Evaluating quality nursing care through peer review and reflection; the findings of a qualitative...

Pergamon hr. .I. Nun. Stud., Vol. 32, No. 2, pp. 162-172, 1995

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Evaluating care through peer review and reflection; the

findings of a qualitative study

RICHARD HOGSTON, M.Sc.(Nurs.), P.G.Dip.Ed., B.A.(Hons.), R.G.N. University of Portsmouth, School of Health Studies, Queen Alexandra Hospital, Cosham, Portsmouth, U.K.

Abstract-The purpose of this study was to examine the everyday methods by which nurses evaluate quality care. The method was qualitative; specifically, a grounded theory approach was used. The sample comprised 18 registered nurses from a large hospital in the south of England. Data was collected through tape recorded interviews and the constant comparative method used to analyze the data. The findings revealed that although nurses used objective methods such as evaluating planned care as part of the nursing process, they also used more subjective methods such as peer review and intuition. The study seeks to explain the value of these less formal methods of evaluation and recognises how difficult they may be to substantiate in light of the recent health care reforms. It is suggested that the use of a more formalised process of peer review using reflection as its foundation would enable nurses to satisfy managerial concerns for a measurable outcome to quality.

Introduction

Given that nurses are responsible for the provision of nursing care, they are also accountable for its quality. It follows that nurses should be in the forefront when it comes to identifying methods for measuring and maintaining the quality of nursing care. It could be seen as one method of preserving clinical autonomy and unless nurses are able to provide the rationale for the care given and ensure that it is of the highest standard, others will impose their own schemes (Lees et al., 1987). As Salvage (1992) suggests, without quality mechanisms nurses are unable to articulate their needs because they lack objective evidence.

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EVALUATING QUALITY NURSING CARE 163

Defining quality assurance

Quality assurance in health care has been defined as a process for ensuring the delivery of high quality care through a programme of ongoing review which is judged against agreed criteria such as standards. Any deficiencies can then be remedied through a review of the professionals’ and institutions’ performance (Irwin, 1992; Renwick, 1992). The past decade has seen rapid acceleration in the field of quality assurance in nursing. Two important developments have been the introduction of general management into the NHS and the RCN standards of care project (Royal College of Nursing, 1989). In 1983, the Griffith’s report (Department of Health and Social Security, 1983) highlighted the lack of attention paid to quality in the NHS. Nurses, particularly those in NHS management, have subsequently developed a quality assurance role and with the new internal market in the NHS, purchasers of care look to providers for evidence of their quality mechanisms (Walshe et al., 1991).

Quality assurance and professional practice

Nurses would appear to be taking a lead role in quality assurance given that over the last 10 years over 1000 papers have been published on the subject (Koch, 1992). High quality nursing care is the right of all patients with the responsibility lying with the nurse who delivers it (Redfern and Norman, 1990). It is arguably with this in mind that clinical nurses have sought to develop quality tools in an effort to preserve their own clinical autonomy. With the changes in the NHS today and the Government’s drive for effectiveness and efficiency, quality evaluation mechanisms can be seen as one method of preserving professional autonomy and freedom of clinical judgement. Unless nurses are able to provide the rationale for their practices, others will impose their own schemes (Lees et al., 1987; Beyers, 1988).

Given that high quality care is the right of all patients (Pearson, 1987) and a professional issue, involvement in quality assurance is one method by which quality of care can be regulated by nurses themselves. According to Schmadl(l979) the purpose of quality assurance in nursing is to assure the client of a specified degree of excellence though ongoing measurement and evaluation. As a consequence, quality assurance programmes can provide valuable justification for the existence and development of nursing within the competitive market of health care.

It follows that nurses must want to review the quality of nursing care themselves or they risk becoming agents of health economists, who will utilise quantitative data which may preclude indications of the real quality and value of nursing care. As Astedt-Kurki and Haggman-Latila (1992) argue, it is not acceptable to assume that the provision of nursing care necessarily results in beneficial outcomes for the client. It is also important to remember that the definition of a profession requires it to have some method of internal regulation (Chinn and Jacobs, 1987). At a national level this is undertaken by the UKCC, but at a more individual level, quality assurance can be welcomed by nurses as a method for ensuring the provision of high quality care.

On grounded theory

The ancestry of grounded theory is to be found in the symbolic interactionist school of sociology. Symbolic interactionism focuses on the meanings of events to people and the

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symbols they use to convey that meaning. Meanings are developed through experience and determine their response through common language and socialisation (Baker et al., 1992). Chenitz and Swanson (1986) describe how symbolic interactionism influences grounded theory and they suggest that the researcher attempts to comprehend the informant’s world through a sharing of interpretations. Grounded theory allows the researcher to discover what is going on in the social setting through an analysis of the dominating social processes emanating from the subject under enquiry (Field and Morse, 1991).

The value of using a qualitative research method such as grounded theory for this study is embedded in the subjective and often emotional nature of quality. Grounded theory was chosen because it allowed the researcher to examine meaning and with the emphasis on understanding quality from the viewpoint of practising nurses this approach seemed logical.

Conduct of study

Permission was sought in the first instance from the senior nurse manager of the acute unit to conduct the study. Further permission and consent was obtained from the individual ward sisters and nurses who participated in the study. It was not necessary to approach the ethical committee for approval to conduct the study as this is only needed for research which requires direct access to clients and their records.

Interview sample

The sample was opportunistic, i.e. the informants were volunteers. The researcher called for volunteers by placing prominent notices on the wall in the offices where nursing handovers normally take place. Unit staff were also addressed on two occasions, briefing them about the purpose of the study and the nature of their contribution. Eighteen subjects (n = 18) participated in the study and were all registered nurses. The original intention was to interview each of the volunteers in the clinical areas chosen for the study. However, time constraints, annual leave and duty rostas reduced the sample from 21 to 18. Two of the sample were male (n = 2) and the remainder female (n = 16). The years of experience as a registered nurse ranged from 6 months to 25 years, the median being 5.5 years (n = 5.5). No other biographical data was obtained.

Data collection

The unstructured formal interview was the chosen method for data collection. This has been described as the use of everyday conversations for the purpose of collecting and validating data, and is the most commonly used method of data collection in qualitative inquiry (Swanson, 1986). The unstructured interview is characterised by natural speech and interaction between the researcher and respondent. In this case it was designed to be non- threatening by asking an open question (“Can you explain to me in your own words how you evaluate the quality of your nursing care?“).

It was stated that the interview would not normally exceed 20 min. The interviews were conducted in a small comfortable room off the main ward, at a mutually convenient time. The use of a tape recorder ensured that attention could be given unreservedly to the informants thus guaranteeing accuracy of data collection, maximising the flow of information and allowing the researcher to return to the raw data at a later date for verification (Clarke, 1992).


Analysis

In grounded theory the explanation and generation of data is verified through theoretical sampling. This is described as a concurrent process of collecting, coding and analyzing data (Smith, 1992). Analysis is not the last phase of the research process but is concurrent with data collection or cyclical. The data was analyzed by coding the verbatim statements of the informants. This is known as “open coding” whereby data is examined word by word and line by line (Stern, 1980) with the codes freely generated and often reflecting the words of the informants themselves. For example the code “reflection” was given to the response:

“Personal reviews on myself, I suppose everyday really, I am always questioning myself, but to evaluate would just be through reflection and feeling” (RlO).

Coding of the data was initially undertaken by the researcher and then reviewed by peers and the subjects themselves. This enabled the researcher to confirm that the interpretation was in keeping with what the informants meant. Data were then reviewed for patterns, reduced and clustered prior to categorising. For example the code “environment” was initially allocated to responses such as:

“I look at how patients have reacted and how staff have reacted because I think the actual environment in which one is actually working needs to be a happy environment and that transmits to staff as well as patients, so I think a calm relaxed atmosphere” (R3). “We feed back to each other, hopefully we have got the right environment where we can do that” (RIS).

However, the environment referred to was one of atmosphere which incorporated the peer support and knowledge-sharing essential for evaluating quality care. This resulted in collapsing the data into the “peer support” code.

Finally, the informant’s pathway was traced through the transcript by colour coding the categories. In grounded theory this related to the “fit” of categories whereby all instances of the phenomena under question relate to the developing category (Glaser et al., 1967) and the fractured data comes together as a coherent whole (Glaser, 1978).

Findings

Three categories emerged from the analyzed data (Table 1). Dialogue and Sharing is a category which reflects the supportive and often critical exchanges that nurses use when evaluating quality care. These may occur on both a formal or an ad hoc basis.

Table 1. Substantive codes and categories

Substantive code -

Managerial support Peer support Knowledge sharing

Category

Dialogue and sharing

Professional judgement Tacit knowledge Reflection Personal satisfaction Personal philosophy

The reflective practitioner

Standards Nursing process Audits

Tools and frameworks

Feedback from patients and relatives

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The Reflective Practitioner is a category which provides evidence of the informal method by which nurses evaluate care but which are intrinsically bound up in their professional expertise and knowledge. It demonstrates how knowledge and expertise are valuable indicators of quality but which are subject to criticism because of their subjectivity. Tools and Frameworks are the objective criteria which nurses use to evaluate their care. They include use of the nursing process, adhering to standards of care as well as the importance of patient feedback.

Dialogue and sharing

Coded data within this category reflects the critical nature of peer review, managerial support and knowledge-sharing between peers, students and the multi-disciplinary team. The concept of peer review was a particularly opulent code. Responses revolved around feedback:

“I think we assess ourselves and how we feel that we have done, but also feedback from each other” (R18).

“General discussion with the nurses in the ward team and see how they feel about it” (RS).

Teamwork: “A lot of it is teamwork, not just how I feel, its what the whole team, whole ward staff, staffing level, its not just us-its not just one, its all of us I think” (R8).

“Another way of assessing it could be other nurses and colleagues, opinions really. There is no other formal way, I suppose just other people’s opinions” (R18).

On support from more senior staff: “I think I would expect my seniors to actually help me to critically appraise and analyze-because I think you do need praise to deliver a good standard of care” (RI).

“Senior Staff nurse-if I have got any problems or she perceives any problems with my nursing care, that’s something we talk about” (R14).

One code, that of “role model” was composed of a single statement: “I do get a lot of feedback from students and everybody saying, oh when I grow up I want to be a nurse like you” (Rl 1).

but the respondent goes on further in the transcript to talk about the knowledge-sharing and peer support that is integral when evaluating quality care and was thus reassigned the code “knowledge-sharing”.

All the codes in this category referred to a process of dialogue and sharing which was evident in the way staff evaluate the quality of the care that they give. The dialogue was between peers, students and the multi-disciplinary team. Similarly knowledge was shared between these individuals in order to evaluate care in a holistic manner.

The reflective practitioner

Within this category, nurses spoke of reviewing and analyzing quality of care through feelings and contemplation:

“I reflect on what I have done looking at how the shift has gone, evaluating my own performance and the performance of people that I am working with” (R3).

“I think-self analysis to actually stop and reflect on what I have just been doing or saying to a patient and actually thinking through for myself how good I think that it is” (Rl).

“Personal reviews on myself, I suppose everyday really, I am always questioning myself, but to evaluate myself would be just reflection and feeling” (RlO).


It would appear evident that nurses are reflecting on their practice and then using these reflections to make judgements about the effectiveness or worth of the care that has been given. This is perhaps most suitably demonstrated by the comment:

“Well I think sometimes when I go home, how I have dealt with something and then if 1 feel that I haven’t dealt with it properly or I feel that I have dealt with it quite well and have had feedback on it then I would use that experience again” (R16).

Closely associated with reflection is the notion of intuition. This code was allocated when nurses spoke of evaluating the quality of care though apparently subconscious processes.

“I don’t know how I do it unless I do it subconsciously-well I think that I give good quality care all the time-well to the best of my ability, but I don’t go round-well I suppose you do check the care that you are giving but you do it in a subconscious way I think” (R5).

“Me myself (emphatic tone), if 1 feel that I have given the right care-if 1 spent a certain amount of time with each patient and felt that the problems are solved and they feel happy” (R6).

“By experience-intuition” (R12).

“Myself-l look at the patient and the surrounding areas and I suppose its my professional judgement” (R4).

Schon (1991) describes reflection as knowledge that is learned through experience but which is hard to describe and Polanyi (1967) talks of tacit knowledge occurring when an individual knows something only by relying on awareness. Hence, the naming of this category appropriately summarises the instinctual approach to evaluating quality described by the informants.

Tools and frameworks

Coded data within this category referred to the more objective data upon which nurses evaluated the quality of care. Use of the nursing process was most frequently cited with comments such as:

“Using the care plans and the nursing process, that is the basic way of evaluating my care” (R18).

“From the documentation-from the standards in the care plan, from the proper assessment and identification of the patient’s needs and from the actual evaluation” (RI).

It is clear that nurses’ evaluation of quality care revolved markedly around the nursing process as a tool by which client outcomes can be regularly monitored. In addition to such a structured approach to evaluating quality, the satisfaction of patients was also cited as being important:

“The only way you can check it is by discussing it with your patient and seeing that they are comfortable” (R12).

“By the response of the patients-mentally how they respond to you and how they respond to the care that you are giving” (R16).

“Well I suppose you go on the patient satisfaction, the patient saying you know, that the care you are giving is good” (R5).

Finally within this category it is pertinent to expand upon the code “standards”. Although these were mentioned by many informants, the nature of the comments suggest that the informants are aware of standards, that they should be using them, but, in reality are not.

“Initially I was involved in standard setting, but that seems to have petered out really, I am sure that someone is still setting standards somewhere, but it hasn’t filtered down to the wards” (R13).

“I know that we are supposed to have written standards which again have written evaluation dates, but to date as long as 1 have been on here I have never been involved in any proper evaluation of standards at all-the standards are written but people don’t look at them”(R11).

168 R. HOGSTON

However, it would appear that there is an informal system of auditing going on: “We do have audits from time to time on the quality of paperwork and things” (R7).

“Well we have audits, but that is external-be it a manager or whatever, sister and I try to self- audit as we go through the care plans when we can, etc., but it is not always possible” (R12).

This category contrasts sharply with the more informal processes demonstrated in the categories “The reflective practitioner” and “dialogue and sharing”. In this category, nurses are exhorting the importance of evaluating quality care through the individual evaluation of a patient care plan and through patient feedback. It is also interesting to note that the notion of standard setting as a method of evaluating the quality of care is one that is given “lip service”, almost as if nurses felt that they should mention standards as an evaluative tool. In addition, the informal system of auditing described above adds weight to the comments about peer review as an evaluative tool and suggests that nurses actually evaluate quality of care through an amalgam of processes.

Discussion

Given the current consumerist and managerial climate within the NHS, evaluating quality of care can be seen to be important for several reasons. The far-reaching reforms of the NHS require outcomes to be measured. Increased costs of health care are requiring managers through the professions to reduce costs and seek the most cost-effective options. The population at large is more informed about health care matters and is arguably less passive as a recipient of health care, demanding a detailed and open explanation for their care. The findings from this study demonstrate that nurses are addressing such issues; however, evaluating quality nursing care has been shown to involve less measurable approaches such as peer review and knowledge-sharing. The value of formal auditing processes was highlighted in the document Working for Patients (Department of Health, 1989). It would appear that nurses are utilising auditing methods but in an unstructured and informal manner. These issues are now discussed with the help of extant literature in an effort to extract implications both for the nursing profession and future research.

Peer review

Leibold (1983) discusses peer review as an essential component of accountability and professionalism. Similarly, Redfern and Norman (1990) encourage the use of peer review as a “bottom up” approach to quality evaluation. Wilson (1987, cited by Manley, 1992, p. 209) suggests that peer review is an important example of a “bottom up” approach to evaluation because practitioners themselves are more likely to be accurate in their judgements. It also establishes quality nursing care as being the domain of nurses and not managers. The managerial role becomes one of “facilitation” in which the peer review process can be cultivated (ibid.).

The NHS Management Executive (1991) recognised the importance of peer review in nursing when it noted that nursing audit allows nurses to measure their performance and to recognise good practice. For such a system of evaluation to be successful, it would seem appropriate to have a set of criteria upon which the peer review process is based (Wright, 1984).

Winch (1989) suggests that if peer review is to be successful there needs to be peer support and constructive feedback in order to encourage professional growth. Practitioners need to


have the skills which allow constructive feedback and criticism of practice and to accept the worth of such judgements.

The peer review process evident in this research demonstrates that nurses are using peer review, albeit on an informal basis. Formalising the process could be made by developing criteria for review. Although it can be stated that peer review has an important role to play in the evaluation of quality of nursing care, the peer review process could therefore be nurtured, but in order to formalise the process, it must be undertaken as a “bottom up” approach and not imposed.

Finally, there has been a wealth of literature examining the nature of nursing audit using more measurable quality assurance tools (Qualpacs, Monitor, Grasp) which have been concisely summarised and critiqued by Redfern and Norman (1990) and Balogh (1992). During the fieldwork for this research there was no reference to nursing audit using such tools (although the author is aware that such tools have been used in the past). This demonstrates that the evaluation of nursing care by nurses is undertaken on a very informal and sometimes sporadic basis. In the light of the health care reforms, this is a situation which nurses will have to address for themselves; if they fail managers will impose their own systems. It is clear that nurses are concerned about quality of care and are addressing the issue but not in a manner which is easily measurable. Nurses need to rationalise their quality assurance mechanisms and undoubtedly one way of doing this is through an established but formalised peer review process.

Reflection

The concept of reflection whereby practitioners self-evaluate their practice as a basis for growth and development is becoming increasingly popular in nursing today. Through the work of Schon (1991) this has catalysed what can be suitably termed as a “reflective movement” that is realising an increasing body of literature subscribing to its importance (Hogston, 1993). Benner’s work on learning from experience states how “a wealth of untapped knowledge is embedded in the practices and know how of expert nurses, but this knowledge will not expand or fully develop unless nurses systematically record what they learn from their own experience” (Benner, 1984, p.9). The descriptions of reflective practice given by the informants in this study recount its importance as an evaluative tool.

Nurses are clearly reflecting on their practice and then using those reflections to make judgements about the effectiveness or worth of the care given. This supports Benner’s work by the nature of understanding that is attributed to these judgements. In contrast, Powell (1989) reports the findings of a small empirical study examining the nature of reflection in nurses’ everyday work. Her findings suggested that reflection was present at a descriptive level, with little evidence of application or synthesis. The findings of this study would suggest the opposite, that nurses are using reflection at a more cognitive and evaluative level, suggesting both growth and understanding of reflection in clinical practice.

Hamric (1983) suggests that “it is difficult for anyone immersed in a role to objectively evaluate his or her own activities. Because of the inherent subjectivity, self evaluation must be coupled with another strategy”. Nurses are in a unique position to develop formalised peer support groups within an auditing programme which utilises reflection as a foundation, This could prove to be an exciting challenge for nurses in the future.

Tacit knowledge

Associated with reflection is the notion of tacit knowledge. This has been defined by Polanyi (1967) as when an individual knows something only by relying on awareness, In

170 R.HOGSTON

other words there is an element of instinctual understanding. This is supported by Woods (1985) who states that we acquire tacit knowledge by experience and an experienced professional “just knows” when a decision is right or wrong yet cannot explain why.

The theoretical and empirical literature supports the notion of tacit knowledge and reflection in practice, yet as a method of evaluating the quality of care it risks criticism from managers and elsewhere because neither are measurable. In today’s market-led NHS, the competent practice of nurses may be difficult to defend if such methods are not exposed for their true value. Stating that care is evaluated solely by intuition begs criticism and will ultimately lead to devaluing of professional nursing practice. The task ahead is therefore one of recognising the true value and worth of reflection and tacit knowledge while attempting to unravel the complexities that are embedded in nursing practice.

This study has shown that nurses have stated quite categorically that they evaluate the quality of care through such processes as reflection, tacit knowledge and peer review and they must continue to use these methods as the basis of their nursing practice. For managers, such processes alone may not be acceptable as they are not measurable criteria, although this does not detract from their importance.

The nursing process

It has been suggested that a fundamental component of quality nursing practice is the practitioner’s ability to process information and make judgements upon which nursing care is based (Fitzpatrick et al., 1992). The nursing process is one method of outcome measurement which has been defined as a methodical approach to individualised patient care (Hayward, 1986). It is clear that nurses’ evaluation of quality care revolved markedly around the nursing process as the tool by which client outcomes can be regularly monitored and evaluated. This supports work described in the literature by Fitzpatrick et al. (1992) and Jones (1989). It is also supported by Hurst et al. (1991), whose empirical work on problem-solving proposes that a sound understanding of the nursing process is a major requirement for high quality patient care.

Bergman (1982) believes that evaluation of nursing care is a combination of both the objective measurement of concrete phenomena, as well as subjective perceptions and opinions. The nursing process can thus be used to plan and implement nursing care, based upon sound professional judgement in conjunction with both objective and subjective data collected from the client. This is subsequently interpreted and negotiated by the nurse. Evaluation becomes an objective measurement upon which to judge the effectiveness or worth of the quality of care that has been given. It can also be seen as an expression of accountability because good quality nursing care is dependent on competent practitioners, who apply knowledge and skills to their practice in order to make clinical judgements about the client’s needs (De La Cuesta, 1983; Boss, 1985).

Patient satisfaction

Nurses focused on patient satisfaction as an additional method for evaluating quality care. It was also seen to link closely with the nursing process whereby care is planned on an individual basis and which takes into account the patient’s wishes. The notion of patient satisfaction as a major contributory factor in evaluating quality has been found to be a contentious issue in the literature. Although the study focused particularly on physical care and patient education, Eriksen (1987) established an inverse relationship between patient


satisfaction and the quality of nursing care. However, Bailit et al. (1975) have suggested that outcome measures are the most important factors when defining quality because they are the only direct indicators of effectiveness.

The recent publication A V’i,sionfor the Future (Department of Health, 1993) identifies 12 targets which are designed to measure the success of nursing in delivering health care. Target two states that patient satisfaction surveys must be instigated and their findings dispersed to the nurses concerned.

The Audit Commission (199 1) also recommends the use of patient opinion surveys as an indicator of the quality of nursing care. It is clear, therefore, that the Government is keen to see consumer satisfaction as a quality indicator, something of which nurses would already appear to be taking heed of, albeit informally.

Conclusion and implications for practice

This study demonstrates that for nurses, the process of evaluating quality nursing care is undertaken in both formal and informal ways. Generally, the informal methods of evaluation predominate. In the light of the health care reforms, nurses need to make explicit and formalise their quality assurance mechanisms. For managers, the perceived use of reflection and peer review alone may not be acceptable as neither lend themselves easily to measurement, although this does not detract from their importance. The challenge is for nurses to devise methods of formalising the peer review process so that health care managers are able to recognise in some quantitive way the importance of reflection and peer assessment.

Since this is the genuine way that nurses evaluate the quality of their practice there is a need to investigate this further and raise questions for future research. A future paper will discuss the use of a formalised process of peer review using reflection as its foundation. Such an approach would be nurse led and satisfy managerial concerns for a measurable outcome to quality.

References

Astedt-Kurki, P. and Haggman-Latila, A. (1992). Good nursing practice as perceived by clients: a starting point for the development of professional nursing. J. Adv. Nuts. 17, 1195-l 199.

Audit Commission (1991). The Virtue of Patients: Making the Best Use af Ward Nursing Resources. HMSO, London.

Bailit, H., Lewis, J., Hochheiser, L. and Bush, N. (1975). Assessing the quality of care. Nuts. Outlook 23(3), 1533 159.

Baker, C., Wuest, J. and Stern, P. (1992). Method slurring: the grounded theory/phenomenology example. J. Adv. Nun. 17, 135551360.

Balogh, R. (1992). Audits of nursing care in Britain: a review and critique of approaches to validating them. ht. J. Nuts. Stud. 29(2), 119-33.

Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison Wesley, California.

Bergman, R. (1982). Evaluation of nursing care--could it make a difference. ht. J. Nurs. Stud. 19(2), 53-60. Beyers, M. (1988). Quality: the banner of the 1980s. Nurs. Clinics North Am. 23(3), 617624. Chinn and Jacobs (1987). Cited by Manley, K. (1991). Knowledge for nursing practice. In Nursing: A Knowledge

Basefor Pracfice (Perry, A. and Jolley, M., Eds), pp. l-27. Edward Arnold, London. Chenitz, W. C. and Swanson, J. M. (1986). Qualitative research using grounded theory. In From Practice to

Grounded Theory: Qualitative Research in Nursing (Chenitz, W. C. and Swanson, J. M., Eds), pp. 3315. Addison Wesley, California.

Clarke, L. (1992). Qualitative research: meaning and language. J. Adv. Nurs. 17,243-252. De La Cuesta, C. (1983). The nursing process from development to implementation. J. Adv. Nurs. 8, 365-371. Department of Health (DoH) (1989). Workingfor Patients. (CMSSS), HMSO, London.

172 R. HOGSTON

Department of Health (DOH) (1993). A Vision for the Future: The Nursing, Midwtfery and Health Visiting Contribution to Health and Health Care. HMSO, London.

Department of Health and Social Security (DHSS) (1983). NHS Management Enquiry (The Griffith’s Report), HMSO, London.

Eriksen, L. R. (1987). Patient satisfaction: an indicator of nursing care quality? Nurs. Manag. I@7), 31-S. Field, P. A. and Morse. J. M. (1991). Nursing Research: The Application of Qualitative Approaches. Groom Helm,

London. Fitzpatrick, J. M., While, A. E. and Roberts, J. D. (1992). The role of the nurse in high-quality patient care: a

review of the literature. J. Adv. Nuts. 17, 1210-1219. Glaser, B. G. and Strauss, A. L. (1967). The Discovery of Grounded Theory. Strategies for Qualitative Research.

Aldine, Chicago. Glaser, B. G. (1978). Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Mill Valley,

California, The Sociology Press. Hamric, A. B. (1983). A model for developing evaluation strategies. In The Clinical Nurse Specialist in Theory and

Practice (Hamric, A. B. and Spross, J., Eds), pp. 83-104. Grune Stratton, New York. Hayward, J. (Ed.) (1986). Report of the Nursing Process Evaluation Working Group. Nursing Education Research

Unit, Department of Nursing Studies, King’s College, University of London. Hogston, R. (1993). An examination of competence in the light of the post registration and practice project

(Prepp). Nurse Educ. Today 13, 167-l 7 1. Hurst et al. (1991). Irwin, P. (1992). Quality assurance. Surgical Nurse 5(4), 20-22. Jones, J. A. (1989). The verbal protocol; a research technique. J. Adv. Nurs. 14, 1062-1070. Koch, T. (1992). A review of nursing quality assurance. J. Adv. Nuts. 17, 785-794. Lees, G. D., Richman, J., Salauroo, M. A. and Warden, S. (1987). Quality assurance: is it professional insurance?

J. Adv. Nurs. 12, 719-727. Leibold, S. (1983). Peer review. In The Clinical Nurse Specialist in Theory and Practice (Hamric, A. B. and Spross,

J., Eds), pp. 219-233. Grune and Stratton, New York. NHS Management Executive (1991). Measuring the Quality: Nursing Care Audit-Teaching Notes. Redhouse

Lane Communications, London. Pearson, A. (1987). Nursing and quality. In Nursing Quality Measurement: Quality Assurance Methods for Peer

Review (Pearson, A., Ed.). John Wiley, Chichester. Polanyi (1967). Cited in Meerbeau, L. (1992). Tacit nursing knowledge: an untapped resource or a methodological

headache? J. Adv. Nurs. 17, 108-l 12 Powell, J. H. (1989). The reflective practitioner in nursing. J. Adv. Nurs. 14, 824-832. Redfern, S. J. and Norman, I. J. (1990). Measuring the quality of nursing care: a consideration of different

approaches. J. Adv. Nuts. 15, 126C1271. Renwick, P. A. (1992). Quality assurance in health care. Inc. J. Hlth Care Qual. Assur. 5(5), 29934. Royal College of Nursing (RCN) (1989). A Frameworkfor Quality. Royal College of Nursing standards of care

project. RCN, London. Salvage, J. (1992). Seizing power. Nurs. Stand. Suppl. 6 (52), 3. Schmadl, J. C. (1979). Quality assurance: examination of the concept. Nurs. Outlook July, 462465. Schon, D. A. (1991). The Reflective Practitioner. How Professionals Think in Action. Cower Publishing, Avebury. Smith, P. (1992). The Emotional Labour of Nursing: How Nurses Care. Macmillan, London. Stern, P. M. (1980). Grounded theory methodology: its uses and processes. Image 12(l), 2&23. Swanson, J. M. (1986). The formal qualitative interview for grounded theory. In From Practice to Grounded

Theory: Qualitative Research in Nursing (Chenitz, W. C. and Swanson, J. M., Eds), pp. 66-78. Addison Wesley, California.

Walshe, K., Lyons, C., Coles, J. and Bennett, J. (1991). Quality assurance in practice: research in Brighton Health Authority. Inc. J. Hlth Care Qual. Assur. 4(2), 27-35.

Wilson, C. R. M. (1987). Hospital Wide Quality Assurance. Saunders, Toronto. Cited by Manley, K. (1992). In Nursing Care: The Challenge to Change (Jolley, M. and Brykcznska, G., Eds). Edward Arnold, London.

Winch, A. E. (1989). Peer support and peer review. In The Clinical Nurse Specialist in Theory and Practice, 2nd edn (Hamric, A. B. and Spross, J. A., Eds). Saunders, Philadelphia.

Woods, E. (1985). Problem based learning and problem solving. In Boud, D. (Ed.) Problem Based Learning in Education for the Professions. Sydney Higher Education Research and Development Society of Australia, cited by Carroll, E. In “The role of tacit knowledge in problem solving in the clinical setting”, Nurse Educat. Today 8,140-147.

Wright, D. (1984). An introduction to the evaluation of nursing care: a review of the literature. J. Adv. Nuts. 9, 451467.

(Received 28 February 1993; acceptedfor publication 27 June 1994)

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