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Measuring quality in a paediatric day care unit

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VOL: 97, ISSUE: 10, PAGE NO: 32

Jessica Higson, BN, RN, is senior staff nurse at the Royal Berkshire Hospital, Reading

Glenis Hawkins, RN, is clinical audit and effectiveness facilitator at the Royal Berkshire Hospital, Reading

The present government's clinical governance agenda has a strong emphasis on ensuring quality in the health service (Department of Health, 1998). One way to measure quality is to establish if users are satisfied (Davis, 1999). Thus, at a new mixed day surgery and medical unit for children opened in April 2000, it was decided to audit parent and child satisfaction with this newly established service.

The present government's clinical governance agenda has a strong emphasis on ensuring quality in the health service (Department of Health, 1998). One way to measure quality is to establish if users are satisfied (Davis, 1999). Thus, at a new mixed day surgery and medical unit for children opened in April 2000, it was decided to audit parent and child satisfaction with this newly established service.

A review of the literature (CINAHL and Medline) highlighted many studies over the last 10 years which describe the measurement of patient satisfaction. As Blackhouse and Brown (2000) identify, however, many of these studies are flawed and give a falsely positive impression of care.

In 1990 the Audit Commission highlighted the lack of attention in many hospitals to measuring the quality of services offered to day-surgery patients, and, in particular, the patients' perceptions of them. On behalf of the Audit Commission, the Health Services Research Unit of the London School of Hygiene and Tropical Medicine developed a simple-to-use questionnaire to record patients' perceptions of day surgery services. The questionnaire was designed for use by health authorities and hospitals, and included a version suitable for use with children and their parents (Audit Commission, 1991).

The questionnaire had been rigorously tested in many other day care areas and was thus adapted to meet the needs of this client group. Self-completed questionnaires have been shown to have the advantages of anonymity and absence of interviewer bias (Polit and Hungler, 1999). The questionnaire was divided into sections covering all aspects of care from preoperative assessment to postoperative recovery. Questions were selected on their potential to influence clinical practice directly.

Method
Questionnaires were given to the first 50 children and their families admitted to the ward. They were accompanied by a covering letter that explained the purpose of the audit and clarified anonymity and confidentiality. The named nurse for each patient also reiterated the purpose of the questionnaire and explained how the results would be used to influence practice on the ward. All questionnaires were distributed with a prepaid envelope direct to the trust's clinical audit department, which analysed all returned questionnaires, assuring participant confidentiality.

Results
Thirty-three responses were received, an overall response rate of 66%, which is good and also sufficient to minimise any response bias (Polit and Hungler, 1999). The questionnaire was divided into four sections: preoperative assessment, in-hospital care, postoperative recovery and follow-up care. There was also a section for free text comments at the end. The majority of the questions were of the tick box variety and included some spaces for additional comments.

Preoperative assessment
Twenty-eight children (90%) attended a pre-clerking appointment run by a dedicated senior staff nurse. Of the remaining children the majority were brought in at the last minute. One child had undergone surgery several times before and the parents were confident about preparations for the procedure. Twenty-seven families found this pre-operative visit useful; the remaining one felt that many of the questions were repeated on the day of surgery. Families were asked whether they had received written information before admission. Twenty-six (78%) said they did and, of these, 25 felt the information was understandable.

In-hospital care
Families were asked if they were satisfied with various aspects of in-hospital care ranging from the physical ward environment to the atmosphere of the ward and attitude of staff. All respondents were satisfied with the atmosphere, availability of help and attitude of the nursing staff.

When questioned about whether they were worried about any particular aspects of the surgery, such as pain, complications and anaesthetic, 24 (73%) were worried about the anaesthetic. The two other highest-score worries were success of the operation (36%) and pain after the operation (50%). Fourteen families (16%) also said that they were concerned about the after-effects of the anaesthetic. This further highlights that, for many parents, the main concern is the anaesthetic itself, rather than the surgery.

All children were accompanied to theatre by one of their parents, and all felt happy and pleased to be able to fulfil this role.

Before discharge, all children are required to meet set criteria to ensure home readiness. Twenty-nine families (83%) said that these criteria were explained to them on admission. Only one parent felt that their child was discharged too early but, unfortunately, did not expand on why this was.

Postoperative recovery
Families were asked about the child's pain following surgery. All participants said they received advice about giving pain relief at home. More than half (60%) of the children experienced some pain at home ranging from a little to a great deal. Two children experienced a great deal of pain postoperatively; both of them had undergone dental extractions.

The parents classified the children's overall recovery: 23 (70%) recovered faster than expected, the remaining 10 (30%) recovered as expected.

Follow-up care
All the children and their families were offered a telephone call on the day following surgery. The purpose of the call was to offer advice and support to the families as well as gather data on the incidence and severity of any postoperative complications. Twenty-eight (84%) received a telephone call. It is possible that the others refused a call or were out when the call was made.

Of the families who were called, 90% found it helpful. Of the others, one parent recorded that the call 'was not necessary as my child has had the surgery so many times before'; the other said the call 'was not helpful, but it was friendly and reassuring'.

Three parents had to seek advice from their GP after the surgery, but they did not explain why.

Sixteen families made free text comments at the end of the questionnaire. These were classified under four main themes: thank you, communication problems, anaesthetic concerns and telephone follow-up. Nine of the comments were expressing thanks and praise for the nursing staff, two discussed the benefits and reassurance of the telephone follow-up, four discussed communication problems with medical staff and two described concerns about the anaesthetic. The box on this page includes a typical example from each category.

Discussion
It is clear that the vast majority of parents were satisfied with the care their child experienced and that any criticism of the service was constructive.

The preoperative assessment is clearly viewed as a valuable service in preparing children and their families for hospital admission. Day surgery places the onus of responsibility on parents for both preoperative preparation and postoperative care. The role of the pre-clerking nurse goes a long way to ensuring that the hospital takes on some of the responsibility for preparation and works in partnership with parents. Parents often need more reassurance and advice than the child does.

Several respondents reported that they did not receive written information about the operation from trust staff. This may well have been an oversight by either staff or parents, as all three of the surgical admissions that did not receive written information attended the preoperative assessment clinic. The information is currently being revised and printed into a standard booklet format.

In general, parents were satisfied with the care, attitudes and availability for help of the doctors and nurses. However, two patients reported that they were dissatisfied with the availability of the doctors and a further four made free text comments about seeing a doctor and getting information immediately after the operation or before discharge.

Implications for practice
Written information needs to be made available for children and their parents at the clinic or pre-assessment appointment. Extra care needs to be taken to ensure that all children and their families receive both written and verbal information on discharge from the ward.

Three-quarters of all parents expressed concerns about the anaesthetic. This information has been fed back to the anaesthetic team. It is felt there is little that an anaesthetist can do to alleviate parents' fear of the anaesthetic, but the study has highlighted to all involved the extra support that parents need. It is now hospital policy that the anaesthetist who will be performing the anaesthetic will visit the child and family before surgery to discuss any concerns.

Some parents reported that they were dissatisfied about the availability of the doctors following surgery. The surgical staff need to consider whether there is time available to see patients on the ward following surgery or, alternatively, decide to inform parents before surgery that they will discuss the operation afterwards at a follow-up appointment.

For more routine surgery, where a postoperative visit is not necessary, the parents should be informed in clinic or at preoperative assessment that the surgeon will not visit following the surgery. This will ensure that parents are fully informed of the routine for the day and will not be disappointed.

Extra care needs to be taken to explain the discharge criteria before the child goes to theatre so that parents and child know what to expect. This experience has also highlighted the importance of including the parents in the decision-making process before sending the child home.

A prospective audit is currently being designed by the nursing staff to monitor morbidity - specifically pain and swelling - following oral/dental surgery. The results will then be shared with the anaesthetic and pain team to help develop a protocol for analgesia following oral surgery.

Parents said they found the follow-up telephone call helpful. This service will be continued but, in light of the result, the practice could be negotiated in advance with parents of children undergoing repeated surgery.

The study will be repeated in six to 12 months.

Conclusions
The main tenet of clinical governance is to ensure a quality service for NHS patients. Nurses play a key role in maintaining a quality service and should therefore be involved in monitoring that service. This audit has provided staff with a valuable insight into the views and feelings of the families and children coming to hospital for the day.

Much of the data has been acted upon to directly improve patient care. The questionnaire has also highlighted certain areas of practice that both medical and nursing staff need to address, such as pain management, concerns about anaesthetic and information-giving.

Finally, the responses have enabled families to express their thanks and appreciation to staff which, in turn, boosts staff morale.

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