quality service and quality nursing care for persons with intellectual

418 Pages·2013·8.28 MB·English

QUALITY SERVICE AND QUALITY NURSING CARE FOR
PERSONS WITH INTELLECTUAL DISABILITIES LIVING IN
RESIDENTIAL CENTRES IN THE REPUBLIC OF IRELAND
A Study o f Issues and Influences A ffecting the Q uality o f N u rsing C are Provided
by R egistered N urses for the M entally H andicap ped in R esidential C entres
Richard Redmond RPN, RNID, RNT, M.Ed, FFNRCSI
Submitted for the degree of Doctor of Philosophy
Supervisor
Dr. Anne Sinnott
Dublin City University
School of Business
May 2005
ACKNOWLEDEMENTS
I would like to express my thanks and gratitude to the following people:
To Dr Anne Sinnott, my supervisor for her advice and guidance and for her constant
availability throughout the research project. Her assistance and encouragement have
been a source o f invaluable support to me during the writing o f this thesis.
To the staff nurses and ward sisters in Stewart’s hospital Services Ltd, for their
assistance with the early part o f the research.
To my colleagues in the School of Nursing and Midwifery Studies, Trinity College,
for their understanding, support and for the advice they provided.
I am especially indebted to Dr Cecily Begley, Director o f the School of Nursing and
Midwifery Studies in Trinity College for her support and encouragement.
To the National Association for the Mentally Handicapped in Ireland for their
assistance and to the group of families who looked at drafts o f the questionnaire.
To An Bord Altranais and especially the Registration Department for their assistance
with the sampling process and the distribution o f the survey questionnaire.
The Selection Committee o f the Joint All Ireland Research Fellowship Awards for
awarding me a Research Fellowship Award for my research.
To Trinity College, University of Dublin for their provision o f research funding.
I am especially indebted to the many nurses and other professionals who participated
during each phase o f the research. Without their co-operation the research would not
have been possible.
Finally, to Marie, for her encouragement, tolerance and patience and to whom I
dedicate this work.
A B ST R A C T
Q uality Service and Q uality N ursing C are for Persons w ith Intellectual
D isabilities L iv ing in R esidential C entres in the R epu blic o f Ireland
R ichard R edm ond
This study is concerned with issues and influences affecting nurses’ provision of
quality care to people with intellectual disability in residential centres. The
methodology is a descriptive study conducted through a two-phase mixed methods
approach using a dominant-less-dominant design. Phase one, the less dominant phase
consisted of a small-scale experience survey of non-nurse experts and two focus
group interviews with nurses in clinical practice. Phase two, the dominant phase,
consisted of a quantitative survey o f a random sample of nurses. Sequential
triangulation was employed for data collection where the outcomes of the first phase
were used for planning the second phase and for exploring and generating the
constructs and variables for the survey. The theoretical perspective for the study is
based on the paradigm of care within which nurses operate. In particular, whether or
not nurses use the medical and humanistic models to underpin their care o f clients in
residential centres. The study investigated the dimensions o f client care that nurses
considered were important to nurses and to clients based on the perception o f nurses.
Also investigated were the approaches nurses used to evaluate care, the organisational
processes used for care and, the influences that organisational management practices
has on the nurses’ ability to provide quality care.
Results reveal nursing care is only provided at the most basic needs level with
physical/health care, safety and emotional care seen as the most important
dimensions. Evaluation of nursing care is carried out but is concentrated at the level
of physical and personal care. These findings are important and indicate that:
1. Nurses do not consider other dimensions o f care to be o f significant
importance for clients in residential centres and are not providing holistic care.
2. Nurses are predominantly utilising the medical model to underpin the care
they provide to clients in residential centres.
This study makes an original contribution to knowledge in the following ways:
It is the only empirical study in the Republic o f Ireland that has looked at quality care
as perceived by nurses for persons with intellectual disability in residential centres.
It provides knowledge and insight into issues and influences affecting quality of
nursing care for persons with intellectual disability in residential centres.
It shows that the predominant model that nurses use in centres is the medical model.
It advances both a typology and conceptual model useful for understanding, planning
and evaluating dimensions of nursing care as needs and the relationship of these needs
with dimensions of quality of life as the outcomes of meeting these needs.
While the model is descriptive it has a fivefold application:
1. It signposts and provides insights about care that is useful for policy making.
2. It shows relationships between dimensions useful for informing care practices,
3. It draws attention to important issues for professional education and training.
4. It provides management with a guide for planning services responsive to needs
5. It is useful for planning and deciding on areas for investigation and research.
Findings add to what is known about the service encounter in residential centres and
make a contribution to evidence for practice for persons with intellectual disabilities.
iv
LIST OF CONTENTS
Declaration ii
A cknow ledgem ents iii
A bstract iv
L ist o f C ontents v
L ist o f T ables and F igures x iii
L ist o f A ppendices xviii
C hapter O ne: Introduction 1
1.1 Background to the research 1
1.2 Quality care and quality of life 2
1.3 Residential Services 2
1.4 Research problem 6
1.5 Rationale for the study 7
1.6 Purpose of the research study 7
1.7 Contribution of the literature 8
1.8 Research questions 8
1.9 Methodology and design for the study 9
1.10 Overview of chapters in the research report 9
1.11 Clarification and definition of terms 12
C hapter Two: Service Q uality
2.1 Introduction 13
2.2 Concept and nature of quality 16
2.2.1 Defining quality 16
V
2.2.2 Quality as difference between two states 18
2.2.3 Difference between product and service quality 19
2.2.4 Implications for quality definitions 21
2.2.5 Developmental approaches to quality 25
2.2.6 Contribution o f quality theorists 27
2.2.7 Summary conclusions on conceptual issues 29
2.3 Dimensions and components o f service quality 30
2.3.1 The Nordic School 31
2.3.2 The North American School 34
2.3.3 A critique o f service quality dimensions 37
2.3.4 Role o f attitude and satisfaction 39
2.3.5 Patient/client satisfaction 40
2.3.6 Summary evaluation of dimensions of service quality 43
2.4 Organisational quality management 44
2.4.1 Organisational readiness for total quality management 48
2.4.2 Mission and vision 49
2.4.3 Employees participation and the service encounter 50
2.4.4 Teams and teamwork 53
2.4.5 Training and education 55
2.4.6 Summary evaluation o f participation, teamwork and
Education 56
2.4.7 Frameworks for quality in health care 57
2.4.8 Summary evaluation o f frameworks for quality in
healthcare 63
2.5 Conclusion 64
Chapter Three: Q uality in Intellectual D isability Services 68
3.1 Introduction 68
3.2 Normalisation and Social role valorisation 70
3.3 Quality of life 73
3.3.1 Concept of quality of life 75
3.3.2 Dimensions of quality of life 78
3.3.3 Measurement of quality of life 80
3.4 Service quality in intellectual disability services 86
3.4.1 Relationship between quality of care andq uality of life 87
3.4.2 Need for quality in intellectual disability services 88
3.4.3 Quality care and human needs 89
vi
3.4.4 Summary of quality initiatives in intellectual disability
services 93
3.5 The Registered Mental Handicap Nurse (RMHN) 94
3.5.1 Role of the RMHN 95
3.5.2 The RMHN in residential care 97
3.5.3 Studies on the role o f the RMHN 100
3.5.4 Summary of the role o f the RMHN 105
3.6 Conclusion 106
Chapter Four: A pproaches to Q uality C are in R esidentia l Services 108
4.1 Introduction 108
4.2 Approaches to quality care 119
4.2.1 Standards of care 111
4.2.2 Individual programme plans 116
4.2.3 Outcome indicators o f quality 119
4.3 Participation o f service users and families in quality care. 125
4.4 Quality o f health care for people with intellectual disabilities 129
4.5 Quality systems 133
4.6 Critical factors impacting on service quality and gaps in
the literature 140
4.7 Rationale for the statistical analysis for the main survey of
Nurses 142
4.8 Summary o f general and intellectual disability quality 144
4.9 Conclusions 146
4.10 General conclusion from the literature 148
C hapter Five: T h eoretica l P erspective and Synthesised M odel 150
5.1 Introduction 150
5.2 Section A: Theoretical Perspective 150
5.2.1 Use o f theory in research 150
vii
5.3 Conceptual models and theory 152
5.4 Paradigms in Intellectual Disability Services 153
5.5 Service models in intellectual disabilities 158
5.6 Theoretical perspective for the study 163
5.6.1 Humanistic or developmental model 163
5.6.2 Medical model 165
5.6.3 Psychomedical model 167
5.6.4 Reasons for selecting the medical and humanistic models 168
5.7 Conclusion to Section A 171
5.8 Section B : Synthesized model and typology o f needs based
Quality 172
5.8 Introduction 172
5.9 Levels o f model abstraction 172
5.10 Conceptual model o f needs and outcomes 173
5.10.1 Needs of clients and dimensions of quality o f life 173
5.10.2 Dimensions o f needs ‘connections’ with dimensions of
quality o f life 175
5.10.3 Typology of service quality for intellectual disability
Services 177
5.11 Conclusion to S ection B 178
C hapter Six: M ethod ology 180
6.1 Introduction 180
6.2 Purpose o f the study 180
6.3 Sample populations 180
6.4 Research questions 181
6.5 Limitations o f the study 181
6.6 Design o f the study 182
6.7 Method o f data collection 182
6.7.1 Purposes o f triangulation 184
6.7.2 Methodological triangulation 185
6.8 Models o f combined design 185
6.9 Sequential triangulation 186
6.10 Literature, theory and research design 187
6.11 Phase 1: Experience survey 187
6.11.1 Format for the experience survey 189
6.11.2 Process for the Experience Survey 190
6.12 Phase 1 : Focus groups 190
6.12.1 Format for the focus groups 192
6.12.2 Process for the focus groups 193
6.13 Phase 2: Quantitative survey 194
6.13.1 Sample population for the dominant survey 196
6.13.2 Sample selection process 197
6.14 Construction o f the survey questionnaire 198
6.14.1 Section A. Biographical details 199
6.14.2 Section B. Organisational details 199
6.14.3 Section C. Organisational quality care details 200
6.14.4 Section D. Nursing quality cared etails 201
6.15 Reliability 209
6.16 Validity 209
6.17 Ethical considerations 212
6.18 Pilot studies 214
6.19 Phase 2. Distribution of the main survey questionnaire to nurses 217
6.19.1 Response rate for the questionnaire 218
6.19.2 Reasons for the response rate 218
6.20 Data analysis 219
6.20.1 Experience survey analysis 219
6.20.2 Focus group analysis 220
6.2.3 Dominant survey analysis 221
6.21 Conclusion 224
ix
Chapter Seven: Research Findings and Analysis 225
7.1 Introduction 225
Section A. Findings from the survey of nurses 225
7.2 Biographical details 225
7.3 Organisational details 228
7.3.1 Size and type o f administration in centres 228
7.3.2 Mixed-sexed homes and adaptive functioning of residents 229
7.3.3 Stakeholder involvement in service quality 230
7.4 Organisational service quality details 231
7.4.1 Mission statement and service philosophy 231
7.4.2 Multidisciplinary teamwork 232
7.4.3 Consultation with nurses and families o f clients 233
7.4.4 Quality accreditation for centres 234
7.4.5 Quality systems in centres 237
7.5 Nursing quality care details 238
7.5.1 Instruction, rating and facilities available for quality 238
7.5.2 Dimensions o f care and client behaviours 240
7.5.3 Standards, nursing models and nursing care plans 245
7.5.4 Individual programme planning 247
7.5.5 Consultation with families of clients 252
7.5.6 Nurses involvement and participation in the service 253
7.5.7 Management practices impacting on quality care 254
7.5.8 Monitoring and evaluating care 256
7.6 Summary and conclusion 261
Section B. Analysis o f findings from the survey o f nurses 261
Theme One: Dimensions and Processes o f Care 262
7.7. Research Question 1: Differences between dimensions 262
7.7.1 Dimensions of care 262
7.7.2 Dimensions considered least important 263
7.7.3 Cross-reference of experience survey findings withs urvey
findings of nurses 265
7.8. Research Question 2: Evaluation of dimensions of care 266
7.8.1 Cross-reference of experience survey findings with survey
findings of nurses 267