TEORIA ETOLOGICA

Portela, Pronovost, Woodcock, Carter and Dixon-Woods (2015:1) propose that improvement interventions, which are purposeful efforts to secure positive change in the practice environment, have become an increasingly important activity within the healthcare environment. The study indicates that registered nurses are willing to support QI initiatives but that they are confronted with several challenges towards the realisation of sustainable implementation of QI initiatives.

4.3.4.1 Challenges to supporting QI initiatives

The findings portray the following challenges that the registered nurse faces in supporting the “Back to basics” QI initiative.

 Insufficient involvement of the registered nurse in the development of QI initiatives in the clinical practice environment

The participants shared their perceptions that quality initiatives are driven from an organisational point of view, without adequate representation of the registered nurse category to provide inputs when QI initiatives are developed. Roussel, Dearmon, Buckner, Pomrenke, Salas, Mosley and Brown (2012:203) address the critical importance of staff engagement in improving the work environment and patient care processes.

The study show that QI initiatives are perceived as not being evidence based, and consequently do not speak to the real situation in the practice environment and healthcare-relevant needs of patients. The methodologies underlying successful improvement interventions remain contested, with limited empirical studies to support the body of work in the area of QI interventions (Portela et al 2015:1). Portela et al (2015:5) maintain that QI reports are not without problems, because the fidelity and quality of reporting, as well as the measurement of quality and interpretation of data in QI projects, often provide unreliable data.

 Insufficient understanding of the nature and extent of QI initiatives to enhance effective implementation

Portela et al (2015:1) suggest that improvement initiatives should provide clear intervention strategies with operational definitions of key terms relating to the context and complexity levels of interventions, as well as mechanisms of change associated with improvement critiques. The participants indicated that registered nurses needed more clarification on the concept of the “Back to basics” initiative, and more in-service training to enable them to balance the managerial and clinical responsibilities to enhance quality in basic nursing care delivery.

A study by Roussel et al (2012:203) addresses the ‘Transforming Care at the Bedside’ (TCAB) QI initiative, which was originally developed to transform care to patients at the bedside, and in addition to establish a positive care experience for the nurse. The TCAB initiative established a framework for change in medical-surgical units and enhanced safety and reliability, team energy and patient-centeredness, with an increased perception of the value of service delivery (Roussel et al 2012:204). Thrall and Cavaliero (2012:187) indicate that the TCAB QI initiative reported a decrease in fall incidents and pressure ulcers; new QI initiatives continue to be developed on the success of the TCAB programme.

 Insufficient ownership of the QI initiative at execution level in the nursing unit

The value of direct patient care involvement was acknowledged from a patient-centred perspective although the participants indicated that the operational expectations underlying the registered nurses’ operational roles and responsibilities make it an almost impossible job to fulfil in view of the existing challenges of role strain and role overload. Active leadership with innovative ideas to instil positive culture changes towards commitment and ownership for the implementation of “Back to basics” QI initiative did not emerge in the findings of this study. Thrall and Cavaliero (2012:187) state that the innovation and transformation initiative includes tools to address leadership growth, culture change and implementation of health reform. Sanders et al (2013:346) confirm that shared leadership enables representation and inclusion of clinical nurse practitioners

Roussel et al (2012:204) concur with the current study regarding the need to involve frontline nursing staff’s expertise in decision-making. Sanders et al (2013:346) discuss the advantages of the Magnet-designated hospital environment, which was implemented as a QI initiative abroad in several hospitals. Magnet-designated hospitals embrace shared leadership approaches to achieve and sustain a healthy work environment (Sanders et al 2013:346). Sanders et al (2013:346) reflect on strategies to enhance nurse competence when managing increased patient volumes, as well as implementing QI strategies aimed at the enhancement of physician-nurse relations as part of the hospital’s wellness programme.

Sanders et al (2013:349) discuss the “capacity management QI initiative” that was undertaken when the chief nursing officer executed a pertinent leadership role to educate the clinical nursing staff on best practices when managing high patient volumes. Nurse practitioners applied these taught principles to create their own solutions to meeting the demands and challenges of the work conditions, such as creating sufficient time to conduct bedside end-of-shift reports for safe transfer of care, and adding flexible personnel on staggered shifts to match high-volume peak time patient intervention (Sanders et al 2013:349). Sanders et al (2013:353) report on the successes of this approach, followed by an initiative where more than 80% of the nursing residents participated in a committee or council to govern nursing care matters.

 Organisational work culture challenges to commit to the “Back to basics” QI initiative

The findings indicate that registered nurses have limited time to enhance professional socialisation at the bedside of the patient. Time restraints due to the proportion of time spent on administrative- and managerial work responsibilities compromise the role of the registered nurse to model the desired caring values to the workforce. Okaisu et al (2014:6) suggest that the organisational culture seems to drive and sustain change in QI initiatives. Culture change may be achieved through socialising newly recruited nurses into new ways of thinking to obtain a workforce with the expected values, beliefs, attitudes and competencies. To steer sustainable change in nursing practice, the problems and challenges underlying the organisational and individual dynamics should be considered and attended to with an integrative leadership approach. Sustained change is realised when multiple interventions are implemented (Okaisu et al 2014:6).

The results of the capacity management QI initiative reported by Sanders et al (2013: 353) were due to a change in the work culture, in that nurses displayed commitment to the organisation and perceived their jobs as a career rather than just being a job. A passion was nurtured among nurses to use evidence as the basis of practice. Involvement of clinical nurses in the decision-making processes related to patient care matters resulted in an overall experience of renewed energy among the entire nursing workforce (Sanders et al 2013:353).