Effect of a Staffing Strategy Based on Voluntary Increase in Working Hours on Quality of Patient Care in a Hospital in Kwazulu-Natal

Two of the issues facing the South African Health Care System are the shortage of nursing staff and a lack o f adequate skills to provide quality patient care. The hospital under study experienced a critical shortage o f applications from professional registered nurses, consequently a staffing strategy was implemented to overcome the shortage o f nurses and to maintain quality patient care. The strategy introduced encouraged nurses to voluntarily work an additional ten hours per week with remuneration. A non-experimental, descriptive design with a quantitative approach was applied to investigate the effect of a staffing strategy aimed at improving the quality o f care in a hospital in Kwa-Zulu Natal based on voluntarily increasing staff working hours. The investigation compared the quality o f nursing care before and after the implementation of the staffing strategy through retrospective audits of randomly selected patient files 372 (11%) of the total population o f3400 files were audited. A random sample of 4 boxes each containing a 100 patient files, o f a total of 34 boxes, was selected from the hospital filing system. Descriptive statistical analyses were performed and correlations between various variables using the Chi-square test. No statistically significant differences (p<0.05) were found between the quality of nursing care before and after the implementation of the management strategy, even though deterioration of results after the implementation was observed. The study shows that the quality o f nursing care in most wards deteriorated after implementation. The staffing strategy failed to improve or maintain the quality of nursing care


Introduction
Two o f the issues facing the South A f rican Health Care System are the short age o f nursing staff and a lack o f ad equate skills to provide quality patient care. In June 2003 the hospital under study experienced a critical shortage o f applications from professional reg istered nurses, consequently a staff ing strategy was implemented to over com e the shortage o f nurses and to maintain quality patient care. The strat egy introduced encouraged nurses to v o lu n tarily w ork an ad d itio n al ten hours per week with remuneration. The South A frican N ursing Council (SANC) believes that "quality nursing practice is based on adequate knowl edge, skills or com petencies, ethically and scientifically based comprehensive and holistic patient care, tim ely/accu rate and com plete or com prehensive recording" (SANC, n.d: iv).
The conceptual framework o f the study was therefore based on D onabedian's fram ew ork w hich has standards d i vided into structural, process and out come standards interacting and con tributing to the quality o f care. Process standards include the steps o f the nurs ing process that are concerned w ith patient care delivery, assessm ent, care planning and im plem entation (Muller, 2004:204-5). Standard setting and evaluation is used for high-risk nursing activities, such as medication administration, patient dis ch a rg e , re c o rd k e e p in g , p a tie n ts ' p ro g re s s and in fe c tio n c o n tro l. Booyens and Minnaar (2004:309) state that high-risk activities are those, when not done, result in p atien t traum a, death or litigation. Measuring nursing practice does not have value unless the audited data is communicated to nurses delivering direct care, their immediate su p erv iso rs and the o rg a n isa tio n 's m anagement, in ways that may stimu late remedial action. As indicated in Figure 1,   . T he e v a lu a tio n p h ase en ab les nurses to determine the efficacy o f the entire process o f caring for patients. The nursing process allows for the crea tion o f holistic, individualised care for each patient and has benefits to pa tie n ts and n u rse s (Y oung ct a l., 2003:182,194). According to Fryer (as cited in Hinchliff et al., 2003:31), it en courages decision making and problem solving.

Qualtiy assurance
Nursing practice standards are based on "setting, promoting and controlling standards o f nursing and m idw ifery education and practice, monitoring and enhancing the m aintenance o f ethical standards" (SANC, nd.  (Muller, 2004:53). Quality in health care is acceptable, accessible, appropriate, effective, effi cient and equitable, produced as col laborative teamwork (Frank, Eckrich & Rohr 1997:13). Nurse M anagers are central to deliver ing high quality care and is therefore responsible to provide human and m a terial resources.

Accountability
Nurses must be able to account for their actions and omissions in any situation and take responsibility for the conse quences o f their actions within their scope o f practice (Muller, 2004:55

Record keeping
R ecord keeping is often neg lected when there are insufficient nurses to do the work. This means that nurses fail in their recording o f tasks performed and observations m ade. A ctions, ef fects or findings not recorded are re garded as not done. Failure to record data results in lack o f credible quality care delivered to patients. If nurses do not complete these tasks before the end o f shifts, they neglect their legal re sponsibility to patients and themselves, and could be accused o f negligence (Geyer, 2006:46). The SANC warns against taking docu m entation for granted and states that it must be taught as an integral part o f the nursing process (Searle, 2000:140-1). The records provide a foundation for planning, assessing and evaluating diagnostic procedures, treatm ent and care. It guides the daily m anagem ent o f patients' problems and is a means o f communication. Patients trust nurses to ensure their protection through in formation in written records o f care. Poor recording and lack o f accuracy, whether done accidentally or purpose fully, result in nurses betraying patient trust (Searle, 2000:262). Records provide a basis for continuity o f care, evidence o f changes in the pa tient's condition and prove that care has occurred. It reflects the patient's response to care (Troskie, as cited in B ooyens, 2004:352). A dditionally, nurses are expected to inform medical practitioners o f changes in a patient's condition. Failure to report changes in a patient's condition may be deemed negligent (Verschoor et al., 2005:45). Record keeping is a professional re sponsibility that is often neglected. It is against this background that this scientific investigation was undertaken.
For the purpose o f this article the ef fect o f the staffing strategy on the qual ity o f care delivered pre and post im plementation will be described.

Objectives
The following objectives were set; to determine whether:

Audit Instrument
For the purpose o f this study, an audit instrument in use at the hospital was adapted by ensuring that it was spe cific to the study objectives. The in strument was based on process stand ards i.e. the phases o f the scientific nursing process namely: assessment, nursing diagnosis, planning, implemen tation and evaluation and discharge. A ccording to the objectives o f the study, the audit instrument was divided into the following steps: Evidence of:  • An initial patient assessment on admission.
• A patient-care plan in place within 24 hours o f admission and based on initial assess ment.
• Nursing interventions and pre scriptions relevant to prioritised problems.
• Implementation o f the planned nursing care according to the identified nursing care plan.
• Records complying with legal requirements relating to patient documentation. Audits were done to determine if the nursing care was planned and executed appropriately according to the require ments o f the nursing process. Docu mentation o f the following was also assessed: Evidence that the: • Appropriate people were in formed o f changes in the pa tient's condition, for example date and time the medical prac titioner was informed.
• Required documentation from the informed people to corrobo rate the nursing entries.
• Adaptations to the nursing care plan were made when the pa tient's condition changed.
• Recording o f activities carried out and the effects o f the ac tivities.
• N urses' recordings at least twice in 24-hours.
• Legally acceptable docum enta tion o f the death or discharge o f the patient from the unit.
• A record o f the patient's final diagnosis.
• Health education given to the patient and/or family on dis charge. • Medication given to the patient to take home, recorded on dis charge. The accepted standard result for all variables and the instrument total score was set at 95% by the researcher to ensure that there is a 95% confidence that the results did not occur by chance (De Poy & Gitlin, 2005:233).

Pilot study
A pilot audit was conducted under simi lar circumstances as the actual study.
A sample o f 40 (10%) files, 20 pre and 20 post implementation was audited o f the total number o f 400 participants ini tially planned for the study. No revi sions for the auditing instrument or the procedure were deemed necessary.

Validity and reliability
Experts in nursing, research methodol ogy, statistics and quality assurance evaluated the modified instrument and felt that it had adequate construct va lidity. The validity and reliability was further supported by a pilot study.

Ethical considerations
Ethical approval for the research was o b ta in e d fro m th e U n iv e rs ity o f Stellenbosch and the ethics committee o f the hospital under study. Confiden tiality and anonymity o f records were maintained providing only access to the researcher and kept in a locked cup board.

Data collection procedure
Files w ere categorised according to date and ward. The researcher person ally audited all files using the adapted audit instrument. The audit instrument was developed by the quality assur ance m anager o f the hospital for use by the quality assurance committee.
The standard o f acceptable care was modified from 75 to 95%. The objec tives and evaluation explanations were deleted, as the researcher was auditing the files herself. Language was cor rected. The items included on the in strument are noted under the section Audit Instrument.

Data analysis
Assisted by a statistician, the Statisti cal Package for the Social Sciences (SPSS) was used to analyse the quan titative data. Data was expressed in frequencies, ta bles, and histograms. Statistical corre lations using the Chi-square test for statistical significance between various variables on a 95% confidence level were done.

Results
No statistically significant results were found between nursing care before and after the implementation o f the staffing strategy. A deterioration o f results af ter the im plementation was observed.

Assessment
Despite the fact that assessments were  Figure 2 shows that docum enta tion both before and after the strategy implementation was incomplete for four o f the six wards. Information required about the discharge o f patients was not done. Wards C (100%) & D which used standardised documentation, complied by com pleting all the sections o f the assessm ent. D eterioration is evident for ward E, from 60% before implemen tation to 30% after the strategy imple-

Nursing Diagnosis
Nursing diagnoses were not made ac cording to data identified in assess ments, nor were realistic expected out comes for the nursing care plans set. Figure 3 shows post-implementation deterioration in making nursing diag noses in wards E and F, while wards C and D show ed im provem ent. These findings suggest that professional reg istered nurses did not supervise patient care or display accountability. The scope o f practice o f professional reg istered nurses requires them to make a nursing diagnosis, formulate a nursing prescription and ensure that the pre scription is implemented, evaluated and reassessed.

Planning
Nursing prescriptions showed no ini tiation and resolution o f problems ini tially or daily. The nursing care plans were not congruent with assessments and problems identified. These findings suggest a lack o f critical analytical skills in u n d e rsta n d in g a sso c ia tio n s b e tween assessment, nursing diagnosis and the planning phase. There were often no set prescriptive nursing orders nor did they specify procedures required to bring about ex pected outcomes. Nursing care plans were repetitive. Figure 4 shows dete rioration in nursing care planning post implementation for four o f the six wards. Again wards C and D showed better planning than the other wards, which could be attributed to the standard care plans used by professional registered nurses in these two wards, but the care deteriorated after implementation. The results revealed that professional reg istered nurses in Wards A, B, E and F were not supervising the writing of care plans and failed to co-sign the plans. Figure 5 shows that recorded nursing actions did not show association with the nursing actions prescribed in nurs ing care plans. Actions were performed w ith o u t p lan s and plans w ere not amended as problem s were resolved and new problems were identified.  Evaluation Figure 7 shows amendments to nursing care plans were not recorded and therefore not done. Despite a slight improvement after the staffing strategy was implemented, the overall results were poor. The amendments to nurs ing care records changed from 8.6% pre -implementation to 19% post imple mentation.

Quality assurance
The study shows that the quality o f nursing care in most wards deteriorated after implementation. The staffing strat-  ing the extra ten (10) hours a week are strictly monitored. Put measures in place, to use nurses in the organization rather than "moonlighters" enabling one to control the working hours o f nurses. Implement a recruitment strategy to alleviate the need for nurses to work the extra ten hours.
• Provide leadership to develop, manage and improve the profes sional registered nurses per formance by conducting strate gic planning with quality care as the focus.
• Establish a quality assurance committee to monitor the qual ity o f patient care, e.g. docu ment audits, infection control, patient satisfaction surveys and negative incidents. Measure whether the objectives set are achieved.

Human Resource Management
Development and up-skilling o f staff are crucial to developing critical ana lytical thinking skills needed to improve patient care. The following steps are recommended: • Encourage participation at all levels o f decision making.
• Introduce a mentorship pro gramme to support nursing staff with nursing practice.
• Formulate a policy for in-serv ice education; include orienta tion and induction programmes where record keeping and nurs ing practice are primary topics. Evaluate record keeping knowl edge o f practicing nurses dur ing employment interviews and during performance appraisals. Hold nurses accountable after quality audits through disciplinary action.

The nursing process
Introduce standardised nursing proc ess documentation, especially nursing care plans, which through repetition, encourage decision-making and problem -solving skills. N urse educators should emphasise the nursing process and the skills o f decision making and problem solving. Holistic, individual ised care for each patient must become a s ta n d a rd . T he n u rs in g p ro c e ss should he used as a practical teaching tool when teaching disease processes and professional practice.

Record keeping
The records are legal documents which must show accurate and honest nurs ing activities perform ed, reflect ac-

Conclusion
The results o f the study indicate that the audit instrument measured the vari ables as was intended, including the phases o f the nursing process and de fining the degree o f quality o f the nurs ing care delivered in the hospital. The professional registered nurses ap peared ethically incompetent, and neg ligent, including the nursing managers. Despite the im plementation o f a strat egy in overcoming the shortage o f staff, deterioration was noted in all phases o f the nursing process in all wards post-im plem entation o f the staffing strategy. The structure standards o f the quality assurance programme put in place by the em ployer were com pli ant with expected standards, as a policy was in place for the nursing process to be used as a basis o f record keeping, h o w e v e r, th e p ro c e s s sta n d a rd s , namely assessment, planning, im ple mentation and evaluation were inad equately addressed having a detrim en tal effect on the outcom e standards, which was evident from the results o f the study. The