Frameworks for midwifery care in Great Britain: an exploration of quality assurance

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Midwifery

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F r a m e w o r k s for m i d w i f e r y care in G r e a t Britain: an e x p l o r a t i o n of q u a l i t y assurance Deborah J F Hughes and Leonard A Goldstone

In o r d e r to design a q u a l i t y assurance tool for midwifery it was necessary to assess c u r r e n t frameworks a n d standards for practice. W i t h t h a t aim a questionnaire was sent to all midwifery m a n a g e r s in the U K . T h e findings showed that ' P l a n n e d Individualised Care' is the f a v o u r e d f r a m e w o r k for midwifery practice and that the use of nursing models (or a d a p t e d versions o f these) and m i d w i f e r y models is widespread b u t not prevalent. D o c u m e n t a t i o n for midwifery care is not always in a c c o r d a n c e with the f a v o u r e d f r a m e w o r k for care as reported. T h e s t a n d a r d s articulated in the three ' M a t e r n i t y Care in Action' reports are those aspired to by most m a t e r n i t y units. M e t h o d s o f assessing the quality of m a t e r n i t y care are m a n y and varied b u t show a clear trend towards giving p r e c e d e n c e to gauging client satisfaction with the service.

INTRODUCTION The 'Griffiths re-organisation' of the National Health Service (NHS) in the United Kingdom (UK) in June 1984 laid the foundation to the current emphasis on performance indicators and quality assurance. Prior to 1984, whilst considerable research into 'quality' was carried out, the quality assurance function (particularly but not exclusively for the Nursing Services Manager) was not explicit in job titles and was only indirectly a major component in nurse management. Since 1977, the 'Monitor' research programmes have been addressing the problem of assessing and subsequently assuring the quality of nursing care. The original objective of the reDeborah J. F. Hughes BA(Hons), MA, SRN, SCM, Research Midwife Leonard A. Goldstone BA(Econ) (Hons), MSc, FSS, Professor, Department of Health and Community Studies, Leeds Polytechnic, Calverley Street, Leeds LS1 3HE. (Requests for offprints to DH) Manuscript accepted5 June 1989

search was to provide a control variable for use in staffing experimentation studies. A method was sought to give some indication of the quality of care delivered to patients on a medical or surgical ward before and after any variations in staffing levels or mix, in order to gain assurance that no consequential damage to patient care had occurred. An easily applicable indicator of the quality of patient care in a hospital was needed and this need resulted in the development of the 'Monitor' quality assessment tools. With 'Monitor' it is possible to identify wards whose practice issufficiently good ro act as a model for others, as part of a quality improvement programme. The research has built on the work of tlae Rush Medicus Nursing Process Methodology of the USA (Jelinek et al, 1974; 1976; 1977; Medicus Systems Corporation, 1979) and modified and developed for use in a variety of specialities in the health-care system in the U K (Goldstone et al, 1983; Ball et al, 1984; Goldstone & Illsley, 1986; Goldstone & Maselino-Okai, 1986; Beeston & Goldstone, 1988; Galvin & Goldstone, 1988). 163

164

MIDWIFERY

These include care of the elderly, of sick children, of patients on neurosurgical wards, and of patients of the community nursing service. These developments have been carried out independently of the research into staffing-levels because, as 'Monitor' has increased in take-up, its original purpose has been augmented and largely superseded by its new u s e ~ n a m e l y as a quality assurance tool, and a teaching and a research instrument. At present there is evidence (RCN, 1988) that 'Monitor' is in experimental or other use in over 80 Health Districts and that parallel versions are being developed overseas. The current developments in 'Monitor' research are 'Health Visiting Monitor' (from June 1987), 'Midwifery Monitor' (from September 1987), and 'Mental Handicap Monitor' (from autumn 1988). These projects are based in the Department of Health and Community Studies at Leeds Polytechnic and will each last 2 years. Publication of the relevant quality assessment tools is therefore anticipated to occur between 1989 and 1991.

METHODS The 'Midwifery Monitor' project comprises the development of a quality assessment tool which could be used by any midwifery unit in the UK. It was planned that this tool should reflect the currently chosen frameworks for midwifery practice. Accordingly, in late 1987 and early 1988, a nationwide survey of midwifery units was undertaken to obtain information on the frameworks used in midwifery. In particular the survey aimed to ascertain the degree to which 'Planned Individualised Care' (PIC) had been adopted, and the extent of the use of nursing or other models in midwifery. It also asked about adherence to formulated standards of care e.g. 'Maternity Care in Action', parts 1, 2 and 3 (MSAC, 1982; 1984; 1985) and about how midwives currently assessed the quality of care. The questionnaire sought to ascertain the level of interest in the project and requested copies of documentation.

Sample Prior to being sent out, the questionnaire was

piloted by 18 Heads of Midwifery Services in Yorkshire and, after a few minor changes, was sent to 230 units in England (out of a believed total of 238), to all 35 units in Wales, to all 16 units in Northern Ireland, and to the Chief Nursing Officers (CNOs) of the 15 Scottish Health Boards. These 15 CNOs were asked to distribute the questionnaire to all midwifery units in their Board area. The pattern of response is shown in Table 1. Although a further 50 reminder letters evoked a good response from units in England, there was no improvement in the response from Northern Ireland and the latter was subsequently excluded from the analysis. This left 190 responses available, of which 186 were complete and usable and covered a wide range of units, from small ones without attached midwifery schools to large teaching centres. Table 1 The d i s t r i b u t i o n a n d r e t u r n o f t h e q u e s t i o n n a i r e Country

Dispatched

Returned

%

England Wales N. Ireland Total Scotland Total responses Responses excluding N. Ireland Usable responses~

230 35 16 281 --

161 11 3 175 18 193

70 31 19 62 -

190 186

* Four responses were omitted from the study as they had not addressed the questions posed in the questionnaire

FINDINGS One hundred and thirty-eight (77.5%) respondents indicated that they had gone some or all of the way towards implementing the Midwifery Process or Planned Individualised Care (MP/ PIC) as shown in Table 2, although the majority of these still had some distance to go. For example, partial implementation as reported might include antenatal wards and postnatal care but not labour care and antenatal clinics. Table 3 shows the implementation of the MP/ PIC by Region/Country and reveals a degree of variation in the same. For example the West Midlands Region and the South East Thames

MIDWIFERY

Table 2 The implementation of the Midwifery Process/ Planned Individualised Care

Full implementation Partial implementation Not implemented Number of responses

Number of units

%

65 73 40 178*

37 41 23 100

* Eight respondents did not answer this question

Region both had a majority of units where partial or no M P / P I C existed, whilst in Wales and the North West Thames Region all units, except one, had full or partial implementation, and in Scotland the picture was more mixed. A surprising finding, given the importance of certain forms of record keeping in effecting the MP/PIC, was that 52 (38%) of the units using those frameworks reported that their records were inconsistent with their approach to care (Table 4). However, the difficulties of working within a framework of MP/PIC, without records which co-ordinate with these concepts may be of short duration, given the replies received regarding the renewal and revision of maternity

records. Examination of enclosed documentation confirmed the reported inconsistencies, together with a small number which had not been reported. In most instances, for example, there was no obvious means to enable the midwife to record the evaluation of care alongside any assessment and planning of care. Many of the midwifery documents enclosed were of a traditional 'Nursing Kardex' type whose structure encourages only a retrospective recording of care carried out. One hundred and thirty-one (74% of those responding to this question) units were in the process of revising records and 114 units (74% of those responsing to this question) planned to revise records in the subsequent 18 months. This widespread activity is obviously engaging a lot of midwifery time. We suggest that co-ordination at regional or national level could save considerable time and duplication of effort. The use of models

The replies suggest that models are rapidly increasing as a midwifery concern. In mid-1987, Christine Midgley undertook a survey of 145 midwifery schools on the use of a model for nursing in midwifery education and clinical practice,

Table 3 Midwifery Process/Planned Individualised Care by Region/Country Number of units

Region/Country Northern Yorkshire North Western Mersey Trent West Midlands East Anglia Oxford N E Thames NW Thames SE Thames SW Thames Wessex South Western Others Scotland Wales Total

165

Full Partial Not implementation implementation used 5 7 4 0 7 2 2 3 3 4 2 2 4 7 3 4 6

5 3 8 5 1 8 3 5 4 5 4 3 4 2 0 9 4

2 5 2 2 4 7 2 2 2 0 5 1 0 1 0 4 1

65

73

40

* Eight respondents did not answer this question

All 12 15 14 7 12 17 7 10 9 9 11 6 8 10 3 17 11 178 ~

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Table 4 The co-ordination of records w i t h the M i d w i f e r y Process/Planned Individualised Care

Table 6 The use of models by region-country Number of units with:

Units with full/partial MP/PIC Records consistent Records partially consistent Records imminently to be coordinated Records inconsistent Total

Region/Country

%

77 7

56 5

2 52

1 38

138

100

and found that only 48% of the respondents were using the nursing process of whom only 37To were basing their care on a model (Midgley, personal communication). This means that of the 135 units who replied to Midgley's questionnaire, only 24 (18~o) were using the nursing process based on a model 6 months before this project's survey was undertaken. Although the two surveys are not directly comparable, the variation in their findings nevertheless suggests an increase in midwifery's attention to models. Table 5 shows the incidence of midwifery or nursing models as reported to this project. Clearly models are still a minority activity but our survey showed use in 37% of units, compared with Midgley's 18~o--a doubling. This finding was surprising not only in relation to Midgley's earlier survey, but also given the paucity of discussion of models in the midwifery press. The Midwives Inform.ation and Resource Service (MIDIRS) confirmed that whilst there is considerable demand from midwives for information on the use of models in midwifery, there is very little information on the subject available (Rosser, personal communication). Table 5 Units using a m i d w i f e r y / n u r s i n g model Number Model in use Model in pipeline Model not used Total

%

64 16 94

37 9 54

174*

1 O0

* Twelve units did not respond to this question

Northern Yorkshire North Western Mersey Trent West Midlands East Anglia Oxford N E Thames NW Thames SE Thames SW Thames Wessex South Western Others Scotland Wales Total

Model in Model in No model use pipeline used All 7 5 3 6 2 5 2 1 3 4 3 2 2 6 2 5 6

0 0 3 1 2 3 0 2 2 0 0 0 0 2 0 0 1

4 11 8 0 7 9 5 7 4 5 7 3 5 2 1 12 4

11 16 14 7 11 17 7 10 9 9 10 5 7 10 3 17 11

64

16

94

174*

* Twelve units did not respond to this question

Use of models for midwifery vary greatly throughout the country (Table 6). For example, the widespread use of models as a basis for care in Mersey compares with a less common use in the Oxford Region and in Scotland. Table 7 lists the models which were reported to be in use. Many of the 16 units who had or were in the process of developing their own models enclosed information which confirmed that this was because they were wanting a model grounded in

Table 7 The models used for maternity care

Orem Roper/Logan/Tierney Henderson Roy Own model Other model*

Number of units

%of 186 respondents

36 15 8 4 16 13

19 8 4 2 9 7

* Examples include Saxton and Hylands, 'Crisis Intervention', Stenhouse, "the ENB model'. The number of units listed is greater than 80 (Table 6) because some units were using an amalgamation of 2 or 3 models as a framework for midwifery care

MIDWIFERY midwifery rather than nursing. They often used words such as 'normal', 'health', and 'holism' to describe their model. Some of the 'other' models referred to by 13 units were not models, on the face of it, but being mentioned as such by respondents, they have been treated here accordingly since it was not clear whether an 'own' model had been built up around them. For example, Stenhouse is an educational theorist and no indication was given by the respondents concerned as to how his work relates to midwifery practice. Furthermore, enquiries failed to confirm the existence of an 'ENB Model', and the respondent concerned had not elaborated on this reply. Some units mentioned more than one model, and some were using an amalgamation of 2 or 3 models. The overall breakdown was very much in line with what Midgley found in her survey and confirmed that Orem's Self-Care Model of Nursing was that in widest use in midwifery up to the end of 1987. O f the 80 units who based care or who planned to base care on a model, 71 indicated whether or not documentation would be affected. Fifty-one (72%) said that the use of a model either did or shortly would affect documentation, whilst 20 (28%) said that documentation was not affected. Examination of enclosed documents did however suggest a discrepancy between what units reported to be their favoured approach to clients and what their records encouraged or allowed them to express of this approach. For example, some units using Roper, Logan and Tierney's model who also said that the use of their model affected documentation, in fact had no specific area in their records for assessing or recording the Activities of Daily Living around which the model is based. Although most units with these and similar discrepancies had reported plans to revise documents, not all of them planned to do so, and the questionnaire did not establish the nature of the planned revisions. It is difficult to understand how any model for care can be used effectively in the absence of appropriate documentation. Such discrepancies must cause intellectual and practical problems for the midwives concerned and some confusion to their clients and midwifery students. This also suggests

16 7

that models may have an ambiguous status in some of the units purportedly using them.

Standards The survey asked about adherence to formulated standards of care and suggested, as examples, the three 'Maternity Care In Action' reports and the All-Wales Nurse Manpower Planning Committee's 'Standards of Care for the Maternity Services'. One hundred and forty-one (81% of units responding to this question) were users of formulated standards. The 'Maternity Care in Action' reports were those most commonly cited and were mentioned by 127 units (68% of those 186 who returned usable responses). Table 8 gives an over-view of the particular formulated standards in use. Table 8 F o r m u l a t e d m a t e r n i t y s t a n d a r d s in use

Maternity Care in Action All-Wales Own/other No formulated standards

Number of units*

% of sample of 186

127 20 15 33

68 11 8 18

* Some respondents were using more than one source for their standards for care

There was a marked variation by region/ country in response to this question--for example, 100% of units in the Mersey and South West Thames Regional Health Authorities who answered the question said that they did adhere to some such standards, whilst only 4 (22%) of the Scottish units who responded said that they did (Table 9).

M e t h o d s f o r a s s e s s i n g the q u a l i t y o f m i d wifery care Regarding means to assess the quality of care given, 95 (56%) of 171 respondents to this question said that they did have a way of assessing quality of care, and most of these 95 mentioned more than one method of assessing quality. Only one respondent failed to mention any. The remaining 94 gave a total of 258 means of assessment (Table 10). As the methods identified included a large

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MIDWIFERY

Table 9 Use of formulated standards by region/country Number of units Region/country Northern Yorkshire North Western Mersey Trent West Midlands East Anglia Oxford N E Thames NW Thames SE Thames SW Thames Wessex South Western Others Scotland Wales

Total

Using standards

Not using standards All

12 14 12 7 11 12 6 8 8 7 8 5 6 8 3 4 10

0 2 2 0 1 5 1 2 0 1 2 0 2 2 0 12 1

141

33

12 16 14 7 12 17 7 10 8 8 10 5 8 10 3 16 11 174"

* Twelve units did not respond to this question

number of items which presumably also apply to units which said that they did not have a way of assessing quality of care (for example, supervision of midwives, staff-sickness levels, letters of complaint and letters of appreciation), the 76 negative responses suggest that quality assessment was perceived by these 44% of respondents as being specific and formal. M a n y of the comments made alongside the 95 affirmative responses reinforce this impression--e.g. 'mainly subjective', 'informal', 'not a specific system', 'in very general terms', 'not formally', 'unofficial'. It is difficult to know how much these replies were prompted by the nature of the project itself--the letter which accompanied the questionnaire clearly stated its intent 'to devise a version of " M o n i t o r " to be used as a quality assessment index for the maternity services' and how much they were prompted by a possible perceived need for a more formal and objective means of assessing quality of care. The methods which were identified as indicative of the quality of maternity care in Table 10, showed a strong inclination towards the gauging of consumer feelings, either through discussion, formalised evaluation, or most popularly at the

moment, client questionnaire. Less c o m m o n l y emphasised were 'perinatal mortality meetings' and 'statistics' which m a y mean that, though the former still take place and the latter collated and both are ofobvious importance, they are not seen by midwives as adequate indicators of quality. Clients' feelings and perceptions appear to be becoming established as of increasing importance. O n the other hand, staff satisfaction was not often identified as an indication of the quality of services. Staff morale measurements (items 34 and 35 of Table 10) were only mentioned three times. This is an area which m a y hold m a n y untapped resources for midwifery managers in the whole area of standards and quality of care, and m a y take increasing importance as demographic changes and staff recruitment become more critical. It was also surprising that Maternity Services Liaison Committees were only mentioned by three respondents (Table 10, item 26), despite the 'Maternity Care in Action' report's emphasis on their role in quality assurance (1985, Part 3, p. 55) and the high percentage of units who had already identified the influence of these reports on their practice. The inter-relation of frameworks

for care

Using the data collected as above, a n u m b e r of cross-tabulations were carried out to discover if certain approaches to care were inter-related, or if they appeared to encourage or inevitably lead to other developments such as quality assessment. Table 11 relates M P / P I C to the use of models. O f the 64 units which base their care on a model, 37 (58%) describe the care as a midwifery process/ planned individualised approach. A further 23 (36%) have moved partially in this direction, with only 4 (6%) using a model but not using M P / P I C . Overall the table shows a statistically significant relationship between the use of models and the use o f M P / P I C ( p < 0 . 0 1 ) , with a noticeable 23 units using M P / P I C who do not use a model and a further 40 who partially use M P / P I C in the absence of a model. Sixty-four units now base themselves on a model; 62 offer M P / P I C but only 37 of these are c o m m o n to both groups. Where standards are in use, 56/140 units

MIDWIFERY

Table 10 H o w m i d w i v e s assess t h e quality of care (responses f r o m 95 units)

Times mentioned

Item 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38.

Client questionnaire/survey Feedback from clients, especially at P/N classes or reunions Letters of complaint Mothers" comments on careplans/evaluation forms/at exit interviews Supervision of midwives Talking to clients Clinical audit (incl, workload assessments, dependency studies, bed occupancy) Checking standard of record-keeping Letters of appreciation Feedback from consumer groups, especially CHC & NCT Perinatal mortality meetings Statistics Unit meetings Personal observation/ward rounds Quality circles Regular updating/use of policies, protocols Midwives' evaluation of care Infection control reports Procedures committee/monitoring procedures Development/monitoring of standards/aims and objectives Breastfeeding/parentcraft and other specific surveys Staff/G.P. questionnaire Senior midwives/unit management meetings University or other large research project Staff appraisal Maternity Services Liaison Committee meetings Talking to midwives In-service training Checking records following stillbirth and perinatal death Suggestion/complaints box Evaluations by student midwives Small (staff/student) research projects Working groups (e.g. 'midwifery process working party') Recruitment, retention, morale of midwives Staff sickness levels Uptake of services by local population Community midwife/health visitor liaison groups None specified

Table 11 Care described as M i d w i f e r y P r o c e s s / P l a n n e d Individualised Care and t h e relationship to use of a model

Care described as MP/PIC

Care based on a model

;(2=27.587

df=4

Yes In pipeline No Total p
Yes

Partially No

Total

37 2 23 62

23 9 40 72

64 16 93 173

4 5 .30 39

42 20 17 17 12 10 10 9 9 8 7 7 7 7 6 6 6 5 5 5 5 4 4 3 3 3 3 3 2 2 2 2 2 2 1 1 1 1

] 69

170

MIDWIFERY Table 12 The relationship between adherence to formulated standards of care and t h e use of M P / P I C

of units

MP/PIC used

MP/PIC partially used

MP/PIC not used

All

Yes No All

56 6 62

54 19 73

30 8 38

140 33 173

Number

Formulated standards in use

;(= = 5.929 N.S.

(40%) use M P / P I C . Where standards are not in use, 6/33 (18%) use M P / P I C . O f those who use M P / P I C , 56/62 (90%) have formulated standards. I n general terms, there is a trend between the use of formulated standards and the use of M P / P I C (Table 12). The cross-tabulation shown in Table 13 is of numbers of units which use some method of assessment with those who use M P / P I C and reveals a statistically significant relationship (p<0.001). Those who use M P / P I C are more likely to assess quality in some way, though there are 16 exceptions amongst M P / P I C users. At the other extreme, those units who do not use M P / P I C are much less likely to assess quality, with 14 exceptions. Units using M P / P I C are therefore probably more aware of quality issues. One h u n d r e d and thirty-five units expressed an interest in further participation in the project, and 86 enclosed a copy of their documentation. T h e former have been taken up on their offers and have been involved in a recent validation study on the midwifery quality assurance tool under development. T h e interest in the development of quality assurance criteria in midwifery appears considerable and widespread.

DISCUSSION This study is based entirely on self-report and therefore the responses given m a y misrepresent or, at the least, introduce an element of bias to the findings obtained. For example, the questionnaire asked whether there was adherence to formulated standards of care such as the 'Maternity Care in Action' reports but did not seek to identify the degree of adherence to these standards. The discrepancies between the frameworks for care reported to be in use (Midwifery Process/ Planned Individualised Care and models) and the documentation used in m a n y instances have already been discussed. Unfortunately the survey did not'glean any information as to the extent to which use of these frameworks was inhibited by inconsistent documentation. If it is significantly inhibited, the findings of this survey will overestimate the extent to which the Midwifery Process/Planned Individualised Care and models are used in midwifery. A national survey of midwifery practice, as a precursor to the development of quality assurance criteria in midwifery, has revealed that the framework known as 'Planned Individualised

Table 13 The relationship between the use of m i d w i f e r y process/planned individualised care and quality assessment

Quality of care assessment

Yes No All

Z== 14.69

df = 2

p < 0.001

Full use

Partial use

Not used

All

44 16 60

35 35 70

14 25 39

93 76 169

MIDWIFERY

Care' is a highly favoured approach in midwifery at the present time. This tendency towards m a k i n g the i n d i v i d u a l w o m a n and her family the centre of midwifery practice is further reflected in the means by which m a t e r n i t y units are currently assessing the quality of their care (Table 10). It suggests to the authors that any 'Midwifery M o n i t o r ' quality assessment tool should reflecl~ both the tailoring of midwifery care to the needs of each w o m a n a n d her family, and the importance attached to g a u g i n g the perceptions of clients as a means of assessing quality. T h e survey did not identify any overwhelmingly p o p u l a r ' m o d e l ' for midwifery c a r e ~ O r e m ' s model, although that most c o m m o n l y cited by respondents, was used in only 36 (19~o) units. T h e diversity of models used, as well as regional variations a n d the unsettled n a t u r e of midwifery's use of models, indicated that it would be difficult to justify basing the tool on a 'model' approach. T h e responses to the questionnaire showed that the ideas put forward in ' M a t e r n i t y Care in Action' do represent the standards of care towards which midwifery is working. Although m a n y of the reports' r e c o m m e n d a t i o n s refer to the structure, as opposed to the process of care, and to medical policies, the content of ' M a t e r n i t y Care in Action' offers a basis on which a consensus of what constitutes good midwifery care can be built. Moreover, any assessment of the quality of midwifery care inevitably includes some attention to its structural components and the n a t u r e of prevailing medical policies. A n y quality assessment tool produced by this project will therefore recognise that midwifery care cannot be isolated from the context in which it occurs. Although 'Midwifery M o n i t o r ' will primarily seek to assess the q u a l i t y of the process of midwifery care, it will also address some issues of structure a n d medical protocol. M e a n w h i l e midwifery interest in methods of quality assurance has been reflected in the response to this survey a n d at a conference, titled

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' T h e Q u a l i t y of Care: towards an objective a p p r o a c h ' , held in J u l y 1988 by the Midwives I n formation a n d Resource Service ( M I D I R S ) . It is hoped that the information gleaned from this survey gives a useful indication of the frameworks a n d standards currently shaping midwifery care.

References BallJ A, Goldstone L A, CollierM M 1984 Criteria for Care: the manual of the North West StaffingLevels Project. Newcastle upon Tyne PolytechnicProducts Ltd Beeston H M, GoldstoneL A 1988 Neuro-Monitor: an index of the quality of nursing care of patients on neuro-medical and neurosurgical wards. Newcastle upon Tyne Polytechnic Products Ltd. GalvinJ, Goldstone L A 1988Junior Monitor: an index of the quality of nursing care forjunior citizenson hospital wards. Newcastle upon Tyne PolytechnicProducts Ltd Goldstone L A, BallJ A, CollierM M 1983 Monitor: an index of the quality of nursing care for acute, medical and surgical wards. Newcastle upon Tyne Polytechnic Products Ltd Goldstone L A, IllsleyV A 1986District Nursing Monitor. Newcastle upon Tyne PolytechnicProducts Ltd Goldstone L A, Maselino-OkaiV 1986 Senior Monitor: an index of the quality of nursing care for senior citizensin hospital wards. Newcastle upon Tyne Polytechnic Products Ltd Jelinek R C, Haussman R K D, Hegyvary S T, NewmanJ F 1974 A Methodologyfor Monitoring the Quality of Nursing Care. United States Department of Health, Education and Welfare, Publication No. HRA 76-25 Jelinek R C, Haussman R K D, Hegyvary S T, NewmanJ F 1976 Monitoring quality of nursing care. Part 2: Assessmentand Study of Correlates. United States Department of Health, Education and Welfare, Publication No. HRA 76-7 Jelinek R C, Haussman R K D, Hegyvary S T 1977 Monitoring quality of nursing care. Part 3: Professional review of nursing--anempirical investigation.United States Department of Health, Education and Welfare, Publication No. HRA 77-70 Maternity ServicesAdvisoryCommittee. Maternity Care in Action. Part 1: Antenatal Care. 1982. Part 2: Care during Childbirth. 1984. Part 3: Care of the Mother and Baby. 1985. Department of Health and Social Security (Crown Copyright) Medicus Systems Corporation, Chicago 1979 Monitoring Quality of Nursing Care. Part 4: The Nursing Process in Four Speciality Areas. U.S. Department of Commerce, National Technical Information Service, Publication No. HRP 0900639 Royal Collegeof Nursing 1988Directory of Quality Assurance