Measuring quality in community nursing: a mixed methods study

Abstract Background High-quality nursing care is crucial for patients with complex conditions and co-morbidities living at home, but such care is largely invisible to health planners and managers. Nursing care quality in acute settings is typically measured using a range of different quality measures; however, little is known about how service quality is measured in community nursing. Objective To establish which quality indicators are selected for community nursing; how these are selected and applied; and their usefulness to service users (patients and/or carers), commissioners and provider staff. Design A mixed-methods study comprising three phases: 1)A national survey of ‘Commissioning for Quality and Innovation’ indicators applied to community nursing care in 2014/2015. Data were analysed descriptively using SPSS 20.0. 2)In-depth case study in five sites. Qualitative data were collected through observations, interviews, focus groups and documents. Thematic analysis was conducted using QSR NVivo 10. Findings from the first two phases were synthesised using a theoretical framework to examine how local and distal contexts affecting care provision impacted on selection and application of quality indicators for community nursing. 3)Validity testing the findings and associated draft good practice guidance through a series of stakeholder engagement events held in venues across England. Setting The national survey was conducted by telephone and e-mail. Each case study site comprised a Clinical Commissioning Group (CCG) and its associated provider of community nursing services. Participants Survey: 145 (68.7%) CCGs across England. Case study: NHS England national and regional quality leads (n=5); commissioners (n=19); provider managers (n=32); registered community nurses (n=45); adult patients (n=14) receiving care in their own homes and/or carers (n=7). Findings A wide range of indicators was used nationally, with a major focus on organisational processes. Lack of nurse and service user involvement in indicator selection processes impacted negatively on their application and perceived usefulness. Indicator data collection was hampered by problematic IT software and connectivity and inter-organisational system incompatibility. Frontline staff considered indicators designed for acute settings inappropriate for use in community settings. Indicators did not reflect aspects of care such as time spent, kindness and respect, highly valued by frontline staff and service user participants. Workshop delegates (commissioners, provider managers, frontline staff and service users, n=242) endorsed the findings and draft good practice guidance. Limitations On-going service re-organisation during the study period affected access to participants in some sites. Limited available data precluded in-depth documentary analysis. Conclusions Current quality indicators for community nursing are of limited use: Commissioners and provider managers should ensure that service users and frontline staff are involved in identifying and selecting indicators. Difficulties with connectivity and compatibility should be resolved before rolling new IT packages out into practice. Quality measures designed for acute settings should not be applied in community settings without modification. A mix of qualitative and quantitative methods should be used to determine service quality Future work Research investigating appropriate modifications and associated costs of administering quality indicator schemes in integrated care settings. Funding details The study was funded by the NIHR Health Service and Delivery Research programme.