planning of patients care is necessary to ensure better care outcomes. All nurses on the surgical ward indicated that care plan is drawn for patients admitted to that ward and this helps them to give systematic care to these patients. They also added that it helps them to know exactly what has to be done for a patient at a particular time; who has to do it and the necessary items needed in solving the patient's problem. This is what some nurses on the surgical ward had to say: "Care plan is drawn for all patients and this helps us to give systematic care to them" P 1. "Drawing care plan helps us to know what has been done for the patients, who did it and the next thing to do for the patient"P2 "Planning patients' care helps to prioritize patients' problems and then solve them accordingly with the needed resources" P4. " ... .i t ensures continuity ofc are" P5. Nurses on the medical ward however reported that although planning patients' care is important in ensuring a better care outcome, they are unable to use the nurses care plan due to increased workload on the ward and limited time factor. This is what participant 7 and 10 had to say: 42 University of Ghana http://ugspace.ug.edu.gh "We know we are to draw a care plan for every patient but because of the workload and limited time on the ward we are unable to do it" P7. "Drawing care plan is time consuming" PI O. Assisting patients with the performance of activities ofd aily living Another aspect of the process of nursing care is assisting patients m performing activities of daily living. The nurses acknowledged that because of ailment some patients are unable to perform activities of daily living (such as bathing, grooming, feeding among others) which they hitherto could have performed unaided. Thus, they are always there to assist these patients. The nurses added that helping patients in this manner makes them feel cared for and recover quickly. P3, P7 and PIO had these to say: "Most of the cases brought to this ward are unable to care for themselves so we assist them with feeding, bathing, grooming and walking" PIO. "We feed the unconscious patients through the nasogastric tube and also assist those who cannotfeed themselves "P7. "Some patients look so grateful when we are always there to assist them to bath, eat or walk around on the ward "P3. 43 University of Ghana http://ugspace.ug.edu.gh Providing health education to patients Another component of the process of nursing care reported by the participants is the provision of health education to patients on the ward. The study findings showed that nurses were involved in the provision of health education to patients on both medical and surgical wards. It was revealed by the nurses that patients are educated on various disease conditions and certain nursing interventions on the ward. According to these nurses, this is usually done to allay the anxieties of patients and to obtain their full cooperation during treatment. This is what some nurses had to say: "Patients going for surgery are always educated on their condition and the possible surgery they will be undertaking so that they do not become anxious" P 1. "We educate patients on various disease conditions and interventions so that they could comply with treatment"P7. A few nurses however indicated that although patients' education is important in patients' care, it is not done on regular basis due to increased workload on the ward. It is done as and when patients ask certain questions about their disease conditions or when patients are being discharged home. This is what some of the participants had to say: "Patient education is only done when the patient asks questions or when they are being discharged home" P9. 44 University of Ghana http://ugspace.ug.edu.gh "Normally, patients are educated on their condition and what to do when they are being discharged home" P6. "The patients are many and we are also few so we educate patients when they ask certain questions about their health" P 3 Communication As part of the process of providing nursmg care to patients, nurses communicate verbally or orally among themselves, with doctors and or with patients and their relations on issues concerning patients' care. The nurses added that effective communication helps them to appreciate the concerns of patients and address them accordingly. It also facilitates free flow of care information among them, with doctors and the patients. The nurses indicated that effective communication between them and doctors help to care more for patients. The study also revealed that nurses tum to pay attention to patients needs when both patients and their relations speak politely to them. This is what some participants had to say: "There is effictive communication between us and doctors ... we tell them of what we observe on patients or what the patients want them to know ... they also communicate verbally or orally with us about patients' care. " P5. 45 University of Ghana http://ugspace.ug.edu.gh "Every procedure carried out on patient is documented in the nurses' notes or communicated to colleagues orally to facilitate caring for patients ... changes in patients' care are also documented in the changes book to help colleagues appreciate what is to be done for the clients" P8. "Effective communication between patients and us helps us to appreciate their concerns ... when patients and their relations speak calmly to us we are encouraged to listen and do more for them" PIO. 4.2.4 OUTCOMES OF NURSING CARE The nurses were also asked to indicate the outcomes of the care they render to patients on the ward. The nurses reported that the outcomes of their care could either be positive or negative. Positive nursing care outcome The study revealed that most of the patients who were nursed on both medical and surgical wards got well and were discharged home looking so cheerful and thankful to the nurses. According to the nurses, anytime patients got well and were discharged home, they become happy and are encouraged to care or do more for other patients to ensure their recovery. One participant had this to say: 46 University of Ghana http://ugspace.ug.edu.gh "Most of our patients recover and are discharged home ... we become so happy and yearn to do more for other patients" P4. Participant 9 also had this to say: "We become so satisfied when we see our patients recover and go home ". Negative nursing care outcomes Negative nursing care outcomes were also reported by the nurses. According to the nurses poor nursing care outcomes makes them feel quite sad and demotivated. The study revealed that few patients develop complications such as wound infections and bed sores due to unavailability of requisite items for wound care and failure by some nurses to tum bedridden patients periodically in bed. Some nurses also reported that a few patients also die at times. These are the words of some participants: "Some unconscious patients develop bedsores because we are unable to turn them frequently in bed'P3. "Wound infections sometimes occur after surgery due to unavailability of sterile instruments and poor wound dressing techniques used by some nurses" P4. 47 University of Ghana http://ugspace.ug.edu.gh "Not all patients recover ... some of them die too. It is sometimes so demotivating to see a patient you have done much for die "P9. 4.3 SUMMARY The study revealed that quality nursing care is provided when a nurse is able to identify specifically patients' needs are and is able to meet these needs; be it physical, psychological, social or spiritual needs. Additionally, quality nursing care is the ability to identify patients' problems and address them appropriately. The study revealed that although the hospital is well set out, things to care for patients are not adequately available. Nurses lack basic equipment such as clinical body thermometers, sphygmomanometer, suction machines and the others. Findings revealed that nurses on both the medical and surgical wards were inadequate to care for the increased patients' flow to the hospital. Besides, the few nurses working in the hospital are not well motivated to care for patients. The study also revealed that nurses in the hospital carried out many activities such as assessment of patients, admitting patients, planning patients' care, providing health education for patients and communicating among themselves and with other colleagues about patients' care. According to the nurses, these activities performed by the nurses impact on patients' health either positively or negatively. Most of the patients recover and go home; however, a few of them also die after being nursed in the hospital. 48 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION This chapter discusses the various findings obtained from this study. The study sought to explore the perception of nurses at the Ridge Hospital on the factors affecting quality care nursing delivery. The discussions were carried out based on the objectives of the study. 5.1 MEANING OF QUALITY NURSING CARE TO NURSES Booyens (1998) indicated that the perception of the meaning of quality nursing care varies among health professionals. Burhans and Alligood (2010) also believe that knowledge of the meaning of quality nursing care is essential in refining the discipline of nursing and to facilitate practice changes; driving improvements in quality care and patient outcomes. Various explanations were given by nurses at Ridge Hospital on what they believe constitutes quality nursing care. The subthemes which emerged were: 'meeting the needs of patients' and 'identifYing problems ofp atients and addressing them '. Quality nursmg care was expressed by the nurses to mean meeting patients' physical, psychological, social and spiritual needs. The nurses expressed that each patient differs from another and as such quality nursing care is provided when a nurse is able to identify these needs and meet them using available resources. Kapborg and Bertero (2003) indicated that quality nursing care is expressed when patients' needs are met. According to Asadi-Lari, Packham and Gray (2003), understanding individual needs of patients and meeting them is one of the major objectives of nurses for achieving efficient care for patients. The finding of this present study is similar to what Kunaviktikul et al (2001) identified in 49 University of Ghana http://ugspace.ug.edu.gh their study. They reported that quality nursing care is the nurses' response to the physical, psychological, emotional, social and spiritual needs of patients provided in a caring manner so that the patients are cured, become healthy to live normal lives, and both patients and nurses are satisfied. Furthermore, this confirms the fact that when the needs of patients are duly met, both patient and nurses become satisfied. Another explanation perceived to be the meanmg of quality nursmg care is the identification of the problems of patients and addressing them following laid down procedures. This finding confirms what Ballard (2003) reported in her study. She indicated that the ability of a nurse to identify patients' problems is prerequisite for providing quality nursing care. Similarly, Florin, Ehrenberg and Ehnfors (2005) also indicated that quality nursing care cannot occur without identifying patients' problems, planning and implementing measures accordingly. From the two explanations provided by the nurses on the meaning of quality nursing care, it can therefore be said that quality nursing care is a nursing care which is holistic, individualized and tailored to meet specific needs of patients. 5.2 STRUCTURAL FACTORS AFFECTING NURSING CARE DELIVERY Nurses were asked to state structural factors which affect the provision of quality nursing care and the subthemes which came up were: nurse staffing, availability of equipment and material resources for care, availability of motivational packages for nurses, availability of care protocols and institutional discipline of care and layout or set up of the hospital. Structural factors are factors which must be in place to enable nurses to carry out various activities which impact on the health of patients. 50 University of Ghana http://ugspace.ug.edu.gh Ridge hospital has a clearly marked out physical structure (building). The nurses reported that the hospital set-up helps them to move freely from one unit to the other in an attempt to ensure that patients receive needed care. This finding supports what Aiken, Clarke, Sloane, Lake and Cheney (2008) expressed in their study. They indicated that a carefully designed care environment helps to achieve high quality of care. It facilitates the movement of nurses and other care providers and also ensures that things are done systematically. Findings of the study revealed that the number of nurses taking care of patients were inadequate. According to the nurses, the introduction of the national health insurance scheme has resulted in increased patients' demand and mounted so much pressure on them on the various wards. Consequently, nurses are often stressed out and are unable to effectively and efficiently care for patients. This finding therefore supports what Irurita reported in 1999; indicating that being short staffed inhibits the quality of care given to patients and also limits time available for nursing care delivery to each patients. Additionally, it confirms what the American Association of Critical-Care Nurses (2005) indicated: saying that nurse staffing shortages increase a nurse's stress, increases their workload, and adversely impact on patients' care outcomes. Although health assistants are on the ward to complement the efforts of the nurses, these people lack the requisite knowledge and skills necessary in caring for patients. This finding confirms what Aiken, Clarke, Cheung, Sloane and Silber (2003) found in their study. They reported that the current nature of the care patient receive is sub-optimal because the hospital wards are filled with health care aides who are less knowledgeable and cannot easily understand and meet the demands of patients. 51 University of Ghana http://ugspace.ug.edu.gh The participants in this study revealed that the wards lack basic equipment and other vital material resources needed in caring for patients. Some of these items include body thermometer, gauze, cotton wool, oxygen, face masks, suction tubes and many others. The nurses reported that because of the unavailability of the needed equipment and material resources on the wards, they are unable to effectively carry out certain nursing responsibilities needed for patients' recovery. The nurses again indicated that they sometimes have to go and borrow items from other wards or wait till some medications and items are bought by patients' relations before care could be provided. This finding confirms what the International Confederation of Nurses (lCN, 2006) expressed. ICN asserted that when organizations fail to provide nurses with essential equipment, they are unable to accomplish their jobs for reasons beyond their control. They added further that institutional deficiency in material resources, in supplies and suitable maintenance of equipment lead to progressive deterioration of health services and create work dissatisfaction among nurses which impacts on the care of patients. The finding of the study also confirms what Meessen, Kashala and Musango (2007) reported in their study. They stated that unavailability of equipment, searching for supplies and having to wait for medications are performance barriers which delay nursing care provision, hence leading to poor nursing care outcomes. The participants of the study also indicated that nurses on the medical and surgical wards are unable to do much for patients because they are not adequately motivated to provide effective care to patients. According to the nurses their efforts are not well appreciated by management and as such are not encouraged to do more for patients. There is no recognition for their hard work and those who would want to pursue further studies are also not granted the opportunity to do so. This finding confirms what International 52 University of Ghana http://ugspace.ug.edu.gh Confederation of Nurses (2006) reported in its work; that the performance of nurses clearly depends on the level of motivation they have at work. Availability of motivational package for nurses stimulate them to come to work regularly, work diligently, be flexible and be willing to carry out tasks expected from them. There were clinical protocols on the ward which help nurses in nursing patients. The nurses reported that the protocols are on the ward to guide them in the delivery of quality nursing care to patients. According to Leight (2002), the availability of care protocols on various wards is necessary to ensure that nurses do not deviate from the standards. It helps nurses to perform exactly as the hospital management expects from them. It is believed that nursing care standards helps to demarcate the scope and content of quality care and provide a benchmark for assessing the quality of care. 5.3 THE PROCESSES INVOLVED IN CARING FOR PATIENTS The process of nursing care deals with what nurses do and how these activities impact on the health their patients (Katz & Green, 1997). The study findings revealed that the process of nursing care in Ridge Hospital involves assessment of patients, admission of patients, planning of patients' care, assisting patients with activities of daily living, providing health education to patients, and communicating patients' care among nurses and between doctors and patients' relations. The study revealed that nurses in the hospital conduct regular assessment of patients and this facilitates effective planning of patients' care. Assessment of patients, according to the nurses is done through observation, asking of questions, physical examination and checking of vital signs. This finding supports the observation made by Hall, Moore and 53 University of Ghana http://ugspace.ug.edu.gh Barnsteiner (2008) in their study. They indicated that a conscientious daily assessment of patients is necessary for positive patients' care outcomess. According to the study, nurses playa significant role in the admission process of patients in the hospital. Nurses at the OPD provide patients with further explanation on the admission process to help them make an informed choice regarding care. Additionally, nurses on the ward also ensure that all necessary items needed to care for patients are in place to ensure that care is not delayed. This confirms what Lane, Jackson, Odom, Cannella and Hinshaw (2009) observed in their study that a quality admission process is essential for safe and comprehensive care and delays in admission of a patient into a ward can delay implementation of treatment and hence affect patients care outcomes. From the study, planning of patients care is carried out by nurses as part of the process of caring for patients and this is vital in giving systematic care to patients. The study indicated that usage of care plan was frequent on the surgical ward as compared to the medical ward. It was however, indicated by some nurses that planning of patients care is time consuming and could not be done because of increased workload on the wards. The nurses admitted that failure in planning patients care resulted in poor patient care; hence poor care outcomes. This finding is similar to that of International Confederation of Nurses (2006); who indicated that nurses are unable to plan and meet patients' needs effectively as a result of increased workload. It was revealed that nurses are always available to assist patients in the performance of activities such as bathing, feeding, grooming and others. When this happens, patients feel cared for and are always satisfied. This finding supports that of Gordon and Nelson (2005) 54 University of Ghana http://ugspace.ug.edu.gh who reported that patients are always happy and satisfied when they are helped by nurses to perform activities of daily living which they are unable to do by themselves. Patients' education was observed to be carried out on the ward by nurses and this according to the nurses helps to allay patients' anxieties and to also ensure the cooperation of patients during treatment or treatment compliance by patients. This finding is synonymous to that of Rankin, Stallings and London (2005) who observed that patient's education is necessary to ensure improved understanding of medical condition, diagnosis, disease, or disability and also compliance or patients' motivation to comply with treatment regime and better patient outcomes. Although nurses on the ward provide patient education, the study revealed that this education is not carried out on regular basis due to high workload and lack of time on the path of the nurse. This education is usually carried out when patients ask questions about their conditions or at the time of discharge. Rankin, Stallings and London (2005) again believe that the inability of nurses to educate patients on their conditions lead to non-compliance and treatment failures. Communication as a factor that affects quality nursmg care, IS important for providing effective care to patients (Costa, 2001). The participants in the study indicated that effective communication among nurses, doctors and patients ensured that accurate care is provided for patients. Additionally, effective communications on the ward ensures free flow of patients care information and also helps in addressing patients' concerns accordingly. Studies have shown that lack of appropriate relationship and communication between nurses and medical officers on the ward bring about unhealthy work environment and poor outcomes for patients (Larson, 1999: Molazem, Ahmadi, Mohammadi & Bolandparvaz, 2011). The study also revealed that nurses were more than willing to listen and attend to 55 University of Ghana http://ugspace.ug.edu.gh patients' needs promptly any time patients and their relations communicated well with them. This finding is similar to what Costa (2001) observed in his study, indicating that some nurses are motivated to perform when patients and their relations communicated effectively with them. 5.4 OUTCOMES OF NURSING CARE According to Attree (2002), nursing care affects patients' outcome positively or negatively. This is in line with what the study found: indicating that nursing care outcome can be positive or negative. From the study it was revealed that most of the patients nursed in the hospital recovered and went home gracefully. However, a few patients according to the nurses, develop wound infection and pressure sores due to unavailability of sterile materials and increased workload on the wards. More also, it was revealed that some of the patients still died after being cared for by the nurses. The nurses added that they are always satisfied and happy when their patients recovered and go home. This satisfaction motivates them to care more for their patients. On the contrary, they become sad or demotivated to do more when patients are unable to survive after doing their best to care for their clients 56 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX SUMMARY, IMPLICATIONS, LIMITATIONS, CONCLUSION, AND RECOMMENDATIONS This chapter presents the summary, implication, conclusion, and recommendations of the study, as well as the limitations encountered during the study. 6.1 Summary The factors affecting quality nursmg care from the perspective of nurses were explored at the Ridge Hospital. Ten nurses with two to fifteen years working experience were purposively sampled from the medical and surgical wards and interviewed using a semi structured interview guide after informed consent had been obtained from them. Face to face interviews with them were conducted at their convenience in English since it is the formal medium of communication among nurses in Ghana. The interviews were tape recorded and transcribed verbatim. Additionally, data from participants were analysed using thematic content analysis approach with Donabedian's model of quality care as a framework. The participants perceived quality nursing care as being able to identify patient needs (be it physical, psychological, social or spiritual needs) and being able to meet them accordingly. Additionally, the nurses perceived quality nursing care as the ability of a nurse to identify patients problems and address them appropriately following laid down protocol. Findings from the study revealed that nurses on both the medical and surgical wards are inadequate to care for the increased number of patients admitted to the wards. Although, there are health assistants to complement the efforts of nurses on the ward, these health aides do not possess the requisite knowledge and skills needed to effectively care for patients. As a 57 University of Ghana http://ugspace.ug.edu.gh result, the few nurses still have to struggle to meet the increasing demands of patients. With time these nurses become frustrated and are unable to provide quality care. Basic equipment such as suctioning machine, sphygmomanometer, clinical thermometers and other materials such as face mask, cotton wool rolls and many others are also not available; therefore making it difficult for the nurses to render quality care. The nurses also indicated they are reluctant to do more for patients because their efforts are not appreciated by management. This has also forced some of the nurses to leave the hospital; compounding on the human resource problem. The study findings also showed that there are protocols on the wards to guide nurses in the care of patients. These protocols ensure that nurses rendered the needed care necessary for patients' recovery. This set up of the wards and the hospital as a whole was also found to facilitate the delivery of quality care. The layout of the wards and the hospital makes it easier for nurses to move from one patient to the other; one department to the other to ensure that patients receive the needed attention. The study also revealed that nurses in the hospital carry out many activities such as assessment of patients, admitting patients, planning patients' care, providing health education for patients and communicating among themselves and with other colleagues about patients' care. According to the nurses, assessment is important in identifying the problems of patients on the ward and is done every day to help plan the care of patients effectively. Nurses playa major role in the admission process to ensure that all the necessary items needed to care for patients are provided sfor patients to receive prompt and efficient care. Planning of patients care is done but not on the medical wards due to staff shortage and limited time factor. The study findings also showed that provision of health education to patients was an essential component of patients' care and is necessary to ensure compliance of treatment by patients. 58 University of Ghana http://ugspace.ug.edu.gh More also, findings of the study revealed that nurses at Ridge hospital assisted patients in the performance of activities of daily living. Anytime this is done patients feel cared for. A word of appreciation from the patient is enough to encourage the nurses to do more. Effective communication was also seen to affect quality nursing care. The nurses indicated that effective communication between doctors and nurses create a conducive atmosphere for patients to receive accurate care. It was revealed that many patients normally get well and are discharged home after being cared for by the nurses on the ward. Nonetheless, a few patients develop complications such as wound infections and bed sores on the wards. Furthermore, some patients die sometimes. The nurses indicated that anytime a patient got better, they were happy however, anytime they lose a patient they feel sad and sometimes demotivated to do more on realizing that their hard work could not help the patient to recover. 6.2 Implications for Nursing 6.2.1 Nursing Practice Practising nurses could use these shared meanings of quality nursing care to inform their own practice and to evaluate the quality of nursing care delivered to patients. The findings of this study brought into focus certain issues which must be addressed in order to improve quality nursing care provision in Ghana. It was revealed that nurses on the wards are saddled with many workloads as a result of the increased number of patients being admitted to the ward. The patients are more to be care for but the nurses are few. An adequate nurse- patient ratio is necessary to ensure that patients receive holistic care on the ward. Additionally, nurses can provide quality care to patients when they are provided with the required material resources and are also well motivated. The findings also inform us that 59 University of Ghana http://ugspace.ug.edu.gh recognition of the efforts of nurses in the care of patients is a great management tool that nurse managers can rely on to get things done in clinical area by nurses. 6.2.2 Nursing Education The findings also bring to bear that improving nursing care quality in the hospital is the responsibility of all; including clinical nurses and nurse educators. From the study, it was revealed health assistants who complement nurses on the ward do not have the requisite knowledge and skills needed in ensuring quality nursing care and as such are unable to do much for the patients. Training and supervisin junior nurses and health assistants is important to ensure that work is properly done. Nurse educators would have to take a look at the curricula of nursing schools so that these health assistants could better understand their duties. 6.2.3 Nursing Research Further studies are required to ascertain the individual effects of structure and process on nursing care outcomes. More also, it is important to also carry out this study using a different setting or site to ascertain if the factors as found in this study would be the same. 6.3 Limitations of the study The findings of this research cannot be generalised due to the research design used. However, the findings of this study add to the body of knowledge of the perception of nurses on factors affecting quality nursing care at Ridge Hospital. 6.4 Conclusion From the study, quality nursing care was perceived to have two meanings. It is a nursing care which focuses on meeting the physical, psychological, social and spiritual needs 60 University of Ghana http://ugspace.ug.edu.gh of patients with available resources. The second meaning deduced from the findings is the ability of a nurse to identify patients' problems and addressed them taking into consideration laid down evidenced based procedures. Based on the findings of the study, quality nursing care can therefore be defined as care which is holistic, individualized and tailored to meet specific needs of patients. It can also be said that nurses cannot render quality care to patients when they do not have the necessary human and material resources needed to care for patients. To achieve positive nursing care outcomes, it is necessary for the hospital management to establish efficient structures needed for patients care. Unavailability of efficient and effective structural factors will prevent nurses from performing their responsibilities on the wards and this will in turn result in poor patient outcomes. From the various findings of this study, it can be concluded the factors affecting quality nursing care delivery at Ridge Hospital is similar to what was reviewed from various literature. 6.5 Recommendations Based on the findings of this study, the following recommendations have been made: 6.4.1 Recommendations to Ghana Health Service • Ghana Health Service should ensure that human and material resources such as essential equipment needed for caring for patients in various facilities are supplied to help nurses perform their duties. • There is the need to ensure adequate distribution of nurses to facilities where they are inadequate. 61 University of Ghana http://ugspace.ug.edu.gh • The regular conduct of clinical audits must be included m nursmg managers' performance indicators so as to hold them accountable. • Standardized nursing care guidelines should be developed and distributed to all nurses to help them provide needed care to patients. 6.4.2 Recommendation to Ridge Hospital • Clinical supervision must be strengthened on the ward to ensure compliance with standards. • Periodic in-service training for nurses is necessary to keep them updated with the changing needs or demands of patients. • Recognition is seen as a key factor that may enhance productivity and job satisfaction and eventually improve the performance of professional nurses. Therefore, it is recommended that strategies for acknowledging, recognizing and rewarding nurses on the ward should be developed and implemented by the hospital management. Management should recognise and acknowledge nurses who are doing a good job under difficult conditions and not only mention the bad attitudes of nurses. • An important aspect of improving performance is the effective leadership skills of managers. Nurse managers must periodically interact with nurses on the ward to ascertain what they do for patients. Nurse managers ought to ensure that subordinates are guided in what they do so that quality care is not compromised. • Management ought to ensure that material resources are duly utilized and equipment are maintained in the various units of the hospital. 62 University of Ghana http://ugspace.ug.edu.gh REFERENCE Aiken, L. H, Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H (2003). Educational levels of hospital nurses and surgical patient mortality. Journal oft he American Medical Association, 290(12), 1617-1623. Aiken L.H & Patrician P.A (2000) Measuring organizational traits of hospitals: the revised nursing work index. Nursing Research, 49(3), 146-153. Aiken L. H, Clarke S. P., Sloane D. M., Lake E. T., Cheney T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal ofN ursing Administration, 38(5):223-229. American Association of Critical-Care Nurses (2005). AACN standards for establishing and sustaining healthy work environments: a journey to excellence. American Journal of Critical Care, 14:187-197. Asadi-Lari, M., Packham, C. & Gray, D. (2003). Patients' satisfaction and quality of life in coronary artery disease. Health and Quality Life Outcomes, 1 :57 Attree, M. (2001). Patients' and relatives' experiences and perspectives of 'Good' and' Not so Good' quality care. Journal ofA dvance Nursing, 33: 456-66. Awases, M., H (2006).Factors Affecting Performance of Professional Nurses in Namibia.(Doctoral thesis) University of South Africa. Retrieved from: httplluir.unisa.ac.zaibitstreamI1 050012358111thesis.pdf on March, 20, 2014. Babbie, E. (2005). The Basics ofS ocial Research. 3rd edition. Wadsworth, Toronto: Canada. Ballard, K. (2003). "Patient Safety: A Shared Responsibility". Online Journal ofI ssues in Nursing, 8(3): 4. Bannerman, c., Offei, A, & Kyeremeh, G.K (2004). Health Care Quality Assurance Manual 63 University of Ghana http://ugspace.ug.edu.gh for Sub districts; Ghana Health Service. Best, M. & Thurston, E. (2004). Measuring nurse job satisfaction. Journal ofN ursing Administration, 34(6). 283-290. Booyens, S. W. (1998). Dimensions of Nursing Management. 2nd edition, Juta : Cape Town. Booyens, S.W., (2008), Introduction to health services management, 3rd edition, Juta : Cape Town. Brink, P. J. & Wood, M. J. (2001). Basic steps in planning research from question to proposal. 5th edition, Boston: Jones and Barlett publishers. Burhans, L. (2008). What is quality? Do we agree, and does it matter? Journal for Healthcare Quality, 29(1), 39-44, 54.1 28 Burhans, L. M. & Alligood, M. R (2010). Quality nursing care in the words of nurses. Journal ofA dvanced Nursing, 66(8), 1689-1697 Burton, C. R, Fisher, A, & Green, T. L. (2009). The organisational context of nursing care in stroke units: A case study approach. International Journal ofN ursing Studies, 46 (1),86-95. Carpenter, D. R (2011). Phenominological Research Methods. 5th edition. Wolters Kluwer HealthlLippincott Williamsand Wilkins: Philadelphia. Charalambous, A & Papastavrou, E. 2006. Nurses' and Patients 'satisfaction as quality indicators in Oncology Departments. Cyprus Nursing Chronicles 7(2), 14-34. Costa, M. J. (2001). The lived perioperative experience of ambulatory surgery patients. Association ofPerioperative Registered Nurses Journal, 74: 874-81. Donabedian, A (1966). Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly, 44(3), 166-203. 64 University of Ghana http://ugspace.ug.edu.gh Donabedian, A (1980). Explorations in quality assessment and monitoring: The definition of quality and approaches to its assessment. Ann Arbor, MI: The University of Michigan: Health Administration Press. Donabedian, A (2005). Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly, 83(4), 691-729. Donkor, N. T., & Andrews, L. D. (2011) Ethics, culture and nursing practice in Ghana. International Nursing Review. 58 (1),109-114. Draper, D. A, Felland, L.E., Liebhaber, & Melichar, L. (2008). The Role ofN urses in Hospital Quality Improvement, Retrieved at http://www.hschange.org/CONTENT/972/on June 26,2014. Dunton, N., Gajewski, B., Taunton, RL., Moore, J. (2004). "Nurse staffing and patient falls on acute care hospital units." Nursing Outlook, 52(1 ):53-50. Ebrahimi, H, Namdar, H, & Vahidi M., (2012).Quality of Nursing Care in Psychiatric Wards of University Hospitals in Northwest ofIran from the Perceptions of Nurses. Journal ofC aring Sciences. 1(2), 79-84 Finfgeld-Connett, D. (2008). Meta-synthesis of caring in nursing. Journal ofC linical Nursing, 17: 196-204. Florin J, Ehrenberg A & Ehnfors M. (2005). Patients' and nurses' perceptions of nursing problems in an acute care setting. Journal ofA dvanced Nursing, 51(2):140-9. Gordon, S, & Nelson S. (2005). An end to angels. American Journal ofN ursing, 105:62-69. Hagbaghery, A, Salsali, M, & Ahmadi, F. (2004). A qualitative study ofIranian nurses' understanding and experiences of professional power. Human Resource Health Journal, 2: 9. 65 University of Ghana http://ugspace.ug.edu.gh Hall, W.L, Moore, S. M., & Barnsteiner, lH. (2008). Quality and Nursing: Moving From a Concept to a Core Competency. Urological Nursing, 28(6):417-426. Heath, J, Johnson W, Blake N. (2004). Healthy work environments: a validation of the literature. Journal ofN ursing Administration, 34(11) 524-530. Hughes R. G., (2008). Patient safety and quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. lrurita, V, F. (1999). Factors affecting quality nursing care: the patients' perspective. International Journal ofN ursing practice, 5: 86-94. IsseI, L., & Bekemeier, B. (2010). Safe practice of population focused nursing care: Development ofa public health nursing concept. Nursing Outlook, 58(5),226-232. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21't century. Washington, DC: National Academy Press. International Confederation of Nurses (2006). Safe staffing saves lives information and action tool kit. Retrieved from the ICN Web site, http://www.icn.chlindkit2006.htm on July 1,2014. Kapborg, I. & Bertero, C. (2003). The phenomenon of caring from the novice student nurses' perspective: a qualitative content analysis. International Nursing Review, 50: 183-192. Katz, l M. & Green, E. (1997). Managing Quality. A Guide to System-Wide Performance Management in Healthcare. 2nd edition, St Louis: Mosby. Korsah, K.A., (2011). Nurses' stories about their interactions with patients at the Holy Family Hospital, Techiman, Ghana. Open Journal ofN ursing, 1: 1-9. Kramer, M, Schmalenberg, c., & Maguire, P. (2004). Essentials ofa Magnetic work 66 University of Ghana http://ugspace.ug.edu.gh environment: part 3. Nursing. 34(8):44-7. Kramer, M., & Schmalenberg, C. E. (2007). Best quality patient care: A historical perspective in magnet hospitals. Nursing Administration Quarterly, 29(3),275-287. Kroposki, M. & Alexander, J. W.(2006). Correlation among client satisfaction, nursing perception of outcomes, and organizational variables. Home Healthcare Nursing, 24(2):87-94. Kunaviktikul, W., Anders, RL., Srisuphan, W., Chontawan, R, Nuntasupawat, R & Pumarporn, O. (2001). Development of quality of nursing care in Thailand. Journal ofA dvanced Nursing, 36 (6)776-784. Lane, B., Jackson, J., Odom, S. E, Cannella, K. A, & Hinshaw, L. (2009) Nurse satisfaction and creation of an admission, discharge, and teaching nurse position. Journal of Nursing Care Quality, 29(2): 148-152. Larson E. (1999). The impact of physician nurse interaction on patient care. Holistic Nursing Practice, 13: 38-46. Leight, S. B. (2002). Starry Night: Using story to inform aesthetic knowing in women's health nursing. Journal ofA dvanced Nursing, 37 (1): 1 08-114. Letvak, S. & Buck, R, (2008). Factors influencing work productivity and intent to stay in nursing. Nursing Economics,s 26(3),159-165. Lynn, M. R, McMillen, B. J., & Sidani, S. (2007). Including the provider in the assessment of quality care: Development and testing of the nurses' assessment of quality scale - acute care version. Journal ofN ursing Care Quality, 22(4), 328-336. Malvarez, S., & Siantz, de Leon, M.L. (2008). Migration of Nurses: A Latin American Perspective. The Online Journal ofI ssues in Nursing; 13(2):2. Meessen, B., Kashala, J-P.I. & Musango, L., (2007). Output-based payment to boost staff 67 University of Ghana http://ugspace.ug.edu.gh productivity in public health centres: contracting in Kabutare district, Rwanda. Bulletin oft he World Health Organization 85 (2), 108-115. Miller, J. F & Haleem, D. (2008). Challenges to Good Work in Nursing: A Cross Cultural Comparison of Factors Influencing Quality of Care in a Health Related Profession. Annual Conference of the Global Awareness Society International; USA. Molazem, Z., Ahmadi, F., Mohammadi, E., & Bolandparvaz S. (2011). Improvement in the nursing care quality in general surgery wards: Iranian nurses' perceptions. Scandinavian Journal ofC aring Sciences, 25; 350-356. Ngussie, N. (2012). Relationship Between Rewards and Nurses' Work Motivation in Addis Ababa Hospitals. Ethiopian Journal ofH ealth Science, 22(2): 107-112. Perry, A. G. & Potter, P. A. (2010). Canadian fundamentals ofnursing. Toronto: Elsevier, Canada. Polit, D. F & Hungler, B. P. (1995). Nursing Research: Principles and Methods. 5th Edition. Philadelphia: J P Lippincott Company. Rafii, F., Oskouie, F. & Nikravesh, M. 2007. Caring behaviors of burn nurses and the related factors. Burns, 33(3):299-305 Rankin, S. H., Stallings, K. D., & London, F., (2005). Patient Education in Health and Illness. 5th ed. Philadelphia, P A: Lippincott. Roussel, L. & Swansburg, RC., (2009). Management and leadership for nurse administrators, 5th edition, Jones and Bartlett: Sudbury. Shortell, S. M. & Hull K. E. (1996). The new organization of the health care delivery system. Baxter Health Policy Review, 2:101-48. Sibotshiwe, E. (2009). Perception of nursing care received by in-patients at the Avenues 68 University of Ghana http://ugspace.ug.edu.gh Clinic (Harare in Zimbabwe): A descriptive study. University of South Africa. Tourangeau, A. E, Cranley, L. A, Jeffs, L. (2006) Impact of nursing on hospital patient mortality: a focused review and related policy implications. Quality and Safety Health Care. 15(1):4-8 Weber, RP. (1985). Basic Content Analysis. Beverly Hills, CA: Sage. Weisman, lS. (2007). Hospital Workload and Adverse Events. Medical Care, 45(5): 448- 454. 69 University of Ghana http://ugspace.ug.edu.gh APPENDIX A CONSENT FORM Title: Factors affecting quality nursing care at Ridge Hospital: Perspective of Nurses Principal Investigator: Michael Bour, Msc. Student School of Nursing, University of Ghana, Legon-Accra, Ghana Address: Ministry of Health P. O. BoxM44 Ministries, Accra. Tel: 0244450571 E-mail: bourgh2000@yahoo.com General Information about Research The aim of this research is to explore factors which affect the quality of nursing care at Ridge Hospital from the perspective of nurses. As part of the objectives, this study seeks to ascertain what quality nursing care means to nurses in the hospital; to identify the process or processes involved in caring for patients in the hospital, to identify outcomes of nursing care and to determine the structural factors which affect quality nursing in the hospital. It is purely for academic purpose and you reserve the right to withdraw from the study at any time but your participation is much valued and appreciated. A semi structured interview guide will be used to collect data and your participation in this study is expected to last for at least 30 minutes. You are humbly expected to give or provide adequate response vital in achieving the aim of this study. 70 University of Ghana http://ugspace.ug.edu.gh In order to be sure that you are informed about being in this research, you are to read this consent form carefully. Possible Risks and Discomforts It is not expected that you will sustain any injury by participating in this research. Possible Benefits Participating in this study would help you to appreciate collective nursing knowledge of the factors affecting quality nursing care. Nurses may be able to use findings of this study to inform their own practice and in evaluating the quality of nursing care delivered by themselves to patients. Confidentiality Every information gIven would be treated with the utmost level of confidentiality. Everything said will be kept secretly so that no one gets access to it. Your real identity will not be disclosed to anyone and any other information given by you; either written or recorded will be kept safely under lock and made only accessible to my supervisor. Compensation There will be no monetary compensation for your participation in this study. Voluntary Participation and Right to Leave the Research Your participation in this research is voluntary and you have the right to withdraw from the study at any point in time. Contacts for Additional Information You have the right to contact the following in case you have any question. 71 University of Ghana http://ugspace.ug.edu.gh Michael Bour School of Nursing, University of Ghana, Legon, Accra, Ghana Tel: 0244450571/0208930911 Email: bourgh2000@yahoo.com Mrs. Adzo Kwashie School of Nursing, University of Ghana, Legon, Accra, Ghana. Tel: 0244276317 Your rights as a Participant This research has been reviewed and approved by the Institutional Review Board of Noguchi Memorial Institute for Medical Research (NMIMR-IRB). If you have any questions about your rights as a research participant you can contact the IRB Office between the hours of 8am-5pm through the landline 0302916438 or email addresses: nirb@noguchi.mimcom.org VOLUNTEER AGREEMENT The above document describing the benefits, risks and procedures for the research title Factors affecting quality nursing care at Ridge Hospital: Perspective of Nurses has been read and explained to me. I have been given an opportunity to have any questions about the research answered to my satisfaction. I agree to participate as a volunteer. Date Name and signature or mark of volunteer 72 University of Ghana http://ugspace.ug.edu.gh If volunteers cannot read the form themselves, a witness must sign here: I was present while the benefits, risks and procedures were read to the volunteer. All questions were answered and the volunteer has agreed to take part in the research. Date Name and signature of witness I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the above individual. Date Name Signature of Person Who Obtained Consent 73 University of Ghana http://ugspace.ug.edu.gh APPENDIXB INTERVIEW GUIDE Part A: DEMOGRAPHIC DATA Ward ............................. . Rank. ............................. . Age ............................... . Numbers of years of work. .................... . Phone number of interviewee .............................. . Part B: QUESTIONS 1. How long have you been working on the ward? 2. How would you define quality nursing care? 3. Please tell me how patients access care in the hospital • Probe re: OPD care, Admission and Discharge 4. Please tell me about the activities you perform in caring for patients on the ward? • Patient assessment • Planning of care • Implementation of care • Patient educationlhealth promotion 5. How are you motivated to give better care to patients? 6. How do nurses engage in communication regarding patient care on the ward? • Probe re: relationship characteristics, professionalism 74 University of Ghana http://ugspace.ug.edu.gh 7. What do you think are important features of the care setting that contribute to quality nursing care? • Probe re: human resources, material resources (basic equipment), ward protocols or policies, nursing leadership etc. 8. What are the desired outcomes of each of these features? How do they influence total health and health related behaviour? 9. On the whole, what is or are the outcomes of the nursing care rendered to patients on the ward? 10. How do you feel about the care you give to patients? 11. Is there anything else you would like to add regarding quality nursing care? Starting time: ......................... . End Time ............................. . Thank you for taking the time to participate in this interview. 75 University of Ghana http://ugspace.ug.edu.gh APPENDIXC SCHOOL OF NURSING COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA LEGON Telephone: 021-513255 (Dean) P. O. Box LG 43 Ext. 6206 ) LEGON, GHANA 021-513250 Secretary 028953l2l3 Fax: 513255 E-mail: nursing@ug.edu.gh Our Ref .......... ~QN(A.J~. ..... ...... .. Apri l 22, 2014 Your Ref ........... " ........ ................... .. The Executive Secretary NMIMR -IRB P.O. Box LG 581 Univ. of Ghana Legon. Dear Sir/Madam, DEPARTMENTAL APPRO VA L LETTER MICHAEL BOUR This is to introduce to you Michael Bour, an M.Sc student of the above School and to inform the Institutional Review Board of the approval of the thesis topic: "Factors Affecting Quality Nursing Care at Ridge Hospital: Perspective of Nurses" by the department of Research, Education and Administration, School of Nursing. Counting on your usual co-operation. Thank you. Yours faithfully, Mrs. Adzo Kwashie SUPERVISOR 76 University of Ghana http://ugspace.ug.edu.gh APPENDIXD NOGUCHI MEMORIAL INSTITUTE FOR MEDICAL RESEARCH Established 1979 A Constituent of the College of Health Sciences University of Ghana INSTITUTIONAL REVIEW BOARD Phone: +233-302-916438 (Direct) Post Office Box LG 58 1 +233-289-522574 Legon, Accra Fax: +233-302-502182/513202 Ghana E-mai l: nirb@noguchi.mimcQmm:g Telex No: 2556 UGL GH 1\1) Ref. No: [)r.:?:? Your Ref. 0: 25 th June, 20 14 ETHICAL CLEARANCE FEDERALWIDE ASSURANCE FWA 00001824 IRB 00001276 NMIMR-IRB CPN 085/13-14 IORG 0000908 On 2S[h June 2014, the Noguchi Memorial Institute fo r Medical Research (NMIMR) Inst itutional Review Board ( IRS) at a full board meeting reviewed and approved your protocol tit led: TITLE OF PROTOCOL Facto rs affecting quality nursing care'llt Ridge Hospital: Perspective of Nurses PruNCIP AL INVESTIGATOR Michael Bour, MSc Cand o Plea e note that a fi na l review report mu t be su bmitted to the Soard at the comp letion of the study. Yo ur research records may be aud ited at any time dur ing or after the implementation. Any modification ofth is research project must be submitted to the IRB for review and approval prior to implementation. Please report all serious adverse events related to th is study to NMIMR-IRB within seven days verbally and fourteen days in writ ing. This certificate is va li d ti ll 24'h June 2015. You are to submit ann ual reports for conti nuing review. S;g",tuo< OfCh,;"f:. . (;;S)Jr(J ... .... \\~ Mrs.Chr i s~ (NMIMR - IRB, Chair) cc: Professor Kwadwo Koram Director, Noguchi Memorial Institute for Medical Research, Uni versi ty of Ghana, Legan 77 University of Ghana http://ugspace.ug.edu.gh APPENDIXE GHANA HEALTH SERVrCr ETHICAL REVIEW COMMITTEE In case ofr eply the •".Jt ...I \ -,-.T. ,k, 0.,.'- Research & Development Division ". number and date oft his Ghana Health Service Letter should be quoted .. - P. O. Box MB 190 ~~ 4D ' * Accra § .' rei: +233·302-681109 Fax + 233·302-685424 My Ref :GHS-ERC: 3 Email: Hannah.Frimpong@ghslllail.org You,Re! No. VUIII,. t:::..LIi .. ~I' :~1I_1"1 13 th August, 2014 Michael Bour University of Ghana School of Nursing Legon-Accra [THlCAL APPROVAL - In NO: GHS-ERC: 02/06/14 The Ghana Health Service Hhics Review Committee has reviewed and given approval for the implementation of your Stud) Protocol titled: "Factors affecting quality nursing care at Ridge hospital: Perspective of nurses" This approval requires that vou inform the Ethical Review Committee (ERC) when the study begins and provide Mid-term reports of the study to the Ethical Review Committee (ERC) for continuous review. The ERe may ob erve or cause to be observed procedures and records of the study during and after impkmentation. Please note that any modification without ERC approval is rendered invalid. You are also required to report all seriolls adverse events related to this study to the ERe within seven days verbally and fourtcen days in writing. You are requested (0 submit a final report on the study to assure the ERC that the project was implemented as per approved protocol. You are also to inform the ERC and your sponsor before any publication of tile research findings . Please always quote the protocol identification~urnber. all future correspondence in relatiOil to this approved protocol SiGNED . . .. . ...... .... ........ ......~....... . . . .. .............. . PROFESSOR FRED BINKA (Gf-IS-ERC CHAIRPERSON) Cc: The Director, Research & Development Division, Ghana Health Service, Accra 78 University of Ghana http://ugspace.ug.edu.gh APPENDIXF GHA NA HEALTH SER ViCE In case of reply the REGiONAL HEALTH number and date ofthi DIRECTORATE leiter should be quoted. GREATER A CRA P. 0 BOX 184 My Ref No. ACCRA Your Ref No. Tel: +233-0302-2342251226203 E-mail: lavanoloo@yahoo.com 25th August, 2014 MR. MICHAEL BOUR SCHOOL OF NURSING COLLEGE OF HEALTH SCIENCES UNIV RSlTY OF GHA A, LEGON RE: PERMISSION TO UNDERTAKE A STUDY AT RIDGE HOSPITAL Your application dated 11th August, 2014 on the above subject matter refers The Greater Accra Regiona l Health Directorate wishes to inform you that approval has been granted to enable you to proceed with the study on the topic: "Factors Affecting Quality Nursing Care at Ridge Hospital: Perspective of Nurses ". You are kindly requested to submit a copy of your report on the study to the Office of the Regional Director of Health Services for reference purposes. Thank you. DR. LINDA A. V ANOTOO REGIONAL DIRECTOR OF HEALTH SERVICES GREATER ACCRA cc: The Medical Director Ridge Regional Hospital Accra 79