JANUARY 2001, VOL 73, NO 1

R E V I E W S

RESEARCH REVIEWS

IMPORTANT ATTRIBUTES OF QUALITY HEALTH CARE: CONSUMER PERSPECTIVES M H Oermann, T Templine Joumal of Nursing Scholarship Vol32 no 2 ( I 998)

ersonnel at contemporary health care agencies are iden- P tifying patient outcomes to

evaluate services and patient care. This research focuses on con- sumer perspectives of high quali- ty health care. Consumer perspec- tives or expectations have been found to be based on demograph- ic characteristics, health care experiences, and specific con- cerns related to consumers’ unique health problems. Further, patients evaluate their experiences by comparing their expectations to actual events. Satisfaction occurs when events match expec- tations. The purpose of this research was to allow consumers to identify important attributes of quality health and nursing care and to examine the relationship of consumcr pcrspcctivcs to health status and selected demographic variables.

Method and sample. This exploratory study examined a convenience sample of 239 health care consumers, of which 50% were recruited from homes in neighborhoods of a large metro- politan area (ie, urban and subur- ban) in the Midwest, and 50% were recruited from waiting rooms of clinics in the same neighborhoods. These participants included 149 women (63.1%) and 87 men (36.9%). These gender totals equal 236, whereas previ- ously stated the sample size was 239. This discrepancy was not

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addressed in the article. The age range varied from 18 to 92 years of age. The mean age was 50.8 years. One-half of the subjects were married. Although half of the participants had a high school diploma, education levels ranged from less than high school to post- graduate education. Participants included 163 (71.2%) Caucasians and 66 (28.8%) African Americans. This totals 229. The ethnicity of the remainder of the participants was not identified.

Participants were asked to complete a SF-36 Survey that measured health status in eight general areas, including

I

physical function, role limitation due to physical health problems, bodily pain, general health, vitality (ie, energy, fatigue), social functioning, role limitations due to emo- tional problems, and mental health.

Additionally, a Quality Health Care Questionnaire (QHCQ) was given to the participants. The investigators developed this instrument, which included demo- graphic information and 27 attrib- utes of health care and nursing quality. Participants completed the QHCQ based on a Likert-type scale-rating the importance of each attribute on a scale from one (ie, not at all important) to five (ie, very important). This tool was developed from the literature regarding health care quality and research on consumers’ perspec- tives of quality care, as well as research about patient satisfaction with nursing care. A factor analy- sis with Eigenvalues greater than one resulted in six factors, includ- ing medical care, teaching by the nurse, provider competence,

choice of provider, nurse-patient interaction, and appointment con- venience. Teaching by the nurse included such items as having a nurse teach about illness, medica- tion, and treatment.

Findings. A rating of the 27 items showed attributes of health and nursing care that participants deemed important. These attrib- utes included understanding physicians’ explanations, having access to specialists when neces- sary, having the opportunity to communicate with physicians, being included in making health care decisions, and having diag- nostic tests performed for early identification of diseases.

of quality nursing care included The most important indicators

being cared for by nurses who are up-to-date and well informed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; and having the nurse teach about illnesses, medications, and treatments.

Interestingly, responses differed significantly between these sam- pled Caucasians and African Americans. African Americans rated medical care as less impor- tant than Caucasians (F [ 1,2291 = 9.95, P < .01); however, they rated teaching by the nurse as sig- nificantly more important (F [1,229] = 6.77, P < .01).

Participants with a number of chronic illnesses rated the impor- tance of teaching by the nurse (r = .25, P < .001), choice of provider (r = .24, P < .001), and conven- ience of appointments (r = .0145, P = .03) as important attributes of quality care. Additional findings showed that participants with less

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JANUARY 2001, VOL 73, NO 1

education and lower incomes rated teaching by the nurse as more important in their care than those with higher education and incomes.

Discussion. The researchers believe the findings from this study are consistent with findings from other research exploring ambulatory care. Attributes of importance have included access to care, coordination of services, education, being treated with respect, and processes of care (eg, waiting times for appointments); however, few previous studies have examined the importance of nursing care in participants’ views of quality. This study shows it is important to be cared for by nurses who are up-to-date and well informed and have the ability to communicate in an unhurried atmosphere conducive to effective teaching. The study also shows that patients who were not well educated found nurse information more beneficial than participants with greater education.

MICHELLE BYRNE RN, MS, PHD, CNOR

NURSINO RESEARCH COMM~TTEE

THE CNSS IMPACT ON PROCESS AND OUTCOMES OF PATIENTS WITH TOTAL KNEE REPLACEMENT E C Wheeler Clinical Nurse Specialist Vol14 (July 2000)

T acceptance of the clinical nurse specialist (CNS) role. Economic pressures force admin- istrators to examine various posi- tions and decide which to retain or eliminate based on revenue and cost-effectiveness. There has been a perception that CNSs do not

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here has been insufficient evi- dence to justify the universal

generate revenue and, therefore, are not cost effective. The purpose of this study was to determine if selected process and outcome variables exist between patients undergoing total knee replacement (TKR) procedures on units with CNSs and on units without CNSs.

Conceptual framework. This study used the model of con- structs important to determining the quality of care according to Avedis Donabedian, author of Explorations in Quality Assessment and Monitoring Volume I : The Definition of Quality and Approaches to Its Assessment. This model includes structure, process, and outcome. Structure variables include char- acteristics of the facility; in this study, facility and unit demo- graphics were considered. Process variables include activities per- formed by the health care provider (ie, using process instru- ment). The process used to obtain an outcome is critical. Process variables were identified by using a process instrument for nursing activities based on the National Association of Orthopedic Nurses Guidelines for Orthopedic Nursing. Outcome refers to length of stay (LOS) and complications.

Methodology. A comparative correlation design was used to collect data via retrospective chart review. Four orthopedic units in the Northeastern United States were chosen for the study-two with unit-based CNSs and two without. Team and primary nurs- ing were the models of nursing care on these units. All units had established guidelines and stan- dards for the care of patients with TKR. All units of study were comparable in nurse-to-patient ratio, number of beds, and physi- cal therapist-to-patient ratio.

Subjects were selected ran- domly from a computer-generated list of patients who had undergone TKR surgery. The researcher used a t test, with an alpha of .05 and medium effect size with a power of .80, to arrive at a sample size of 64 patients for this study. The investigator designed the process instruments (ie, the Acute Pain Process Instrument [APPI] and the High Risks for Disuse Syndrome Process Instrument [HRDSPII). These instruments captured those nursing activities documented as being provided to the patient. The investigator estab- lished content validity and inter- rater reliability for both instru- ments. The assumption used for both instruments was that the more activities a nurse performs, the better the quality of care. Data for the APPI and HRDSPI were collected for the first 24-hour period postoperatively because these were determined to be the more critical hours when nursing care has a significant effect on the patient’s condition.

Resulk. The results showed that patients on units with CNSs received more nursing care inter- ventions more frequently than patients on units without CNSs (P < .OOOl). There was a sigmficant difference in total LOS between the two groups (P < .001), with patients on units with CNSs hav- ing a shorter LOS. Total LOS included time on a hospital unit plus LOS on a rehabilitation unit; however, there was no difference in the LOS on the orthopedic unit between the two groups. There were fewer complications on units with CNSs than those without- six (9%) complications on units with CNSs versus 17 (26%) com- plications on units without CNSs. The research revealed a significant

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