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Development of Strategic and Clinical Quality: Indicators in Postoperative Pain Management
Linköping University, Department of Medical and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
2001 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of this thesis was to identify important aspects of surgical nursing care, designing strategic and clinical quality indicators in postoperative pain management, investigate content validity, develop and evaluate psychometric properties of an instrument to measure the indicators, test the applicability of the instrument and investigate patient and nurse assessment.

To identify the important aspects of nursing care which might impact on quality of care in surgical wards, it was conducted 4 focus group interviews with clinical nurses (n=20). A tentative model with 15 categories in 2 dimensions, elements of performance and prerequisites, emerged from the data analysis. The categories were, e.g. detecting and acting on signs and symptoms, informing and educating, promoting relationships, responsibility and attitudes. The model was used as a foundation for developing indicators in postoperative pain management, one in each category, each supported by a literature review. To assess the content validity of the indicators, a questionnaire was compiled and sent to registered nurses with a special interest in pain (n=210) and to a random sample of clinical nurses working in surgical wards (n=321). The groups assessed the indicators as essential for achieving high quality, realistic to carry out and possible for nurses to influence management. The first group validated 14 of the 15 indicators and the second group validated 12 as “major” factors in terms of being essential to achieve high quality of care. The remaining factors were classified as “supportive”. No indicator was discarded.

To measure the indicators, an instrument was developed and psychometric properties were evaluated. The indicators were converted to statements suitable for a patient questionnaire and were scored on a 5-point scale with higher values indicating higher quality of care. Patients (n=198) answered the questionnaire on their second postoperative day. The inter-item and item-total correlation coefficients were in a satisfactory range, and Cronbach’s coefficient alpha (0.84) supported internal consistency reliability. Four sub-scales, entitled communication, action, trust and environment emerged from the factor analysis with a total variance of 61.4%. The total scale correlated (rs=0.53) with the single item pain-relief-satisfaction question. The patients who reported more pain than expected scored lower on the total scale and the patients who received epidural analgesia reported higher scores on the total scale. A nurse questionnaire, similar to the patient questionnaire, was compiled. The responsible nurse at the time (n=63) answered 196 questionnaires paired with the individual patient. The new instrument appeared to be useful in identifying important areas for improvement both from the patients’ and nurses’ perspectives, based on the number of disagreements (1 and 2). Differences were found among departments. The patients’ assessments on the environment sub-scale and the overall satisfaction question were higher than the nurses’ assessments. The findings suggest initial support for the instrument as a means to measure the quality of nursing care in postoperative pain management. Key words: quality indicators; health care, pain; postoperative, focus groups, psychometrics, questionnaires, nursing care.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2001. , 67 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 671
Keyword [en]
quality indicators; health care, pain; postoperative, focus
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-5158ISBN: 91-7219-966-0 (print)OAI: oai:DiVA.org:liu-5158DiVA: diva2:21062
Public defence
2001-05-11, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (English)
Opponent
Supervisors
Note
On the day of the public defence of the doctoral thesis the status of the articles III was: Accepted; article IV and V was: Accepted for publishing.Available from: 2001-05-29 Created: 2001-05-29 Last updated: 2012-01-24Bibliographically approved
List of papers
1. Important aspects of nursing care in surgical wards as expressed by nurses
Open this publication in new window or tab >>Important aspects of nursing care in surgical wards as expressed by nurses
1998 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, Vol. 7, no 6, 512-520 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to find out clinical nurses' perceptions of important aspects of nursing care that might have an impact on quality of care in surgical wards. A qualitative approach using focus group interviews was used. The data analysis revealed 15 categories of important aspects of care which could be condensed into two dimensions, here called 'prerequisites' (i.e., staffing, routines and attitudes) and 'elements of performance' (i.e., detecting and acting on signs and symptoms and acting on behalf of the patients). These aspects could be a starting point for developing quality indicators. Carper's four fundamental patterns of knowing were used to make a theoretical interpretation, and three of them were identified.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13613 (URN)
Available from: 2001-05-29 Created: 2001-05-29
2. A tentative model for developing strategic and clinical nursing quality indicators: postoperative pain management
Open this publication in new window or tab >>A tentative model for developing strategic and clinical nursing quality indicators: postoperative pain management
1999 (English)In: International journal of nursing practice, ISSN 1322-7114, Vol. 5, no 4, 216-226 p.Article in journal (Refereed) Published
Abstract [en]

The purpose of the study was to evaluate the usefulness of a tentative model, based on important aspects of surgical nursing care, for designing strategic and clinical quality indicators. Objective postoperative pain management was chosen for the model because it is a priority area in surgical nursing care. Items within a questionnaire were designed by using the tentative model as a base and by means of a literature review. The questionnaire, directed to clinical nurses (n = 233), was compiled to establish the validity and the usefulness of the indicators. Fourteen items were assessed as essential for achieving high quality outcomes in postoperative pain management (11 as realistic to carry out, and 13 as possible for nurses to influence) with mean scores > or = 4 (on a 5-point scale). The conclusion reached was that the tentative model combined with a literature search was found to be effective for designing items that might be useful as strategic and clinical indicators of quality in postoperative pain management.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13614 (URN)
Available from: 2001-05-29 Created: 2001-05-29 Last updated: 2009-05-19
3. Quality indicators in postoperative pain management: a validation study
Open this publication in new window or tab >>Quality indicators in postoperative pain management: a validation study
2001 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, Vol. 15, no 4, 331-338 p.Article in journal (Refereed) Published
Abstract [en]

In a previous study, strategic and clinical quality indicators were developed from a tentative model to assess high quality in postoperative pain management. The aim of the present study was to investigate the content validity of these 15 indicators. The indicators were compiled in a questionnaire, and two groups of nurses (n=210, n=321) scored each indicator on a 5-point scale (strongly disagree to strongly agree) from three different standpoints: whether it was essential for achieving high quality, whether it was realistic to carry out, and whether it was possible for nurses to influence management. The respondents were also asked to choose the most crucial indicators for the quality of care. The results showed that both groups of nurses judged the 15 indicators to have content validity from all three standpoints. Both groups also found the same six indicators to be the most crucial. These indicators concerned detecting and acting on signs and symptoms, performing prescriptions, informing and educating, acting on behalf of patients, competence/knowledge, and attitudes. The validated indicators should be useful to consider when implementing a strategy for postoperative pain management and when planning to evaluate the quality of care.

Keyword
pain, postoperative, quality indicators, validitym, clinical nursing research
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13615 (URN)10.1046/j.1471-6712.2001.00037.x (DOI)
Available from: 2001-05-29 Created: 2001-05-29 Last updated: 2009-05-19
4. Development of an instrument to measure strategic and clinical quality indicators in postoperative pain management
Open this publication in new window or tab >>Development of an instrument to measure strategic and clinical quality indicators in postoperative pain management
2002 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, Vol. 37, no 6, 532-540 p.Article in journal (Refereed) Published
Abstract [en]

AIM OF THE STUDY: To develop and evaluate psychometric properties, that is reliability and validity, of an instrument to measure strategic and clinical quality indicators in postoperative pain management.

BACKGROUND: Strategic and clinical quality indicators in postoperative pain management were previously developed from a tentative model of important aspects of surgical nursing care and assessed to have content validity, that is to be essential for the quality of care, realistic to carry out and possible for nurses to use to influence management.

METHODS: The quality indicators were converted to items suitable for a patient questionnaire and were scored on a 5-point scale, with higher scores indicating higher quality of care. Inpatients from five surgical wards took part in this study on their second postoperative day. The response rate was 96% and the average ages of the female (n=120) and the male (n=78) respondents were 62 and 63 years, respectively.

RESULTS: Items in the total scale had an average inter-item correlation >0.20 and an item-total correlation >0.30. Cronbach's coefficient alpha was 0.84 for the total scale. Four factors entitled 'communication', 'action', 'trust' and 'environment' emerged from an orthogonal factor analysis, with a cumulative variance of 61.4%. Patients who received epidural analgesia had higher scores on the total scale compared with those who did not receive epidural analgesia. Patients who reported more pain than expected had lower scores on the total scale compared with those who did not report more pain than expected. Correlation between the total scale and an overall pain relief satisfaction question was 0.53.

CONCLUSION: The results suggest initial support for the new instrument as a measure of strategic and clinical quality indicators in postoperative pain management, but it must be further refined, tested and evaluated.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13616 (URN)10.1046/j.1365-2648.2002.02130.x (DOI)
Available from: 2001-05-29 Created: 2001-05-29 Last updated: 2009-05-19
5. Patient and nurse assessment of quality of care in postoperative pain management
Open this publication in new window or tab >>Patient and nurse assessment of quality of care in postoperative pain management
2002 (English)In: Quality & Safety in Health Care, ISSN 1475-3898, Vol. 11, no 4, 327-334 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To describe and compare patient and nurse assessments of the quality of care in postoperative pain management, to investigate differences between subgroups of patients, and to compare patient assessments in different departments.

Design: Patient and nurse questionnaires.

Setting: Five surgical wards in general surgery, orthopaedics, and gynaecology in a central county hospital in Sweden.

Sample: Two hundred and nine inpatients and 64 registered nurses. The response rates were 96% for the patients and 99% for the nurses; there were 196 paired patient-nurse assessments.

Method: The Strategic and Clinical Quality Indicators in Postoperative Pain Management patient questionnaire was used which comprises14 items in four subscales (communication, action, trust, and environment). The items were scored on a 5 point scale with higher values indicating a higher quality of care. Five complementary questions on levels of pain intensity and overall satisfaction with pain relief were scored on an 11 point scale. Twelve of the 14 items in the patient questionnaire and two of the complementary questions were adjusted for use in the nurse questionnaire.

Results: The patients’ mean (SD) score on the total scale (scale range 14–70) was 58.6 (8.9) and the nurses’ mean (SD) score (scale range 12–60) was 48.1 (6.2). The percentage of patients who scored 1 or 2 for an individual item (disagreement) ranged from 0.5% to 52.0%, while for nurses the percentage ranged from 0.0% to 34.8%. Forty two patients (24%) reported more pain than they expected; these patients assessed the quality of care lower. There were differences between patient and nurse assessments concerning the environment subscale, the question on overall satisfaction, and patients’ experience of worst possible pain intensity.

Conclusion: The results provided valuable baseline data and identified important areas for quality improvement in postoperative pain management.

Keyword
postoperative pain, quality improvement, patient assessment, nurse assessment
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13617 (URN)
Available from: 2001-05-29 Created: 2001-05-29 Last updated: 2009-05-19

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