I am a sister responsible for a large orthopaedic surgical service with three orthopaedic surgery consultants. I feel that patients on my wards would benefit if the nurses could participate with the surgeons in audit of some aspects of patient care, but when I broached the subject with one of the consultants, he expressed the opinion that audit was a medical matter. How might I attempt to introduce clinical audit in my service?

Think carefully about your objectives and what you truly want to achieve, select the surgeon with whom you wish to pursue your idea initially, then plan carefully how you will present the idea of clinical audit. The surgeon you approached took the view that audit is for the surgeons. There are three possible explanations for this attitude:

1. The surgeons may be in an early stage of developing their own audit programme and may prefer to develop and stabilise these activities before inviting another professional group to join them.
2. They may concentrate solely on medical/surgical issues in their present audit meetings and may not see how nurses could or should be involved in such matters. For example, orthopaedic surgeons could be discussing indications for disc surgery or when they should or should not do arthroscopy. These subjects require surgical knowledge and judgement and there may not be much overlap with nursing considerations.
3. There may be marked differences in practice between the surgeons. For example, they may have diverse views on prophylaxis for deep vein thrombosis or infection; one may accept profoundly obese patients for elective surgery while the others don't, or one may have significantly longer pre and postoperative stays. If the surgeons think nurses may raise these differences in their judgements or practice at audit meetings, they may prefer to exclude nurses.

In many medical specialties, one consultant has been designated as the lead consultant for audit. Enquire if this is the case among your surgeons and, if so, which one has been so designated. If not, approach the one who is clinical director or lead consultant.

The most important part of your approach is to be specific about why you would like doctors and nurses to work together. It would be wise to make clear that you do not expect all audit activity to be done together, but rather would like to approach some particular problem or aspect of care jointly.

In orthopaedic wards, problems such as planning for timely discharge, including arranging for community-based nursing or therapy, meeting patients' nutritional needs or the incidence of chest or urinary tract infections are likely to interest doctors as well as nurses.

An even better approach would be to complete your own audit on a key aspect of patient care and offer to present the findings to the doctors. Your presentation could be offered as a basis for consideration by both professional groups as to how the key aspect of care should be taken forward to achieve improvement.

In summary, be prepared to concentrate on tangible benefits to patients of a clinical audit approach. If you have a specific and realistic plan in mind which has the potential to improve quality of patient care, it is unlikely the surgeons will turn you down.

My manager is talking about using focus groups to learn about how to improve the quality of our services. What are focus groups and how can they contribute to improving the quality of patient care?

A focus group is a type of interview of a group of people. Focus groups were developed originally in the 1940s by social scientists for the purpose of examining the persuasiveness of wartime propaganda efforts. The idea of focus groups was adopted by market researchers in the USA in the 1960s: they were used, among other applications, to assist companies in selecting names for new products such as the Ford Mustang car; to provide feedback on consumers' responses to potential advertising campaigns; to help manufacturers to field test potential characteristics of products such as putting coloured designs on kitchen paper towels.

Focus groups have recently been used for another purpose. During Bill Clinton's US Presidential campaign, small groups of men and women, of whom only a few initially favoured Clinton, were asked what they thought of the candidate. Their initial reactions were: “He plays both sides of the street” and “if you asked his favourite colour he'd say 'plaid'”. The interviewers then described Clinton's life story, including his modest upbringing, working his way through Yale Law School and his record as Governor of the State of Arkansas.

After hearing more about the candidate, participants were asked if they would change their views about him and the participants began to note that he “sounds like he has a lot more morals than the papers give him credit for.” The Clinton campaign went on to listen and respond to messages which the focus group provided, such as the need for government to expand opportunities for jobs and job training.

With a skilled interviewer, focus groups of actual or potential patients, clients and/or carers could provide useful information about how patients and/or carers perceive the present level of quality in a particular service and how they might respond to changes in the service. Possible applications of focus groups in medical or healthcare settings might include:

• Identifying how patients/carers feel about the current service eg, its good and not-so-good points.
• Generating ideas about changes patients/carers would like to see in the service.
• Evaluating patients'/carers' reactions to potential alternative changes in the service.
• Identifying issues to be developed in a more extensive survey of patients/carers about the services.
• Obtaining patient/carer reactions to changes actually made in the service.

There are a number of practical questions to be considered about using focus groups to investigate healthcare issues such as criteria for selection of patients/carers, suitable times and venues for such groups, avoidance of subjects which may be sensitive and whether or not to pay participants for their time.

Focus groups may provide valuable insights into patients' and/or carers' views of the quality of service. But in the end, the management and team providing the service will have to make decisions about responding to the views. After all, patients may say that now you ask, they would prefer regular evening and Saturday hours for clinics and community services!

Reference
Manhattan Projects (1992) Newsweek, November 16, 28-21

Back to top of page