current situation and effectiveness of chief nurse capacity improvement intervention from 2010 - 2013 in nghe an province

Rate of Chief Nurse not trained about management was still high 62.2% [42]; Pham Duc Muc’s research [59], to investigate systems and human resource for Chief Nurse in central and provinc

INTRODUTION:

1 Urgency of theswas:

In our country, Chief Nurse System (CNS) is the first management level

of the hospital Chief Nurse is responsible for implementing the medical command of doctor, management of human resources and department administration Efficient quality of care, patient service, use of resources depends significantly on CNS According to survey in year 2007 of the Viet Nam Nursing Association, Chief Nurse has had generally intermediate level 84.8%, College 7.2%, University 7.8% and postgraduate 0.2% Have been trained the nursing management with the rate of 37.8%, the effectiveness of executive leadership, participation in the activities of training, guidance and specialization guidance has been only done good 33.7% [42], [43]

In Nghe An (2008), Number of Chief Nurse has been more than 400 people, intermediate professional qualification has been 91.9%; college 8.1%; Trained on nursing management 19.2% [71], [95] In recent years, Nghe An has gradually strengthened and perfected the nursing management system However

in fact revealed a certain number of limitations, such as low-level professional qualification, management capacity was not effective, management system was insufficient, has been influenced on the quality of patient care

With the challenges in health care, hospital overcrowding has increased the shortage of nursing manpower, limitation of proficiency was barrier in whole patient care This was that the role and responsibility of the Chief Nurse became very important in the planning, coordination of the work, the thesis was the key to solve the above challenges, became more urgent and meaningful practice

Proceeding from the above requirements we have carried out

implementation of the project: Status and effect of Chief Nurse ability intervention in Nghe An province with the goals:

1 Describe the situation and factors that has affected the ability of Chief Nurse at the hospitals in Nghe An province in 2010 - 2011

2 Evaluate capacity improvement intervention effect of Chief Nurse at the hospitals studied in 2011-2013

2 New contributions of the thesis:

- Describe the task performance capacity status for the management of Chief Nurse in the hospital - Nghe An province

- Identify the factors affecting to the task performance capacity for the management of Chief Nurse in the hospital - Nghe An province

- Consider about the task performance capacity status for the management

of the hospital of Chief Nurse in the hospital - Nghe An province

- Proven intervention activities raised Nursing Management Capacity for Chief Nurse

- Strengthen capacity of health systems (building the technical management system, records and report system) to contribute improvement of the nursing care service quality in the hospitals - Nghe An province

3 Layout of thesis: Including 125 pages, Introduction 2 pages, Overview for document 40 page, object and methodology 18 pages; Research Results 40 pages, Discussion 22 page, Conclusions 2 pages and Recommendations 1 page There were 18 sets, 17 figures, 02 diagrams and 159 references (Vietnamese:

110, English: 49)

Chapter 1 GENERAL

1.1 Concepts and relevant definitions:

- Management capacity has been evaluated based on the ability to apply knowledge and skills in management operations: including knowledge for the skills and management content Perform proficiently management processes and attitudes before the assigned work in a spirit of responsibility, solidarity, self-dwascipline, sacrifice for the community [74]

- Nursing Management Capacity (NMC) has been expressed on the ways

of knowledge, practices and attitudes: the nursing dean (ND) has had the excellent technical expertwase, both have has good management skills and seriousness and responsibility before actions However, the application of the preeminent quality management system, supporting Manager would increase management efficiency [46], [47], [74], [91]

1.2 Nursing management capability:

1.2.1 Nursing management competency assessment skills:

Based on the knowledge and practice of the nursing management skills, including 16 following skills [16], [14], [20], [30], [40], [95]: Organizing wholly care for patients; Directing the hygiene work; Human resource management; Asset - Materials Management; Participation in training, scientific research; Planning; Plan performance organizations; Evaluation; Supportive supervision; Application of information technology; Decwasion making; Problem solving; Organization of meetings; Time management; Administrative documents and drafting method of text and Records Management

1.2.2 Nursing Management Capacity Method:

- Periodical, regular evaluation; - Extraordinary evaluation; - Periodical evaluation interposed extraordinary [6], [10], [11], [39], [95]

1.2.3 Factors affecting the Nursing management capability:

Factors have affected nursing capacity, including:

- NURSE Qualifications was low [127], [129]

- The administration and documentation works of nurse occupy percentage of time equivalent to the direct time for patient care (CP) (28%) Meanwhile, each activity, work had not guidelines, procedures work to help management methodically and unified [94]

- Awareness of staff, the low self-esteem, the complacent of the medical staff for nursing person have affected to some extent the management operation and covering and extending level of whole patient care (WPC) in the hospitals The hegemony of doctor, the coordination between the nurse and each other [79]

- The Nursing person (Nurse) has had often passive and dependent behavior, they have taken the initiative in the struggle for the branch Internal branch was often not united

- Lack of educational opportunities, re-training for specialization and management

- In addition, low-income, large number of patients, lack of equipment and coordination of the patient and family were also factors affecting not less the quality of nursing work

1.3 Research for Nursing Capacity:

According to Roderick’s researchers at the United States for improvement

of the patient care quality (PC) [147] has shown that the patients’ satisfaction proportion for the doctor was the higher than Chief Nurse, Nurse in intensive clinic department, but in obstetrics satisfaction for Nurse, Chief Nurse was 73%, for the doctor 71%

1.3.2 In Viet Nam:

* For nursing management:

According to the survey results of the Vietnam Nursing Association in

2007 has shown that levels of Chief Nurse in hospitals in Vietnam have had professional qualifications limited intermediate 90.6%, below the age of 35 accounted for 23, 9% Rate of Chief Nurse not trained about management was still high (62.2%) [42];

Pham Duc Muc’s research [59], to investigate systems and human resource for Chief Nurse in central and provincial hospitals in 2007 shown: Trained for Nursing management was 63.3% Implementing authorities tasks: Organizing and directing the implementation of whole patient care (WPC): good 72.3%; medium 22.1%; poor 4.1%; no done 1.5% Speech, check the implementation in accordance technical procedures hospital regulations: Good

90.0%; Average 3.2%; poor 5.2%; no done 1.5% Organize training and rawasing the level: good 62.4%; Average 22.5%; poor 9.2%; no done 5.9% Join practice guide for pupil - student: Good 35.8%; Average 31.4%; poor 26.6%; no done 6.3% Procurement planning, test use and preservation: good 48.0%; Average 31.4%; poor 26.6%; no done 6.6% Check the hygiene, infection protection: Good 88.2%; Average 5.5%; poor 5.2%; no done 1.1% Join the organization, recruitment work: Good 60.5%; Average 24.0%; poor 12.5%; no done 3.0% Participation in scientific research: Good 38.0%; Average 22.1%; poor 34.7%; no done 5.2% Participation in guidance of branch: Good 45.8%; Average 20.3%; poor 22.8%; no done 5.2% Sum up partially, generally: good 62.0%; Average 27.5%; poor 8.0%; no done 2.5% Participation in propose ideas regarding the nursing policies: good 77.9%; Average 17.0%; poor 4.1%; no done 1.1%

According to Do Dinh Xuan’s research (2007) [107], has shown that 6,787 Chief Nurse were working in the public hospitals in the country, including: Nurse 78.4%, Midwife 7.4%, Medical Engineering 8.2%, 6.0% Chief Nurse with no professional qualification was nurse participating in nursing management (doctors, pharmacists) Regarding the capacity status of Chief Nurse Dean: 84% Chief Nurse Dean have assessed themself that they were able

to complete from more fairly in the contents: patient care organization; Sanitation work guideline of departments; rooms; human resource management; asset and materials management Only 54.5% Chief Nurse Deans jointed in the courses for management, in training, scientific research and direction of branch, with 61.40% gain from the good level and more, especially, 20.20% Chief Nurse Deans were weak in scientific research work Weak implementation or

no organization of scientific meetings accounted for 24.40% Still 21.10% Chief Nurse Deans have achieved an average or less within the formulation, organization and maintenance of wholly care work Chief Nurse Dean was weak or may not participate in the selection of new employees for 24.40%

* For affected factors:

Do Dinh Xuan’s research (2007) [107], indicating that the factors such as age, sex, equipment and working conditions, the coordination of patient families and doctors as well as the work overload, etc were considered as relevant factors and influenced directly the ability of Chief Nurse Dean

Very little themes research factors affecting nursing capacity, might have re-statwastic some related factors directly affecting the quality of professional management No analytical research has evaluated the affecting factors to give solution to effective interventions

* For the document, form of nursing management:

According to Vo Thi Dinh , the record, storage of document, form were pretty good, record status surpluses or deficits, duplicate information stipulated

by the Ministry of Health that also occurred [32] Nguyen Thi Thanh Mai said that recording the developments of patients recently being in the department

were less than 5%, average 73%, rather 22%; developments in the treatment process were less 4%; average 78%, rather 18%; handling care were less 6%; average 75%, rather 19% [55]

* For satisfaction of patient:

According to Vuong Kim Loc, research for the situation of nursing management work at Saint Paul hospital in 2007, patient’s satisfaction results have reached 55% [52]

Le Thi Binh’s research (2008), the Central Hospital was very satisfied by people 42.1%; satisfied 48.2%; Provincial/ citify hospitals very satisfied 62%, satisfied 36% [2] Ha Thi Soan’s research (2007) has assessed the satisfaction

of patients and their family for the medical staff about attitude >90% satisfied, specialization >90%, patients boards 94% However, 10-12% non-satisfied were mainly on administrative procedures, made the test but not explain, no dietary guidelines, patients have had to buy more medicines outside [71] Survey results of Nguyen Thi Ngoc (2005) at the General Hospital Thong Nhat, Dong Nai, the average satisfaction rate was 45.3% primarily not satisfied with guidance, explanation and health education yet thoughtful [64] Hoang Thu Nga’s research said: satisfaction rate for attitude of service 87.8%; guidance in hospitalization 87.1%; mode of hygiene 84.8%; facilities, equipments 80.1%; security 62.9% and expertwase 93.7% [63]

1.3.3 In Nghe An:

Research in 2009, Nursing staffs, midwives in Nghe An has had 1,735 workers, mostly women 84.5% In which university degrees, college was 11.7%, foreign language level A was 12.3%, Office informatics were 24.8%, trained nursing Management 38.5% [72]

According to the 2008 survey in Vinh City shown: Chief Nurse has had intermediate level about 91.9%; Average age of 35-55 accounted for 78.8%; not trained nursing management about 76.8%, capable of office computing and foreign language level A accounted for 54.5 - 62.6% [96]

In recent years, although there have been many positive changes in the domains of nursing, patient care in Nghe An However, the nursing scientific research has had still many limitation because the force of nurse, midwife and technicians were mainly intermediate, an knowledge for research design and methods of scientific research was weak The major topics has used the description method, bringing the summarization, report, very little research analysis titles, content focuses mainly on human survey, conducted nursing technical procedures, understanding patient service attitude Especially intervention research for Chief Nurse capacity did not have any topic

Chapter 2 OBJECTS AND RESEARCH METHOD

2.1 Research objects:

- Chief Nurse was working at the hospital in Nghe An province

- Management staff of department, research hospitals

- The system of records, books, management forms of research hospitals;

- Patients who were inpatients in the departments, research hospitals

2.2 Capacity investigation location of Chief Nurse: at 40 public hospitals and

private in Nghe An

2.4.2 Research sample sizes:

Stage 1: Current status and factors affecting the status of Chief Nurse capacity

2.4.2.1 Quantitative Research:

Chief Nurse object:

Thus, the research samples of Chief Nurse object were 403

Records, books, saving reports:

Analysis of records, books and reports related to the nursing care and nursing management works of the years 2009 - 2013, including: case history, monitoring sheet, care vote, the management books of materials, manpower, plans, preliminary reports and summarization

Patients’ inpatient treatment:

Thus, the samples have selected to research of patient object were 400

2.4.2.2 Qualitative Research:

- Depth interview: Director/Vice Director of the hospitals: 8 persons

- Discussion under groups: 02 groups, each group was 8 head or deputy department

Stage 2: Evaluation of effectiveness of intervention "improvement of Chief

Nurse capacity"

2.4.2.3 Intervention research:

Total of Chief Nurse required to research 100 (Intervention group 100 and control group 100)

2.4.4 Research sample selection method:

2.4.4.1 Cross-sectional descriptive research:

- For the Chief Nurse:

Choose whole Chief Nurse working in 40 public hospitals, non-public in Nghe An province

- For inpatients: Select samples with 02 stages:

- Stage 1: Divise the provincial, district, citify hospitals into two ecoregions (advantages and disavantages)

- Stage 2: Each ecoregion randomly has selected in proportion, disavantage 3/12 hospital and advantage 7/28 hospital to conduct an investigation, in each hospital investige 40 patients

2.4.4.2 Qualitative Research:

Intentionally select 8 above research hospitals: Depth interviews with 8 Director/ Vice Director Organize Discussion into 2 groups, each has been 8 head or deputy department[84]

2.4.4.3 Intervention research:

Step 1: Select the research locations: Select 21 hospitals/ 32 public hospitals

randomly assign the intervention group and control group

Step 2: Pre-intervention assessment: Assess capacity of Chief Nurse; The

success indexes before the intervention:

Step 3: Implement intervention situations to improve the capacity of Chief Nurse:

* Develop a plan of implementation, inspection and evaluation;

* Carry out the service supply and longitudinal inspection of research indexes during the intervention time, was 02 years (24 months):

- Implement training solutions in Nursing Management [17], [106]: Training Program: issued by Ministry of Health attaching the Text No 5909/YT-K2DT dated 16/08/2004 of the Ministry of Health, including 16 skills for nursing management [104], [105]; Develop and use procedures, guidelines and forms for nursing management

- Organize the application of knowledge, skills and forms of Nursing Management in daily activities of Chief Nurse

- Implement periodic supervision: 1 month/time to support supervision, 3 months/time meetings, learn from experience

Step 4: Collect, process data, and post-intervention effectiveness

- Collect post-intervention data

- Evaluation in comparison with post-intervention: Two intervention and non-intervention groups was initially the same (ptct and ptc), any difference (the index) was later through the horizontal invertigation in psct and psc that could relate the impact of intervention method

+ The result index of intervention group = (psct - ptct )/ptct x 100%

+ The result index of control group = (psc - ptc)/ptc x 100%

+ Effective intervention = The result index of intervention group - The result index of control group

In which: The result index: Performance Index; ptct: The pre-intervention research index of intervention group; psct: The post-intervention research index

of intervention group; ptc: The pre-intervention research index of control group;

psc: The post-intervention research index of control group

The result index of intervention group > 0 and Intervention result = The result index of intervention group - The result index of control group > 0, so the intervention was effective

2.5 Data collection and processing method:

Chapter 3 RESEARCH RESULT 3.1 Status and factors affecting the Chief Nurse management capacity: 3.1.1 Characteristics of the research subjects:

Results for General Information about Chief Nurse: Sex: Mostly female (81.6%); under age 40 was 57.1% higher; Main ethnic was Kinh (95.1%); Main professional qualifications was Intermediate (62.9%); Nursing specialization accounted for 68.4%; trained nursing management was 25.7%; Foreign language levels were mainly A, B (58.0%); Computer levels A, B (70.6%) and overseas study tours most (98.3%) have not been away

3.1.2 Management capacity status of Chief Nurse:

3.1.2.1 Chief Nurse’s management knowledge:

Classification of Chief Nurse’s management knowledge under the qualification: The results have shown that 412 Chief Nurse, the rate of general management knowledge graded fair, good 72.5%; in the group from College degree and more account for 26.4%, Intermediate group 46.1% According to the provincial and district branches: General management knowledge rate grades fairly, good at provincial group was 29.4% (x = 65.43), the district group was 43.2% (x = 64.32) According to public hospitals and private: rate of general management knowledge grades fairly, good in public group was 65.1% (x = 66.22), non-public group was 7.5% (x = 57.16) According to the disadvantage and advantages regions: rate of general management knowledge grades fairly, good in disadvantage regions was 23.5%, advantages was 49.0%

Grade point average for general management knowledge according to qualification: of 153 Chief Nurse having college degree or more was 65.36 (standard deviation = 15.2), of 259 Chief Nurse having intermediate degree was 64.73 (standard deviation = 15.7) The results have shown that the college degree or more higher than intermediate degree was 0.63 with confidence

intervals 95% (-2.49 to 3.74) This difference did not mean the statistics with p

= 0.693 According to the provincial and district branches: Grade point average for general management knowledge of 173 Chief Nurse in provincial branches was 64.32 (standard deviation = 15.2), the 239 Chief Nurse in district branches was 65.43 (standard deviation = 15.8 ) The results shown that the provincial branches were lower than district branches, was 1.10 with confidence intervals 95% (-4:16 to 1.94) This difference did not mean the statistics with p = 0.476 According to public, non-public: Grade point average for general management knowledge of 355 public Chief Nurse was 66.22 (standard deviation = 14.7), of

57 public Chief Nurse was 57.16 (standard deviation = 18.3) Public > public was 9.06 with confidence interval 95% (3.99 to 14.14) This difference meant the statistics with p = 0.001 According to the disadvantage and advantage regions: Grade point average for general management knowledge of 121 Chief Nurse in disadvantage regions was 69.14 (standard deviation = 14.6), of 291 Chief Nurse in advantage region was 63.23 (standard deviation = 15.6) Disadvantage region higher than advantage region was 5.91 with confidence interval 95% (2.65 to 9.17) This difference meant the statistics with p = 0.0001

non-3.1.2.2 Chief Nurse’s management Practices:

Research results classify Chief Nurse’s management practices according

to qualification: rate of general management practices was classified fair, good accounting for 72.5%; at group from college degree or more (26.4%), intermediate group (46.1%) Head under the provincial and district branches: the rate of general management practices was classified average in provincial branch group was 19.7%, and in district branch group was 17.0% According to public and non-public: In 412 Chief Nurse, the rate of the general management practices have classified average in the public group was 34.0%, non-public group was 2.7% According to disadvantage, advantage regions: The rate of general management practices was classified average in disadvantaged regions was 11.4%, advantage regions 25.2%

Research result of grade point average for Chief Nurse’s management practice under qualification: of 173 Chief Nurse having college degree or more was 64.4 (standard deviation = 17.4), of 239 having intermediate degree was 64.5 (standard deviation = 16.1) Results shown that the college degree or more and intermediate degree were approximately equivalent with confidence interval 95% (-3.51 to 3.28) This difference did not mean the statistics with p = 0.945 According to the provincial and district branches: Grade point average for management practices of 173 Chief Nurse in provincial branches was 69.78 (standard deviation = 16.3), the 239 Chief Nurse in district branches was 60.64 (standard deviation = 15.7) The results shown that the provincial branches were higher than district branches, was 9.14 with confidence interval 95% (6.01

to 12.27) This difference has meant the statistics with p = 0.0001 According to Public, non-public hospitals: Grade point average for management practices of

355 public Chief Nurse was 65.39 (standard deviation = 16.9), of 57 non-public was 58.77 (standard deviation = 13.4) The results shown that the public group higher non-public group was 6.62 with confidence interval 95% (2.66 to 10.58) This difference had meant the statistics with p = 0.001 According to the disadvantage and advantage regions: Grade point average for management practices of 121 Chief Nurse in disadvantage regions was 63.21 (standard deviation = 17.79), the 291 Chief Nurse in advantage region was 65.01 (standard deviation = 16.04) The results shown that disadvantage regions lower than advantage region was 1.80 with confidence intervals 95% (- 5:49 to 1.89) This difference did not mean the statistics with p = 0.337 Classification results

of Chief Nurse’s Management Capacity shown that the fair, good rate for general management knowledge was 72.6%; x = 64.97 (Std: 15.5); Fair, good rate for general management practices was 0%, average 36.6%; x = 64.48 (Std: 16.6); Fair management capacity was 13.8%, mainly average (67.7%); x = 129.44 (Std: 23.2)

3.1.2.4 Satisfaction assessment of patient for Chief Nurse:

Assessment of patients by satisfaction, very satisfaction with Chief Nurse capacity

at a high level However, there were still dissatisfaction, very dissatisfaction for professional performance planning and effective 25.6%; Speech 23.6%; Gesture 23.5%; Examination procedures and hospitalizations 23.1%

3.1.2.5 Factors affecting the ability of DDT:

Factors related to the management capacity of Chief Nurse in the univariant model: The Chief Nurse respond to be supported the factors so the nursing management capacity was higher than of Chief Nurse who were not supported this: Direction table, scheme (1.98 times); Workflows (0.28 times); Discussion with colleagues (2.25 times)

Table 3:13: Factors affecting the Chief Nurse’s ability after bring into a multivariate model to adjust jammed control:

Comment: In a logistic multivariate regression model to control jamming

factors, the results shown that factors supporting profession has helped really Chief Nurse, was factor of Workflows The Chief Nurse had answered to be supported for the Workflows have had capacity less greater than 0.29 times the Chief Nurse being not supported this That was more supported for workflows, the Chief Nurse has had higher capacities

3.2 Evaluate the effectiveness of interventions:

3.2.1 The assessment results before and after training:

Chief Nurse’s knowledge assessment before and after training: After training, Chief Nurse’s knowledge met requirement (100%) higher than before training Effective training = 42.1 Effective intervention

3.2.2 Chief Nurse’s management knowledge:

Evaluation of Chief Nurse’s management knowledge before and after intervention: Before intervention Chief Nurse’s management knowledge between two intervention groups (good, fair 7.5%) and controls (good, fair 5.2%) have not had differences with p > 005 After intervention Chief Nurse’s management knowledge of intervention group (good, fair 48.0%) > control group (7.9%), the difference has meant the statistics with p <001

Result Index of intervention group = 540%; Result Index of control group

= 50%; Intervention efficiency = 490% So, intervention was effective

The discussions under group has shown also a similar opinion, knowledge for nursing management of Nursing deans has had limited, often done under medical command and made administrative duties of the department mainly, the deployment tasks through content of meetings

After a period trained about nursing management, still be perplexed at first, subsequently be monitored and supported so Chief Nurse understant now the concepts, contents of management activities process Opinions of hospital managers have given more positive comments

Generally, the assessment for Chief Nurse’s management knowledge has been recognizes well by the hospital managers/ departments, complete assigned works with better quality Thus, assessment of intervention activities was effective initially have contributed to improving the quality of healthcare services

3.2.3 Chief Nurse’s management skills practices:

Assessment of Chief Nurse’s Management Practice: Before intervention assessment for Chief Nurse’s management practice between the two groups of intervention (good, fair 5.7%) and control (good, fair 7.5%) have not had the differences with p > 0.05 After intervention, Chief Nurse’s management practices of intervention group (good, fair 41.5%) higher than the control group (good, fair 4.8%), the difference has meant the statistics with p < 0.001 Result index of intervention group = 630%; Result index of control group = - 40%; Intervention result = 670% So intervention was effective

The opinion for depth interviews and group discussions also have turned around comments on nursing management skills of Chief Nurse was clearly improved Thus, for the management skills of Chief Nurse has been highly appreciated by the hospital managers/ departments, the significant improvement for the quality and effectiveness of patient care

3.2.4 Chief Nurse’s management capacity:

Table 3.16: Assessment for Chief Nurse’s management capacity:

Management

capacity

Intervention group

Control group

p

Intervention group

Control group

Comments: Before general management capacity intervention of intervention

group (good, fair 3.5%) lower than the control group (good, fair 6.1%), the difference has meant the statistics with p < 0.005 After the general management capacity intervention of Chief Nurse in the intervention group (good, fair 47.2%) higher than the control group (good, fair 7.9%), the difference has meant the statistics with p <0.001

Result index of intervention group = 1250%; Result index of control group = 30%; intervention result = 1220% → intervention was effective

The depth interviews and concentrated group discussions have confirmed that:

To improve the quality of patient care, strengthening nursing management capacity, overcoming the existence of the actual management status, we have had

to pay attention synchronously to conditions: Material basic, medical equipment; Improving the quality of professional qualifications, attitudes, responsibilities and professional conscience of Chief Nurse Thus, to improve the nursing management capacity, education in improving, training, updating knowledge, skills, dissemination for medical ethics for Chief Nurse was necessary

3.2.5 Documents, form of nursing management:

The pre-intervention research results of current documents, forms of nursing management of intervention group (good, fair 20.5%), control group (good, fair 20.1%), the difference between the two groups did not mean statistics with p> 0.05 post-intervention current document, forms of nursing management of intervention group (good, fair 44.1%) higher than the control group (good, fair 22.8%), this difference has meant statistics with p <.05