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Nursing education and the quality of care: Towards a new conceptualisation of good nursing care
02606917/89/0009-03201t10.00
Nurrr Educafton Today (1989) 9,320-326 0 Longman Group UK Ltd 1989
Nursing education and the quality of care: Towards a new conceptualisation of good nursing care Helena Leino-Kilpi
The article examines the quality objectives adopted in Finnish nursing education and the principles of student evaluation. The concept of ‘good nursing care’ reflected in these objectives and principles is compared with the views of practising nurses (N = 269) and nursing teachers (N = 223). [The comparison suggests that the official definition of good care is very similar to the views of nursing practitioners: in both the emphasis is on the comprehensiveness of nursing care, the treatment of patients as individuals, and certain other basic principles.] The analysis is based on ‘grounded’ theory and involves both qualitative and quantitative elements. The latter are present in the assessment of the unanimity of the two groups investigated and in the search for (tetracore) correlations between the concepts derived. The evaluation of the quality of care is based on a classification of 70 different content categories, reduced to eight main categories, which are here defined in rather general terms. Using these categories, good nursing care may be defined follows: it is comprehensive; based on the needs of the patient; oriented to the patient as an individual; conducive to a sense of security in the patient; forms a complex process; involves self-care on the part of the patient; is based on certain philosophical foundations; and contains certain situational factors.
objectives, as laid down in the nursing curricula
INTRODUCTION This article is concerned
with the quality aspect
of nursing care, more specifically with the quality objectives adopted in nursing education and the principles applied in evaluating nursing students. We shall begin by looking at the official
Helena Leino-Kilpi Lit. NSc. NT, RN Chief Assistant, University of Turku, Department of Nursing, Lemminkaisenkatu 3.20520 Turku, Finland (Requests for offprints to HL-K) Manuscript accepted April 1989
320
of the 1930s 60s and 80s and then proceed to compare these objectives with the views of practising nurses (N = 269) and nursing teachers (N = 223) on ‘quality’ or good care. The former are employed at university central hospitals, and the latter are all trained nurses by education. On the basis of these analyses our aim will be to develop a tentative conceptual system of good care, which should also be applicable to student evaluation. The frame of reference for this system is provided by grounded theory (Glaser & Strauss 1967).
NURSE EDUCATION
THE FINNISH NURSING CURRICULUM: A BRIEF HISTORY The first Finnish nursing curriculum, dating from the 193Os, contained no explicit educational objectives. However, from the courses included in that curriculum it is clear that nurse training was very much illness-oriented, with nursing and medical subjects representing the hard core of the curriculum. Health care as a whole received only marginal attention (Nurse Training Programme 1930). The same emphasis is evident in the curriculum that was adopted in the 1960s: the primary aim was to teach nurses how to work with hospital patients. The practice of nursing was still the main subject, although in the educational objectives it was stated that nurses should develop comprehensive skills so that they can give not only physical but also mental and social help to their patients (Curriculum for Nurse Training Institute 1964). A further step towards the health-oriented concept of nursing was taken in 1972 when the goal of nursing education was defined as ‘providing such nursing skills as are required both in hospital work and in the public health sector’. The 1980 curriculum for nursing education contains far more general purpose information than any of its precursors: the aim now is to train specialists in nursing (Curriculum for Professional Nurse Training 1987). This document lists the following specific objectives: nurses should be able to promote and maintain the health of their patients; minimise the inconveniences caused to patients by handicaps or illindividual patients and their ness; support families in the process of recovery; develop methods of rehabilitation; and provide mental support to the dying patient. The curriculum is based on a dialectic structure (cf. Stevens 197 1): it starts from the concept of health and a health proceeds to an illness-oriented orientation, approach, and then finally moves back to the health perspective. Also, the theoretical element in general is of key importance. In spite of these changing emphases, there are certain aspects of nursing education that have
TODAY
32 1
remained unchanged throughout the decades. Most importantly, nurses have always been expected to pay special attention to the treatment of their patients as individuals; to give absolute priority to the safety of their patients; and to learn a broad range of skills so that they can cope with all the various aspects of their demanding job.
THE PRINCIPLES OF STUDENT EVALUATION In conjunction with these revisions of the there have also been nursing curriculum, changes in the principles of student evaluation. In 1930 the emphasis was on each individual nurse’s personal qualities and on the specific requirements of the nurse’s job tasks (National Board of Health 1934). It was stressed that nurses should be friendly, helpful, patient, and sympathetic towards their patients, who should always be treated as individuals; they must be trustworthy; they must be able to make accurate observations and take quick decisions; they must take their work seriously and show initiative in keeping their knowledge up to date; they must be punctual, composed, and methodical; and finally, nurses must show the good example of looking after their own health. Importantly, the 1930 guidelines for student evaluation said that the student nurses should always be kept informed about the results of evaluation, since this was primarily intended as a constructive pedagogic process. was of student evaluation The scope expanded in the 1960s (National Board of Vocational Education, no date). It now covered three different aspects: attitude towards work, situation control, and working methods. In the first area, the focal concerns were the nursing student’s sense of responsibility and her positive interest in the patient. In the case of situation control, primary attention was given to the student’s initiative, her ability to make accurate observations, and to her interaction with the patient in the sense of keeping her informed about what kind of medical treatment she was Finally, in the working methods receiving.
322
NURSE EDUCATION
section
the
accuracy,
main
TODAY
items
skilfullness,
included
growing
carefulness,
emphasis
on
openness
and
self-
evaluation.
and the ability to provide
were later revised somewhat by nursing colleges:
On the whole then, it seems that the principles of evaluation applied in nursing education have
the term ‘skilfullness’,
for instance,
developed
by the more accurate
description
individual
care. These
treatment
of evaluation was replaced of ‘mastery of
methods’.
It is noteworthy Board
principles
Education
from the 1960s
explicitly forbids what was recommended 1930s: nursing students
about the results of evaluation. The most recent set of guidelines evaluation
of professional
the National
Board
in the
were no longer to know for
the
skills, published
by
of Vocational
Education
in
1987, define and describe those skills in considerable detail. The main dimensions are the mastery of nursing theory, mastery of nursing procedures, and professional identity (National Board
of
document nursing
Vocational
Education
1987).
says that the basic general education
is to develop
broad understanding
This
objective of
in students
of and competence
a
in their
special field. Within
demands three
that
1) a
the
first
component
overview
-
mastery
of
of the subject
provide nursing
students
with the tools they will
and justification
procedures.
Special attention
application
of scientific
contexts. the
knowledge
procedures’,
managment
communication
cooperation
skills.
is defined
of nursing
is also given to the
In the second
‘mastery of nursing
understanding
matter,
of the field as a whole, and to
need in the planning
identity’
in practical
component
of
the three main of
nursing
and interaction Finally,
proskills,
‘professional
as a solid and internalised
of the nursing
profession
and of
one’s own particular role within that profession; a nurse with a strong professional identity can perform
considered
crucial
serious and responsible with
a
in reliable and responsible
fashion.
One particularly important change occurred in the principles of evaluation past few decades
is that norm-referenced
ation has been discarded evaluation (Curriculum
that has over the evalu-
in favour of absolute for Nurse Training
Institute 1964, National Board of Vocational Education 1987). Additionally, there has been a
of
main
to
good
attitude
strong
to work
professional
mastery of nursing;
3) mastery of nursing
theory.
GOOD CARE DEFINED BY PRACTISING NURSES AND NURSING TEACHERS Materials
and methods
The material
for this study was collected
Responses asked
and
are
identity;
2)
sive theoretical
are
there
the spring of 1987 at various nursing
an understanding
issues
are
combined
nurses
cedures,
Today,
nursing:
nursing theory - the aim is to give a comprehen-
nursing
from the 1930s to
the profession. points
that the report by the National
of Vocational
quite consistently
the 198Os, along with the changing
were obtained
and
223
from
nursing
to give in writing
following
269
teachers,
during
seminars. practising who were
a short answer
to the
question:
‘We all have our own ideas of what constitutes “good
care”.
describe
I would
like
you
to briefly
your own notion of what this means,
and summarise
the main
points
which you
think should form the basis of evaluating practice The
practising
specialised resented
the
of nursing.’ nurses
training the country’s
who
took
in clinical
part
care,
five university
had
and
a
rep-
hospitals.
The teachers, who were also trained nurses by education, came from eight nursing colleges. The question of sample representativeness was not considered important because there was no intention respective
to describe professional
the ‘average’ images of the groups.
The approach may be described as inductive: the analysis of the responses was guided by no specific theoretical framework, the aim being to extract from the responses as ‘pure’ notions of good care as possible. A further
objective
was to
NURSE EDUCATION
uncover
models
and patterns
vailing in the day-to-day
of thinking
pre-
reality of nursing prac-
tice and nursing education. teaching
have
been
caring and educational Bauman
et
Johansson 1976;
al.
Sheahan (Glaser 1986),
Cottrell
and
on various
et
al.
(e.g. 1986;
1980; Moritz et al. 1970; Morton et al.
Pearson
present
based
frames of reference
1976;
1979;
1975;
Reed
Wood
1986;
1982
Ryden
and
& Strauss
1967;
Chenitz
methods theoretical
analysis
generalisation
The
direct
Earlier nursing studies using this approach
have
other
nursing
student’s
world
nursing
student’s
clinical
things, with the
(Melia
carried
the
comparative
analysis
out by first identifying
nursing evaluation the material, principles
to
has
been
the principles
of
that occur most frequently
in
and then comparing
each of these
with the other ones. This means our
analysis is first and foremost The
the choice
(Simms 1981).
relationships
between
gories are described
a qualitative the different
as tetracore
one. cate-
correlations.
by the
and
data.
among
behind
& Swanson
from empirical
been concerned,
the factors
theory
characterised
of comparative
1977;
1987).
analysis is based on grounded which is typically
and
Here
Most earlier studies of student evaluation clinical
1981);
specialise in administration
323
TODAY
1982);
behaviour
Table 1 Good nursing care: principles of evaluation
the
(Arpin
RESULTS From
the comparative
six main content
analysis there
categories
ation (Table 1). Two further categories formed
and their qualitative
even though
emerged
for nursing
these occurred
evalu-
were also less fre-
dimensions
1. COMPREHENSIVENESS - patient - general principle - strategy of work - professional skill - health care system ‘Good nursing care means a comprehensive approach to the job and to the patient as an individual personality.’ ‘The common thread that runs through all our work is comprehensiveness.’ ‘Good care is a professional skill, a strategy of work. The key to this strategy is comprehensiveness.’ ‘It all depends on how the system works. When the system works and people can get help from all the different parts of the system, then you get good and efficient nursing. 2. ORIENTATION - patient
TO PATIENT’S
NEEDS
‘Good nursing care is based on the patient’s needs - physical, psychic and social needs.’ ‘I would define good care as something where the nurse works to meet the patient’s needs.’ 3. -
INDIVIDUALITY patient general principle patient’s right of self-determination
‘The treatment of every patient as an individual is the key to good nursing care.’ ‘I would single out the general principle of individuality in treatment.’ ‘It is important to understand that every patient is an individual. She must always have the right to decide on those things that are important to her-even if this may cause inconvenience to the nurse. . . ’ 4. -
SECURITY patient’s sense of security general principle sense of responsibility mastery of nursing interventions
‘I think the chief thing in good care is that the patient can feel secure, that he feels he is properly taken care of.’ ‘Safety is a principle. This involves both a sense of responsibility and a general mastery of nursing work. I cannot see any difference between these two factors, they are both equally important.’
324 5. -
NURSE EDUCATION
TODAY
INITIATIVE/SELF-CARE patient’s initiative general principle patient’s satisfaction
‘You get good results when the patient is capable of helping you. I suppose in the end the patient does everything.’ ‘It is important that the patient is given the opportunity to take part in the decision-making, to let the patient use her initiative.’ 6. NURSING AS A PROCESS - process method - individual phases of the complex process ‘In good nursing care you get all the stages of the whole process.’ ‘The nursing process must be there in its entirety.’ 7. -
PHILOSOPHICAL humaneness equality ethical aspects
FOUNDATIONS
‘Good care is humane; a good nurse is a humanist.’ ‘The key to good nursing care lies in its ethical basis. Without that basis everything is meaningless.’ ‘Equality and respect for the patient are the ethical principles that I think are all-important.’ 6. SITUATIONAL - resources - dynamism
FACTORS
‘In order to have good nursing you need adequate resources. You need more than just a bed for the patient.’ ‘You have to go by what you have here and now. What is good today may no longer be good tomorrow.’
quently: ‘philosophical foundations’ and ‘situational factors’. The three commonest criteria of good care mentioned by the respondents (appearing in over 40% of the answers) were that nursing care should be comprehensive; that it should start from the specific needs of the patient; and that it should deal with patients as individuals. These were followed by the safety of nursing care, initiative, and the principle that nursing should be above all a process. These points were mentioned in more than 20% of the answers. In the first category of the principles a considerable number of respondents use exactly the same word - comprehensiveness - to describe their views on good nursing care. However, upon closer inspection we can find at least five different qualitative dimensions within this category: some are talking about comprehensiveness in the sense of dealing with the patient comprehensively, are others referring to comprehensiveness as a general principle of nursing, others see it in the context of a strategy of nursing, others see it in the context of a
strategy of work, others as the basis of the nurse’s professional skill, and others still as a characteristic of our health care system. The second requirement that nursing care should start from the patient’s needs is mainly a general statement that it is important for practising nurses to take into account their patients’ specific needs; no definitions are given of the exact content of this concept. The requirement of individual treatment was raised both as a general principle and, importantly, in the context of the patient’s right of self-determination. In the principles classified under the category of safety, frequent reference was made to the importance of the nurse’s sense of responsibility and to the mastery of nursing interventions. There were also many respondents who stressed the importance of approaching the practice of nursing as a process. The different phases of that process were mentioned quite often, most particularly the phase of planning. Evaluation was mentioned less frequently. Among the principles that were classified in
NURSE EDUCATION
the category of philosophical foundations, the commonest were those that pointed to the ethical basis of nursing care and to the principle of equality in the nursing relationship. Situational factors included a number of minor and more concrete points - usually relating to resources which none the less were directly relevant to the question of flexibility and the design of nursing care. On the whole then, there seemed to be a broad consensus of opinion among practising nurses and nursing teachers about the main principles that determine the quality of nursing care. Nevertheless there were also some interesting differences. First, nursing teachers referred more often than practising nurses to the factor of initiative and to the process nature of nursing care. Second, there was also a clear difference along the abstract/concrete dimension, in that there was a tendency for the teachers to describe their criteria in terms of general principles and for practising nurses to single out concrete situational factors. It was also interesting to see that the comments by the teachers were not restricted to the theoretical element of nursing education, but also included such practical aspects as the mastery of intervention methods and the importance of close interpersonal interaction. However, in these and in fact most of the answers there was the problem that the principles of evaluation were stated in abstruc@ without any explanation of how the respondents themselves understood these principles. The differences that were found between the two groups of respondents were in no way systematic, and all the correlations were low. The conclusion we may draw at the present stage, before proceeding to more detailed interviews is that there seems to be and questionnaires, widespread agreement among nursing professionals as to what ingredients are required for nursing care to qualify as good.
DISCUSSION As we have seen in the foregoing, the general objectives included in Finnish nursing curricula
TODAY
325
and the principles applied in the evaluation of nursing students reflect a rather consistent development in official definitions of what constitutes good nursing care. There has been no change in the basic principles that the patient should be treated as an individual and that treatment should be as comprehensive as possible. These and other fundamental nursing principles are very much in the fore in the present findings as well. On the other hand, there was a marked absence of references to the orientation of nursing to health care as opposed to the treatment of illnesses, which is one of the cornerstones of the present curriculum of nursing education. This is quite surprising: the question of health-vs. illness oriented one of the hottest issues Finnish health care policy.
nursing has been in contemporary
Another aspect which failed to emerge as prominently as one would have expected was the ‘scientific’ or research-oriented approach to nursing; there were very few respondents indeed who said that the quality of care has something to do with nursing science or research. There was no difference in this respect between practising nurses and nursing teachers. As far as the validity of this investigation is concerned, there are two main limitations which need to be borne in mind. First, the respondents were required to produce their answers within the time-span of 1 hour, which meant that these were often presented in the form of lists of main points. Therefore, in the classification of the answers in the relevant content categories, it was necessary to interpret and make generalisations from them - a process which in itself may easily undermine the validity of the results (Miles et al. 1984). On the other hand, the low correlation coefficients clearly reduced the risk of oversimplification and misinterpretation. The research design, then, may be regarded as valid and certainly a suitable one for the present purposes. In building our conceptual framework for the definition of ‘good care’? we have consulted those people who are most directly responsible for the quality of nursing care practising nurses and nursing teachers - and in
326
NURSE EDUCATION
TODAY
this sense sought for the principles
of nursing
evaluation from the grassroots level. As well as serving the needs of both searchers ceptual
and
nursing
system
effective
will also make
control
encountered
in the day-to-day
This is one of the reasons on
grounded
possible
of the structures
theory:
re-
our con-
practitioners,
a more
and processes
reality
of nursing.
why this work is based the
aim
is to produce
concepts that are directly relevant to the substantial field of nursing (cf. Glaser & Strauss
1967;
Chenitz 8c Swanson 1986). At the present stage, of course, the conceptualisation can hardly go beyond
the
identification
elements of the system. The present material . was not possible proper,
of
constitutive
was so extensive
to do a qualitative
but it was nevertheless considered
to keep it intact Therefore
nrocess. The aim in the further
analysis of the miterial
will be to corroborate,
a higher level of precision, dimensions
derived
here.
offer a useful starting-point scrutiny of what is meant nursing.
useful
at least for the time being.
twice - was a rather laborious and
time-consuming
must
conducive
that it analysis
the analysis of this material - which
was repeated
indeed
the
at
the tentative content These
dimensions
for a more detailed by phrases such as
be comprehensive,
to a sense of security,
individual, etc. -
and
of the very concept of the quality of care.
References Arpin K 198 1 Behaviour in clinical practice of final year students in a baccalaureate nursing programme. University of Toronto, Faculty of Nursing, Toronto Bauman A, Benoit E 1976 A multidimensional tool for clinical evaluation. Nursing Papers, Spring 1976: 25-30 Chenitz W & Swanson J 1986 Qualitative research using grounded theorv. In: Chenitz W & Swanson 1 1986 From practice to grounded theory. Qualitatice research in nursing. Addison Wesley, Menlo Park. California. l-15
Cottrell B H, Cox B H, Kelsey S J, Ritchie P J, Rumph E A & Shannahan M K 1986 A clinical evaluation tool for nursing students based on the nursing process. Journal of Nursing Education 25, 7: 270-274 Curriculum for Nurse Training Institute 1964 National Board of Health. Helsinki. (In Finnish) Curriculum for Professional Nurse Training 1987 National Board of Vocational Education, Helsinki. (In Finnish) Glaser B G, Strauss A L 1967 The discovery of grounded theory. Strategies for qualitative research Aldine, New York Johansson B 1980 Vardutbildning. Effektivitet i omv%rdnad och virdutbildning. Goteborgs universitet, Pedagogiska institutionen, Goteborg Melia K M 1982 ‘Tell is as it is’ - qualitative methodology and nursing research: understanding the student nurse’s world. Journal of Advanced Nursing 7: 327-335 Miles M B & Huberman A M 1984 Qualitative data analysis. A sourcebook of new methods. Sage, Beverly Hills, California Moritz D & Sexton D 1970 Evaluation: a suggested method for appraising quality. Journal of Nursing Education 9: 17-34 Morton J et al. 1976 A clinical evaluation tool for student nurses. The Canadian Nurse 76.6: 37-41 National Board of Health 1934 Student evaluation. (In Finnish) National Board of Vocational Education, n.d. Student evaluation. Helsinki. (In Finnish) National Board of Vocational Education 1987 Student evaluation. (In Finnish) Pearson B 1975 A model for clinical evaluation. Nursing Outlook 23,4: 232-235 Nurse Training Programme 1930 The National Board of Health, Helsinki. (In Finnish) Reed P 1986 A model for constructing a conceptual framework for education in the clinical speciality. Journal of Nursing Education 25, 7: 295-299 Ryden M 1977 The predictive value of a clinical examination of interpersonal relationship skills. Journal of Nursing Education 16, 5: 27-3 1 Sheahan J 1979 Measurement in nursing education Journal of Advanced Nursing 4: 47-56 Simms L 198 1 The grounded theory approach in nursing research. Nursing Research 30, 6: 356359 Stevens B 197 1 Analysis of structural forms used in nursing curricula. Nursing Research 20, 5: 388-397 Wood W 1982 Evaluation of student nurse clinical performance - a continuing problem. International Nursing Review 29, 1: 11-18 Wood W ‘i987 The nursing instructor and clinical teaching. International Nursing Review 34, 5: 120125.
Nurrr Educafton Today (1989) 9,320-326 0 Longman Group UK Ltd 1989
Nursing education and the quality of care: Towards a new conceptualisation of good nursing care Helena Leino-Kilpi
The article examines the quality objectives adopted in Finnish nursing education and the principles of student evaluation. The concept of ‘good nursing care’ reflected in these objectives and principles is compared with the views of practising nurses (N = 269) and nursing teachers (N = 223). [The comparison suggests that the official definition of good care is very similar to the views of nursing practitioners: in both the emphasis is on the comprehensiveness of nursing care, the treatment of patients as individuals, and certain other basic principles.] The analysis is based on ‘grounded’ theory and involves both qualitative and quantitative elements. The latter are present in the assessment of the unanimity of the two groups investigated and in the search for (tetracore) correlations between the concepts derived. The evaluation of the quality of care is based on a classification of 70 different content categories, reduced to eight main categories, which are here defined in rather general terms. Using these categories, good nursing care may be defined follows: it is comprehensive; based on the needs of the patient; oriented to the patient as an individual; conducive to a sense of security in the patient; forms a complex process; involves self-care on the part of the patient; is based on certain philosophical foundations; and contains certain situational factors.
objectives, as laid down in the nursing curricula
INTRODUCTION This article is concerned
with the quality aspect
of nursing care, more specifically with the quality objectives adopted in nursing education and the principles applied in evaluating nursing students. We shall begin by looking at the official
Helena Leino-Kilpi Lit. NSc. NT, RN Chief Assistant, University of Turku, Department of Nursing, Lemminkaisenkatu 3.20520 Turku, Finland (Requests for offprints to HL-K) Manuscript accepted April 1989
320
of the 1930s 60s and 80s and then proceed to compare these objectives with the views of practising nurses (N = 269) and nursing teachers (N = 223) on ‘quality’ or good care. The former are employed at university central hospitals, and the latter are all trained nurses by education. On the basis of these analyses our aim will be to develop a tentative conceptual system of good care, which should also be applicable to student evaluation. The frame of reference for this system is provided by grounded theory (Glaser & Strauss 1967).
NURSE EDUCATION
THE FINNISH NURSING CURRICULUM: A BRIEF HISTORY The first Finnish nursing curriculum, dating from the 193Os, contained no explicit educational objectives. However, from the courses included in that curriculum it is clear that nurse training was very much illness-oriented, with nursing and medical subjects representing the hard core of the curriculum. Health care as a whole received only marginal attention (Nurse Training Programme 1930). The same emphasis is evident in the curriculum that was adopted in the 1960s: the primary aim was to teach nurses how to work with hospital patients. The practice of nursing was still the main subject, although in the educational objectives it was stated that nurses should develop comprehensive skills so that they can give not only physical but also mental and social help to their patients (Curriculum for Nurse Training Institute 1964). A further step towards the health-oriented concept of nursing was taken in 1972 when the goal of nursing education was defined as ‘providing such nursing skills as are required both in hospital work and in the public health sector’. The 1980 curriculum for nursing education contains far more general purpose information than any of its precursors: the aim now is to train specialists in nursing (Curriculum for Professional Nurse Training 1987). This document lists the following specific objectives: nurses should be able to promote and maintain the health of their patients; minimise the inconveniences caused to patients by handicaps or illindividual patients and their ness; support families in the process of recovery; develop methods of rehabilitation; and provide mental support to the dying patient. The curriculum is based on a dialectic structure (cf. Stevens 197 1): it starts from the concept of health and a health proceeds to an illness-oriented orientation, approach, and then finally moves back to the health perspective. Also, the theoretical element in general is of key importance. In spite of these changing emphases, there are certain aspects of nursing education that have
TODAY
32 1
remained unchanged throughout the decades. Most importantly, nurses have always been expected to pay special attention to the treatment of their patients as individuals; to give absolute priority to the safety of their patients; and to learn a broad range of skills so that they can cope with all the various aspects of their demanding job.
THE PRINCIPLES OF STUDENT EVALUATION In conjunction with these revisions of the there have also been nursing curriculum, changes in the principles of student evaluation. In 1930 the emphasis was on each individual nurse’s personal qualities and on the specific requirements of the nurse’s job tasks (National Board of Health 1934). It was stressed that nurses should be friendly, helpful, patient, and sympathetic towards their patients, who should always be treated as individuals; they must be trustworthy; they must be able to make accurate observations and take quick decisions; they must take their work seriously and show initiative in keeping their knowledge up to date; they must be punctual, composed, and methodical; and finally, nurses must show the good example of looking after their own health. Importantly, the 1930 guidelines for student evaluation said that the student nurses should always be kept informed about the results of evaluation, since this was primarily intended as a constructive pedagogic process. was of student evaluation The scope expanded in the 1960s (National Board of Vocational Education, no date). It now covered three different aspects: attitude towards work, situation control, and working methods. In the first area, the focal concerns were the nursing student’s sense of responsibility and her positive interest in the patient. In the case of situation control, primary attention was given to the student’s initiative, her ability to make accurate observations, and to her interaction with the patient in the sense of keeping her informed about what kind of medical treatment she was Finally, in the working methods receiving.
322
NURSE EDUCATION
section
the
accuracy,
main
TODAY
items
skilfullness,
included
growing
carefulness,
emphasis
on
openness
and
self-
evaluation.
and the ability to provide
were later revised somewhat by nursing colleges:
On the whole then, it seems that the principles of evaluation applied in nursing education have
the term ‘skilfullness’,
for instance,
developed
by the more accurate
description
individual
care. These
treatment
of evaluation was replaced of ‘mastery of
methods’.
It is noteworthy Board
principles
Education
from the 1960s
explicitly forbids what was recommended 1930s: nursing students
about the results of evaluation. The most recent set of guidelines evaluation
of professional
the National
Board
in the
were no longer to know for
the
skills, published
by
of Vocational
Education
in
1987, define and describe those skills in considerable detail. The main dimensions are the mastery of nursing theory, mastery of nursing procedures, and professional identity (National Board
of
document nursing
Vocational
Education
1987).
says that the basic general education
is to develop
broad understanding
This
objective of
in students
of and competence
a
in their
special field. Within
demands three
that
1) a
the
first
component
overview
-
mastery
of
of the subject
provide nursing
students
with the tools they will
and justification
procedures.
Special attention
application
of scientific
contexts. the
knowledge
procedures’,
managment
communication
cooperation
skills.
is defined
of nursing
is also given to the
In the second
‘mastery of nursing
understanding
matter,
of the field as a whole, and to
need in the planning
identity’
in practical
component
of
the three main of
nursing
and interaction Finally,
proskills,
‘professional
as a solid and internalised
of the nursing
profession
and of
one’s own particular role within that profession; a nurse with a strong professional identity can perform
considered
crucial
serious and responsible with
a
in reliable and responsible
fashion.
One particularly important change occurred in the principles of evaluation past few decades
is that norm-referenced
ation has been discarded evaluation (Curriculum
that has over the evalu-
in favour of absolute for Nurse Training
Institute 1964, National Board of Vocational Education 1987). Additionally, there has been a
of
main
to
good
attitude
strong
to work
professional
mastery of nursing;
3) mastery of nursing
theory.
GOOD CARE DEFINED BY PRACTISING NURSES AND NURSING TEACHERS Materials
and methods
The material
for this study was collected
Responses asked
and
are
identity;
2)
sive theoretical
are
there
the spring of 1987 at various nursing
an understanding
issues
are
combined
nurses
cedures,
Today,
nursing:
nursing theory - the aim is to give a comprehen-
nursing
from the 1930s to
the profession. points
that the report by the National
of Vocational
quite consistently
the 198Os, along with the changing
were obtained
and
223
from
nursing
to give in writing
following
269
teachers,
during
seminars. practising who were
a short answer
to the
question:
‘We all have our own ideas of what constitutes “good
care”.
describe
I would
like
you
to briefly
your own notion of what this means,
and summarise
the main
points
which you
think should form the basis of evaluating practice The
practising
specialised resented
the
of nursing.’ nurses
training the country’s
who
took
in clinical
part
care,
five university
had
and
a
rep-
hospitals.
The teachers, who were also trained nurses by education, came from eight nursing colleges. The question of sample representativeness was not considered important because there was no intention respective
to describe professional
the ‘average’ images of the groups.
The approach may be described as inductive: the analysis of the responses was guided by no specific theoretical framework, the aim being to extract from the responses as ‘pure’ notions of good care as possible. A further
objective
was to
NURSE EDUCATION
uncover
models
and patterns
vailing in the day-to-day
of thinking
pre-
reality of nursing prac-
tice and nursing education. teaching
have
been
caring and educational Bauman
et
Johansson 1976;
al.
Sheahan (Glaser 1986),
Cottrell
and
on various
et
al.
(e.g. 1986;
1980; Moritz et al. 1970; Morton et al.
Pearson
present
based
frames of reference
1976;
1979;
1975;
Reed
Wood
1986;
1982
Ryden
and
& Strauss
1967;
Chenitz
methods theoretical
analysis
generalisation
The
direct
Earlier nursing studies using this approach
have
other
nursing
student’s
world
nursing
student’s
clinical
things, with the
(Melia
carried
the
comparative
analysis
out by first identifying
nursing evaluation the material, principles
to
has
been
the principles
of
that occur most frequently
in
and then comparing
each of these
with the other ones. This means our
analysis is first and foremost The
the choice
(Simms 1981).
relationships
between
gories are described
a qualitative the different
as tetracore
one. cate-
correlations.
by the
and
data.
among
behind
& Swanson
from empirical
been concerned,
the factors
theory
characterised
of comparative
1977;
1987).
analysis is based on grounded which is typically
and
Here
Most earlier studies of student evaluation clinical
1981);
specialise in administration
323
TODAY
1982);
behaviour
Table 1 Good nursing care: principles of evaluation
the
(Arpin
RESULTS From
the comparative
six main content
analysis there
categories
ation (Table 1). Two further categories formed
and their qualitative
even though
emerged
for nursing
these occurred
evalu-
were also less fre-
dimensions
1. COMPREHENSIVENESS - patient - general principle - strategy of work - professional skill - health care system ‘Good nursing care means a comprehensive approach to the job and to the patient as an individual personality.’ ‘The common thread that runs through all our work is comprehensiveness.’ ‘Good care is a professional skill, a strategy of work. The key to this strategy is comprehensiveness.’ ‘It all depends on how the system works. When the system works and people can get help from all the different parts of the system, then you get good and efficient nursing. 2. ORIENTATION - patient
TO PATIENT’S
NEEDS
‘Good nursing care is based on the patient’s needs - physical, psychic and social needs.’ ‘I would define good care as something where the nurse works to meet the patient’s needs.’ 3. -
INDIVIDUALITY patient general principle patient’s right of self-determination
‘The treatment of every patient as an individual is the key to good nursing care.’ ‘I would single out the general principle of individuality in treatment.’ ‘It is important to understand that every patient is an individual. She must always have the right to decide on those things that are important to her-even if this may cause inconvenience to the nurse. . . ’ 4. -
SECURITY patient’s sense of security general principle sense of responsibility mastery of nursing interventions
‘I think the chief thing in good care is that the patient can feel secure, that he feels he is properly taken care of.’ ‘Safety is a principle. This involves both a sense of responsibility and a general mastery of nursing work. I cannot see any difference between these two factors, they are both equally important.’
324 5. -
NURSE EDUCATION
TODAY
INITIATIVE/SELF-CARE patient’s initiative general principle patient’s satisfaction
‘You get good results when the patient is capable of helping you. I suppose in the end the patient does everything.’ ‘It is important that the patient is given the opportunity to take part in the decision-making, to let the patient use her initiative.’ 6. NURSING AS A PROCESS - process method - individual phases of the complex process ‘In good nursing care you get all the stages of the whole process.’ ‘The nursing process must be there in its entirety.’ 7. -
PHILOSOPHICAL humaneness equality ethical aspects
FOUNDATIONS
‘Good care is humane; a good nurse is a humanist.’ ‘The key to good nursing care lies in its ethical basis. Without that basis everything is meaningless.’ ‘Equality and respect for the patient are the ethical principles that I think are all-important.’ 6. SITUATIONAL - resources - dynamism
FACTORS
‘In order to have good nursing you need adequate resources. You need more than just a bed for the patient.’ ‘You have to go by what you have here and now. What is good today may no longer be good tomorrow.’
quently: ‘philosophical foundations’ and ‘situational factors’. The three commonest criteria of good care mentioned by the respondents (appearing in over 40% of the answers) were that nursing care should be comprehensive; that it should start from the specific needs of the patient; and that it should deal with patients as individuals. These were followed by the safety of nursing care, initiative, and the principle that nursing should be above all a process. These points were mentioned in more than 20% of the answers. In the first category of the principles a considerable number of respondents use exactly the same word - comprehensiveness - to describe their views on good nursing care. However, upon closer inspection we can find at least five different qualitative dimensions within this category: some are talking about comprehensiveness in the sense of dealing with the patient comprehensively, are others referring to comprehensiveness as a general principle of nursing, others see it in the context of a strategy of nursing, others see it in the context of a
strategy of work, others as the basis of the nurse’s professional skill, and others still as a characteristic of our health care system. The second requirement that nursing care should start from the patient’s needs is mainly a general statement that it is important for practising nurses to take into account their patients’ specific needs; no definitions are given of the exact content of this concept. The requirement of individual treatment was raised both as a general principle and, importantly, in the context of the patient’s right of self-determination. In the principles classified under the category of safety, frequent reference was made to the importance of the nurse’s sense of responsibility and to the mastery of nursing interventions. There were also many respondents who stressed the importance of approaching the practice of nursing as a process. The different phases of that process were mentioned quite often, most particularly the phase of planning. Evaluation was mentioned less frequently. Among the principles that were classified in
NURSE EDUCATION
the category of philosophical foundations, the commonest were those that pointed to the ethical basis of nursing care and to the principle of equality in the nursing relationship. Situational factors included a number of minor and more concrete points - usually relating to resources which none the less were directly relevant to the question of flexibility and the design of nursing care. On the whole then, there seemed to be a broad consensus of opinion among practising nurses and nursing teachers about the main principles that determine the quality of nursing care. Nevertheless there were also some interesting differences. First, nursing teachers referred more often than practising nurses to the factor of initiative and to the process nature of nursing care. Second, there was also a clear difference along the abstract/concrete dimension, in that there was a tendency for the teachers to describe their criteria in terms of general principles and for practising nurses to single out concrete situational factors. It was also interesting to see that the comments by the teachers were not restricted to the theoretical element of nursing education, but also included such practical aspects as the mastery of intervention methods and the importance of close interpersonal interaction. However, in these and in fact most of the answers there was the problem that the principles of evaluation were stated in abstruc@ without any explanation of how the respondents themselves understood these principles. The differences that were found between the two groups of respondents were in no way systematic, and all the correlations were low. The conclusion we may draw at the present stage, before proceeding to more detailed interviews is that there seems to be and questionnaires, widespread agreement among nursing professionals as to what ingredients are required for nursing care to qualify as good.
DISCUSSION As we have seen in the foregoing, the general objectives included in Finnish nursing curricula
TODAY
325
and the principles applied in the evaluation of nursing students reflect a rather consistent development in official definitions of what constitutes good nursing care. There has been no change in the basic principles that the patient should be treated as an individual and that treatment should be as comprehensive as possible. These and other fundamental nursing principles are very much in the fore in the present findings as well. On the other hand, there was a marked absence of references to the orientation of nursing to health care as opposed to the treatment of illnesses, which is one of the cornerstones of the present curriculum of nursing education. This is quite surprising: the question of health-vs. illness oriented one of the hottest issues Finnish health care policy.
nursing has been in contemporary
Another aspect which failed to emerge as prominently as one would have expected was the ‘scientific’ or research-oriented approach to nursing; there were very few respondents indeed who said that the quality of care has something to do with nursing science or research. There was no difference in this respect between practising nurses and nursing teachers. As far as the validity of this investigation is concerned, there are two main limitations which need to be borne in mind. First, the respondents were required to produce their answers within the time-span of 1 hour, which meant that these were often presented in the form of lists of main points. Therefore, in the classification of the answers in the relevant content categories, it was necessary to interpret and make generalisations from them - a process which in itself may easily undermine the validity of the results (Miles et al. 1984). On the other hand, the low correlation coefficients clearly reduced the risk of oversimplification and misinterpretation. The research design, then, may be regarded as valid and certainly a suitable one for the present purposes. In building our conceptual framework for the definition of ‘good care’? we have consulted those people who are most directly responsible for the quality of nursing care practising nurses and nursing teachers - and in
326
NURSE EDUCATION
TODAY
this sense sought for the principles
of nursing
evaluation from the grassroots level. As well as serving the needs of both searchers ceptual
and
nursing
system
effective
will also make
control
encountered
in the day-to-day
This is one of the reasons on
grounded
possible
of the structures
theory:
re-
our con-
practitioners,
a more
and processes
reality
of nursing.
why this work is based the
aim
is to produce
concepts that are directly relevant to the substantial field of nursing (cf. Glaser & Strauss
1967;
Chenitz 8c Swanson 1986). At the present stage, of course, the conceptualisation can hardly go beyond
the
identification
elements of the system. The present material . was not possible proper,
of
constitutive
was so extensive
to do a qualitative
but it was nevertheless considered
to keep it intact Therefore
nrocess. The aim in the further
analysis of the miterial
will be to corroborate,
a higher level of precision, dimensions
derived
here.
offer a useful starting-point scrutiny of what is meant nursing.
useful
at least for the time being.
twice - was a rather laborious and
time-consuming
must
conducive
that it analysis
the analysis of this material - which
was repeated
indeed
the
at
the tentative content These
dimensions
for a more detailed by phrases such as
be comprehensive,
to a sense of security,
individual, etc. -
and
of the very concept of the quality of care.
References Arpin K 198 1 Behaviour in clinical practice of final year students in a baccalaureate nursing programme. University of Toronto, Faculty of Nursing, Toronto Bauman A, Benoit E 1976 A multidimensional tool for clinical evaluation. Nursing Papers, Spring 1976: 25-30 Chenitz W & Swanson J 1986 Qualitative research using grounded theorv. In: Chenitz W & Swanson 1 1986 From practice to grounded theory. Qualitatice research in nursing. Addison Wesley, Menlo Park. California. l-15
Cottrell B H, Cox B H, Kelsey S J, Ritchie P J, Rumph E A & Shannahan M K 1986 A clinical evaluation tool for nursing students based on the nursing process. Journal of Nursing Education 25, 7: 270-274 Curriculum for Nurse Training Institute 1964 National Board of Health. Helsinki. (In Finnish) Curriculum for Professional Nurse Training 1987 National Board of Vocational Education, Helsinki. (In Finnish) Glaser B G, Strauss A L 1967 The discovery of grounded theory. Strategies for qualitative research Aldine, New York Johansson B 1980 Vardutbildning. Effektivitet i omv%rdnad och virdutbildning. Goteborgs universitet, Pedagogiska institutionen, Goteborg Melia K M 1982 ‘Tell is as it is’ - qualitative methodology and nursing research: understanding the student nurse’s world. Journal of Advanced Nursing 7: 327-335 Miles M B & Huberman A M 1984 Qualitative data analysis. A sourcebook of new methods. Sage, Beverly Hills, California Moritz D & Sexton D 1970 Evaluation: a suggested method for appraising quality. Journal of Nursing Education 9: 17-34 Morton J et al. 1976 A clinical evaluation tool for student nurses. The Canadian Nurse 76.6: 37-41 National Board of Health 1934 Student evaluation. (In Finnish) National Board of Vocational Education, n.d. Student evaluation. Helsinki. (In Finnish) National Board of Vocational Education 1987 Student evaluation. (In Finnish) Pearson B 1975 A model for clinical evaluation. Nursing Outlook 23,4: 232-235 Nurse Training Programme 1930 The National Board of Health, Helsinki. (In Finnish) Reed P 1986 A model for constructing a conceptual framework for education in the clinical speciality. Journal of Nursing Education 25, 7: 295-299 Ryden M 1977 The predictive value of a clinical examination of interpersonal relationship skills. Journal of Nursing Education 16, 5: 27-3 1 Sheahan J 1979 Measurement in nursing education Journal of Advanced Nursing 4: 47-56 Simms L 198 1 The grounded theory approach in nursing research. Nursing Research 30, 6: 356359 Stevens B 197 1 Analysis of structural forms used in nursing curricula. Nursing Research 20, 5: 388-397 Wood W 1982 Evaluation of student nurse clinical performance - a continuing problem. International Nursing Review 29, 1: 11-18 Wood W ‘i987 The nursing instructor and clinical teaching. International Nursing Review 34, 5: 120125.