This paper attempts to carry out a critical review of two research articles and examine their appropriateness as reference sources in the compilation of The Essence of Care (DoH, 2001).

University Degree Subjects allied to Medicine

In the document The Essence of Care (DoH, 2001) the National Health Service (NHS) is encouraged to ensure uniform provision of high quality health care by exploring the benefits of benchmarking. This paper attempts to carry out a critical review and of two research articles and examine their appropriateness as reference sources in the compilation of The Essence of Care (DoH, 2001). I shall look at the privacy and dignity benchmark focussing on privacy, dignity and modesty factor. Essence of Care shall be looked at briefly and also illustrate how best practice is achieved through process benchmarking. I shall also draw on evidence from other literature reviews relating to attaining best practice. In conclusion I shall relate evidence from my area of practice and also offer evidence based recommendations on best practices from other trusts that can be copied by my trust.

The Essence of Care offers nurses a toolkit for reflecting on, comparing and sharing best practices, to improve continuously the care offered to patients (Davies, 2002). Best clinical practice benchmarking involves reaching a consensus on what constitutes best practice by examining processes by which it is achieved and using them to compare individual practices. The Essence of Care (DoH, 2001) document defines privacy as freedom from intrusion, dignity as being worth of respect and modesty, as not being ashamed. The agreed patient focused outcome of this benchmark is for patients to benefit from care that promotes their privacy and dignity and protects their modesty.

I have chosen this benchmark because of the realisation on my part that respect for patients’ privacy and dignity is important in establishing and maintaining their trust. During my current training I have observed that dignity and privacy are poorly respected on many a ward. By concentrating on this benchmark I believe it teaches me what best practice are in this area, how it has been achieved and gives me guidance on what is expected of me as a nurse and make me a better practitioner. Studies, such as the ones examined in this paper, help practitioners take a structured approach to sharing and comparing practice, enabling them to identify the best practice and to develop action plans to remedy poor practice. Basing government policies on research and evidence based practices helps to deliver quality care that exceeds patient expectations (Lipley, 2001).

Attempts at enhancing the system to this is evident in the recent history of the NHS which shows a proliferation of management inspired approaches – Total Quality Management (TQM), business process re-engineering and ISO 9000. The handicap with these approaches was their emphasis on organisational quality rather than clinical care. By the mid 1990s, the idea that the quality of clinical practice must be based directly and demonstrably on recent, robust research evidence and that common standards could be set had become attractive to the NHS (Davies, 2002). The embracing of benchmarking in setting quality of clinical care practice is evidence of government’s paradigm shift on delivery of care. Benchmarking is a practical tool for improving performance by learning from best practices and the processes by which they are achieved (http://www.psigroup.co.uk). It involves looking outside your own area of practice to examine how others achieve their performance levels and to understand the processes they use. In this way benchmarking helps explain the processes behind excellent performance. When the lessons learnt from a benchmarking exercise are applied appropriately, they facilitate improved performance in critical functions within an organisation or in key areas of the business environment (Stark, MacHale, Lennon&Shaw, 2000).

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Clinical governance is the first policy driver that has paved the way for the production of clinical benchmarks (Chambers &Jolly, 2002). Whilst clinical governance is a quality assurance system, the focus is often on management systems and there is a danger of not paying much attention to quality of services. What the Essence of Care, does, is offer a framework with patients, clients and their carer’s experiences at the heart of the process – a qualitative approach to identifying, measuring and reflecting on quality of services provided (Lunn, 2003). The two articles being reviewed show the patient as the central figure in all these systems and processes. The patient is now given recognition as the key adviser for healthcare development and improvement. The government strategy on a local and national level is that wards and departments performing well will share how they do this with others, so that patient care can improve equally at all levels. Benchmarking should not be considered a one-off exercise. To be effective, it must become an ongoing, integral part of an ongoing improvement process with the goal of keeping abreast of ever-improving best practice (Ellis, 2000). This marries well with current government strategy to bring in a culture of continuous improvement of evidence based patient care. The privacy and dignity benchmark addresses the patient’s freedom from intrusion and being worthy of respect. One source for the motivation to improve practice is comparing your own performance against some internal or external reference points (Scalon&Whitfield, 2002). Benchmarking involves measuring quality and evaluating changes in process, provides the opportunity and reference points for that comparison. The articles under review are:

The concepts of expectation and satisfaction: do they capture the way patients evaluate their care. Staniszewska, S. & Ahmed, L. (1999). Journal of Advanced Nursing 29(2), p. 364-372
Privacy or help? The use of curtain positioning strategies within the maternity ward environment as a means of achieving and maintaining privacy, or as a form of signalling to peers and professionals in an attempt to seek information or support. Burden, B (1998). Journal of Advanced Nursing 27(1), p. 15-23

I shall utilise a qualitative research tool Critical Appraisal Skills Programme (www.phru.org.uk/~casp.htm) to assess the two research papers. This tool looks at three areas – rigour, credibility and relevance of the research, in other words the critical appraisal of evidence about effectiveness.

For clarity of purpose, I am very pleased to give full credit to both articles. In both papers the purpose of the research is expounded in the introduction. Burden (1998) the impetus for research was necessitated by the decline in interactions between women within a maternity unit environment. Patients had started spending long periods behind curtains drawn around the bed space. Staniszewska & Ahmed (1999) looked at the issue of patient involvement in the evaluation of care by examining the concepts of expectation and satisfaction. Both articles clearly formatted statements of the research questions and hypotheses into well-organised categories. Both provided an adequate detail of literature review references. The papers are well supported by research data and in-text citations abound. This is a sign that the research was thorough and credit was given where due. Based on the research needs discovered from the literature review, the authors determined to conduct their work for searching advance information. Therefore, I was convinced that both authors knew what they expected their works to reveal, to describe feedback information acquired systematically from patients as the basis for improving quality services. The authors of the articles are of a high academic and professional calibre, which warrant them to be competent contributors in their subject areas.

Burden (1998) studied social interactions and actions of women within a maternity ward and get their perceptions on privacy and dignity. The author used the ethnography approach “the description and understanding of communicative behaviour in specific cultural settings .....and formulation of concepts and theories upon which to build a global metatheory of human communication” (Coulmas, 2000, p.347). Ethnography was the best research methodology to obtain the most accurate result.

Staniszewska & Ahmed (1999) explored the concepts of expectation and satisfaction doing pre-admission interviews to know patients’ expectations and an evaluation after care. A qualitative research methodology was used on a condition-specific group, cardiac patients.

The research articles being qualitative in nature prove that they were appropriate to be used as reference sources for this benchmark. The articles show how patients can be effective contributors in having their needs met by the health sector through patient involvement.

The Essence of Care is a valuable resource to help improve quality, because it involves all the stakeholders -health professionals, patients, service users and their carers and representatives (Ellis, 2000).

On reflection, I have learnt that maintaining a patient’s dignity is an essential component of care. Section 2.2 of Nursing and Midwifery Council (NMC) Code of Professional Conduct (2002) addresses a nurse’s accountability to promote and protect patients’ dignity.

There is no evidence of co-coordinated best care practice in my area of practice. Bad practices include asking a patient to use a bedpan without adequate screening; wearing ill-fitting hospital gown that gapes and mixed wards that do not preserve patients’ modesty. To share and compare best practices in the benchmarking process evidence has to be collected on other areas of practice. I have collected the following information that I feel would be beneficial to my area of practice.

Where benchmarking has succeed it is documented in literature that the Trusts have taken a holistic approach, involving all stakeholders, to effect change. Below are examples of such success:

Rotherham General hospital – in recognition of the need to maintain patients dignity – worked with linen services to design specialist ITU gowns
Wirral Hospital – patient feedback led to new gowns being introduced into the Outpatients Department to maintain patients’ dignity
Royal Sussex Hospital – large coloured curtain clips used to hold curtains together so patient’s dignity is maintained. The clips also act as a signal to other staff and visitors not to enter the cubicle.

(Picker Institute Europe, 2003)

In conclusion, it is evident that the two articles have built a case for improving patient care through involving the patient in formulating best practice clinical care. Benchmarking is a process and should not be considered as a one-off exercise. To be effective, it must become an ongoing, integral part of an ongoing improvement process with the goal of keeping abreast of ever-improving best practice. The fundamental and essential aspects of care can be identified in patient complaints, ombudsmen reports and professional and patient/consumer feedback.

Reference

Burden, B. (1998). “Privacy or help? The use of curtain positiong strategies within the maternity ward environment as means of achieving and maintaining privacy, or as a form of signalling to peers and professionals in an attempt to seek information or support”. 27(1). P.15-23. Journal of Advanced Nursing. (online). Availablefrom:http://gateway1.ma.ovid.com/ovidweb. [Accessed 23 July 2003]
Chambers, N. &Jolly, A. (2002). “Essence of care: making a difference”. Nursing Standard. 17(1). P.40-44
Coulmas, F. (2000). The handbook of sociolinguistics. Oxford . Blackwell Publishers Ltd.
Davies, C. (2000). “Approaches to quality in health and social care”. Nursing Management . 9(4) p. 34-37.
Department of Health (2003) The Essence of Care Patient-focused benchmarking for health care practitioners (online). London. Available from: C:\My Documents\Encarta Researcher Home.htm. (Accessed 12 September 2003).
Ellis, J.,Cooper, A., Davies, D., Hadfield, J., Oliver, P., Onions, J & Walnsley, E.(2000). “Making a difference to practice: clinical benchmarking part 1.”.Nursing Standard. 14(32). P. 33-37
Lipley, N. (2001). “Government sets out key standards for quality care”. Nursing Standard. 15(24). P.5
Lunn, C.(2003). “Care is a big factor”. Nursing Standard. 17(30). P.24
NHS Public Health Resource Unit. (2003). “Qualitative Studies”.Available from: . [Accessed: 31 July 2003]
Nursing &Midwifery Council (2002). Code of professional conduct. London
Picker Institute Europe (2003). “Improving patients’ experience: sharing good practice-respect, privacy and dignity”
Scalon, E. & Whitfield, N. (2002). “Benchmarking pressure ulcers”. Nursing Standard. 16(22). P.50-60
Staniswewska, S. & Ahmed, L. (1999). “The concepts of expectation and satisfaction: do they capture the way patients evaluate their care”.101(6). P.69-73. Journal of Advanced Nursing. (online). Available from :http://gateway1.uk.ovidweb.cgi [Accessed 19 July 2003]
Stark, S., MacHale, A., Lennon, E., & Shaw, L. (2002). “Implementing the process in practice”. Nursing Standard. 38(1). P. 59-67

This paper attempts to carry out a critical review of two research articles and examine their appropriateness as reference sources in the compilation of The Essence of Care (DoH, 2001).

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