QUALITY ASSURANCE: AN

EVALUATION OF THE
QUALITY OF NURSING CARE
IN SWAZILAND
By: DR. N. T. SHONGWE
SWAZILAND
At the Ecsacon 6th Scientific Conference
± Dar-es Saalam ± August 2002
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þ The nursing profession has a social obligation to
monitor and evaluate the care provided to
patients/clients and communities. There is a
social contract between the nursing profession
and society. Thus the nursing profession is
expected to be mindful of society¶s trust and act
in a respectful, responsible and accountable
manner. In review of this expected responsibility,
respect and accountability, the nursing profession
has an obligation of self-regulation, whereby the
nurses determine whether their services are still in
line with the social contract entered into with the
society.
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þ To ensure that there is delivery of quality health
services, it is mandatory to emphasize the nursing
care aspect. According to Papps(1994) good
nursing care is a critical facet of health care and
has an impact on all the business aspects of
hospital and community care. In hospitals nursing
care must be provided for 24 hours every day of
the year. Without nursing care neither patients
nor other health professionals will be satisfied
with services provided.
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 identification contd...
þ Although there is increasing interest in evaluating
nursing/health services, historically nurses have
also been committed to the evaluation of the care
they provided to patients/clients. Schroeder
(1991: 7) refers to this as a commitment to
Quality Assurance. An example of this
commitment was the introduction of standards of
infection control by Florence Nightingale during
the Crimean war, which resulted in a decline in
the mortality rate of soldiers from 42% to 2%.
Problem w  

 Contd...

þ There should be evaluation of that care so

that strategies for improvement are
scientifically based.
 Purpose of The Study

þ To provide information to be utilized for

the improvement of the quality of nursing
care in Swaziland, through the
identification of areas that needed to be
corrected or changed.
 Research Questions
þ Is the clinical practice environment in
medical and surgical wards and rural
clinics conducive to the provision of
quality nursing care?
þ What are the lodgers and patients¶/clients¶
opinions, as well as those of the nurses
about the quality of nursing care
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þ Quality: Degree of excellence
þ Quality Assurance: A process of
establishing a specified degree of
excellence to ensure that each patient/client
receives the agreed level of care. It relates
directly to identification of criteria and
standards, and the construction of tools to
assess whether or not the standards have
been achieved. It leads to action promoting
achievement of agreed standards (Pearson
1991: 7)
 Definition of

 Contd...
þ Quality Nursing Care: Is an acceptable degree of
nursing services (based on standards) provided to
patients/clients, families and communities. NB:.
These standards of nursing are developed by the
profession and serve as a basis for evaluation.
þ Lodgers: Patients¶ relatives or guardians who stay
in hospitals looking after their sick relatives.
þ Nurse: Is a profession/registered nurse or nurse
midwife working in medical and surgical wards
of the four selected regional hospitals and rural
clinics and is authorized by the Swaziland
Nursing Council to practice as a registered nurse.
 Definitions from Uganda
þ Quality: Doing the right thing, the right
way at the right time.

þ Quality assurance closes the gap between

what is being achieved and what can be
achieved with the same resources
 Conceptual Framework

þ Donabedian¶s structure, process and

outcome approach to quality was utilized in
conjunction with developed nursing
practice standards (1999) and Attrees
attributes of quality nursing care.
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þ Exploratory study where both qualitative
and quantitative methods were used
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 : Data was collected
using the following:
þ Observation checklist for the environment
(ward)
þ Questionnaire: to determine nurses¶ opinion
on QNC
þ Focus group interviews: to determine
lodgers¶, clients¶ and patients¶ opinions of the
quality of nursing care.
 Target 


þ Nurses in medical and surgical wards of the
four regional hospitals: 103 (81 %)

þ Lodgers in the medical and surgical wards

of the four regional hospitals: 88

þ Patients/clients in the selected clinics: 71

þ Total respondents: 262

 
þ Purposive sampling was used for selection
of the research settings (Polit and Hungler
1999:284). (A total of 21 wards) Four
regional hospitals and four regional clinics
were selected.

þ Convenience sampling was used used for

the selection of research respondents:
nurses, lodgers and patients/clients (Polit
and Hungler 1999: 28, Wilson 1993: 178
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þ Quality assurance process
þ Identification of values
þ Identification of standards:
þ Structure
þ Process
þ Outcome
þ Securing measurement instruments and
data collection
þ Data analysis= Triangulation of
quantitative and qualitative data (Note:
Data analysis approach)
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þ Factor analysis of the quantitative data (SPSS )
was utilized for grouping of the data as follows:
þ Professionalism
þ Resources
þ Management
þ Basic Nursing Care
þ Nursing process
þ Caring
þ Quality nursing care
þ Education: Nurses, Lodgers, patients
þ Long waiting time
 Data Analysis cont.

þ Qualitative data was grouped into thematic

catagories
þ Triangulation of both qualitative data was
done under the factor analysis grouping.
   of Findings
þ The general quality of nursing care was found to
be unsatisfactory.
þ The majority of nurses (75 % ), lodgers and
clients/patients concurred that the quality of
nursing care was not at the acceptable level and
they called for improvement of that care
þ The nurse purceived severe shortage of
nurses,equipment as well as medical supplies and
nurses poor working conditions to be the main
problems underlying the poor quality of nursing
care.
  
 



þ Ô The lodgers and patients/clients¶ view point
was that the general ³uncaring´ attitude and lack
of respect of the nurses and the lack of proper
supervision was the reason for the poor state of
affairs.
þ Ô The lodgers and patients emphasized
individual differences among nurses (good nurses
and those who are not so good i.e. Caring and
uncaring nurses). Two wards in one hospital were
singled out as having very good nurses and good
supervisors
  
 
 ..
þ The lodgers and patients/clients ascribed
non-nursing problems to nurses,
particularly, the alleged poor quality care,
e.g. problems about doctors, laboratory
personnel, orderlies, cleaners and high
health care costs.
  
 



þ There is evidence of inadequate resources
e.g
þ shortage of nurses (R/N) resulted in situation
where nursing assistants were sometimes left
alone to man a ward.
þ Medical equipment and supplies were
wanting. In some instances, even life saving
equipment were lacking ( e.g. suction
machine, oxygen apparatus)
  
 



þ Nursing standards which form a base for
evaluation of quality nursing care was
found in only 52% of the wards. In 71% of
the wards where some nursing standards
were found, some nurses were not sure
about their existence and had to look for
them in the files. This indicated that the
existing standards were not fully utilized in
the care of the patients. Yet 99% of the
nurses agreed that nursing standards form
the basis of quality nursing care.
  
 


þ There was inadequate documentation,

particularly in the use of nursing process.
Sixty five (65) % of the nurses said lack of
management support for nursing process
makes utilization thereof difficult.
 


 
þ Values
þ Philosophy
þ Mission
þ Scope of practice
þ Nursing practice standards
þ Quality of Nursing care status
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þ Develop a national QA programme

(Institutionalize QA)
þ Create culture of quality
þ Facilitate ownership of programme and team
work for all health workers
þ Conduct nursing audit/evaluation on
regular basis
þ Develop/strengthen and utilize quality
performance indicators
þ Continuing education to be structured and
continuous (e.g. QA principles)
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þ Review and organize requisitioning of
equipment
þ Strengthen legislation and regulations for
facilitating nurses¶ professional conduct,
performance and efficiency
þ Review/upgrade emergency referral system
þ Ensure coordination and integrated
management: all health workers should be
involved in quality assurance activities




þ The study indicated dissatisfaction about the the
quality of nursing care.
þ Both consumers and nurses concured that the
quality of nursing care was unacceptable.
þ Causes For the unacceptable levels of quality
was multifactoral and included non nursing
problems, inadequate resources, lack of
supervision and uncaring attitude as well as lack
of respect of the nurse.
þ Overal outcome of the study included
development of nursing values, philosophy,
mission statement, scope of practice, nursing
practice standards and the quality of nursing care
status.
 Conclusions cont¶d
þ Consumers recognize that nursing tasks were
difficult and emotion-laden, thus they
recommended some form of counselling or
mental health services for nurses.
þ The dynamism in the health care delivery system
demands on-going evaluation of the quality of
nursing care, to ensure that the care is continually
improved to meet the ever-changing consumers
expectation and needs.
þ Quality insurance activities/programs are a must
in today¶s health care delivery system.
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