INTRODUCTION/BACKGROUND
The healthcare industry, specifically the nursing fraternity, has become a competitive platform in the health market. Nursing practices are critical components of high-value care, and crucially, they are fundamental in driving the success of healthcare systems. Hospital leaders and nurse managers have therefore desired to establish a competitive and sustainable advantage by understanding and implementing a range of factors that influence nursing and midwifery practices (American Nurse, 2016; Jennings et al., 2015). Key Performance Indicators (KPIs) have now become the norm in nursing and midwifery to measure, monitor and collect evidence of their contributions to patient and client care (Northern Ireland Practice and Education Council for Nursing and Midwifery [NIPEC], n.d.; Rees et al., 2016). The article by Gray, McCance and Brown (2021), therefore, sets out to explore how KPIs influence nursing and midwifery practice across the United Kingdom and the Republic of Ireland and to determine how they influence healthcare organisations’ practices. The authors believe that KPIs have become a cornerstone for improving patient care, but there “are incongruities in how quality assurance and accountability are reported across different healthcare sectors” (Gray, McCance and Brown, 2021, 4901; Bail and Grealish, 2016). The authors also suggest that there is little empirical evidence on how KPIs improve the quality of care but also argue that nurses and midwives emphasise the importance of gathering meaningful data to help establish care delivery standards and to implement changes. Arguably, measuring the quality of nursing care is not an easy task, and that’s why there is little empirical data on how KPIs support nursing and midwifery practices. However, regardless of the organisations and institutions involved, KPIs have been integral in reshaping performance metrics and strategically aligning all aspects of the organisation and customer experience (Wilson, McCance and Pesa, 2012; Aiken et al., 2018). Research has shown that KPIs have the potential to be integrated and improve other organisational agendas while also showing an ability to facilitate a person-centred approach to care (Wilson, McCance and Pesa, 2012; McCance et al., 2020). The appraised article also notes that there is little discussion on how KPIs are integrated at the organisational and clinical levels, and this, therefore, forms the basis for an exploration that will help determine the link between KPIs and the implementation processes that guide monitoring and reporting from an organisational context and how they maximise clinical care.
METHODOLOGY
Ethics and Sampling
In this research conducted by Gray, McCance and Brown (2021), a mixed approach has been integrated to facilitate a qualitative approach involving human participants. Henceforth, the researchers seek approval from the Ulster University Governance Filter Committee, the host NHS organisation, and the regional NHS research coordinating bodies (Gray, McCance and Brown, 2021; McCusker and Gunaydin, 2015). Accordingly, since this is a U.K.-based research undertaking, all approval processes must go through the relevant NHS research ethics committee body as part of a single ethical approval process (Gelling, 2016; Shannon-Baker, 2016). In this case, the researcher’s decision to seek ethical approval from the two NHS bodies identified above falls in line with the EU Clinical Trials Directive 2001/20/EC. It is unusual for researchers to seek approval from the NHS and the university, but in this case, the researchers sought approval from both bodies since researchers are required to meet local requirements (Gelling, 2016; Lilley et al., 2020).
The researchers went further and followed ethical codes of practice whereby under Phase One of the research studies, the researchers returned the completed questionnaires to the relevant approval bodies as a sign of providing consent that the study is underway and the participants have accepted the terms set out (Gray, McCance and Brown, 2021). This was followed by the deletion of the IP recorded by Qualtrics, which enabled the organisations involved to stay anonymous during the research undertaking (Gray, McCance and Brown, 2021, 4903). The Declaration of Helsinki in 1964 set forth a raft of guidelines to help researchers in their various research undertakings and significantly, set-forth ethical considerations amounting to participants having the right to informed consent (Wu et al. 2019; Schoonenboom and Johnson, 2017). Since this is a published research article, it falls in line with the consent guidelines under the declaration to which the lack of consent would have led to the termination of the research or, on the other hand, non-publication (Wu et al. 2019; Hong et al., 2018). The decision to permit consent and thus facilitate publication also falls in line with guidelines provided by the International Committee of Medical Journal Editors (ICMJE), the World Association of Medical Editors (WAME) and the Committee of Publication Ethics (COPE) (Heinrichs, 2019; Wilson, Brown and McCance, 2021). Moreover, ensuring the participating organisation stays anonymous is also part of informed consent as guided by the above organisations.
The sampling technique used in this research article involved the selection of Nursing Directors, considered key informants owing to their knowledge of applicable KPIs in their respective organisations (Gray, McCance and Brown, 2021). Non-probability sampling was at the centre of the selection process. Although this approach is less likely to produce accurate and representative samples, it was effective in the quantitative part of the study. Every organisation was given an equal opportunity for selection while also allowing generalisation, supporting the above assumption that accuracy is not at the centre of the research (Gray, McCance and Brown, 2021; Radhakrishnan, 2014). The demographical characteristics, however, permit the inclusion of non-probability sampling, thus helping to eliminate any arising bias among the variables included.
Data Collection
The researchers use a sequential, exploratory mixed-methods approach to conduct their research, supported by preliminary quantitative data and core qualitative methods (Gray, McCance and Brown, 2021). This was based on a research design that integrated the identification of existing literature and information about KPIs as part of a literature review, followed by phase 1, quantitative analysis that encompassed the development of cross-sectional questionnaires, the dissemination of the questionnaire and finally, the use of SPSS (V22) for content and data analysis (Gray, McCance and Brown, 2021 4902). the second phase of this mixed-method approach included the development of the interview guide, followed by the use of semi-structured interviews for data collection and, finally, thematic data analysis. This methodological approach is significant in this research as it enables the researchers to facilitate complementarity in that they can obtain mutual viewpoints relating to similar experiences and associations when comparing secondary with primary data (Caruth, 2013). Initially, the researchers want to explore the influence of nursing and midwifery practices on the quality and safety of patient care which has been largely invisible based on the lack of evidence from scholarly articles (Gray, McCance and Brown, 2021). The researchers are concerned with understanding the role of nurses and midwives in providing quality care but, at the same time, argue that KPIs are a new performing science yet to be fully understood by most professionals (Gray, McCance and Brown, 2021). Since patient feedback, mostly soft intelligent data is crucial to the development of KPIs, most nurses and midwives are inexperienced in understanding these measures, henceforth necessitating the need to have interviews with Directors of Nursing to gain perspectives as part of quantitative questionnaire data collection to gain perspectives on the indicators that facilitated KPIs (Gray, McCance and Brown, 2021; Fabregues et al. 2020). The application of this mixed-methods approach in this research has several advantages, one being that the researchers can explore the issue of KPIs from various perspectives. Initially, the qualitative approach permits the institution of subjective inquiry and insights that later lead to standardised and generalised data through quantitative research (Regnault, Willgoss and Barbic, 2018). Using this approach, the researchers found it easy to draw the most out of the simple samples they used, owing to the flexibility of this approach. For example, the researchers could categorise KPI criteria using the information provided by the Key Informants while also measuring their significance based on the samples used to identify the KPIs that were most effective based on the feedback provided. However, this approach has several drawbacks, including its inability to minimise costs and resources (Wasti et al., 2022). For example, the researchers had to visit the facilities for the interviews, which is costly, and also file back the questionnaires to the different ethical review boards, which required more resources for submission and extra costs that might not have been included in the initial project timelines.
DATA ANALYSIS
The researchers in this article employed the six-step thematic analysis developed by Braun and Clark (2013) to facilitate an inductive approach to analysis. The data analysis was divided into two phases; phase 1 entailed the documentation of questionnaire feedback from hospitals and community organisations within the five selected regions in the U.K., and the Republic of Ireland and Phase 2 was qualitative documentation of interview responses from senior managers and clinical managers involved in the research. This approach is fundamental in mixed methods analysis as it first allows the researchers to familiarise themselves with the data, more so by transcribing the interactions collected through quantitative analysis (Clarke, Braun and Hayfield, 2015; Hristov and Chirico, 2019). Through this process, researchers can note initial ideas that will later be used to identify recurring themes. The next step will then enable the researchers to generate initial codes that later lead to identifying themes, followed by reviewing the themes. Essentially, the identification of familiar responses that helped in identifying emerging things on KPIs, such as factors influencing KPI selection, mechanisms that support and encourage the action of KPI data, the most valuable KPIs and KPI examples adopted within the organisations (Clarke, Braun, and Hayfield, 2015;). In the end, the researchers were able to identify and name themes that signified how healthcare organisations adopt KPIs and the challenges that nurses and midwives face when determining data for effective KPI documentation and application. Using the above approach was influential in improving the validity and reliability of the findings/results owing to the development and application of codes to facilitate data coding and testing for the development of themes (Roberts, Dowell and Nie, 2019; O’Connor et al., 2018). The use of this coding system benefited the researchers and improved the validity of information as the coding system was a demonstration of rigour, thus facilitating a clear trail of evidence for validity (Roberts, Dowell and Nie 2019; Hadi and José Closs, 2016). The development of the codebook approach has been essential in mixed methods research, especially in enabling an inductive and deductive process. In this case, the inductive approach was essential in helping the researchers deduce a priori from the initial search while also enabling deduction from literature searchers in mapping out the emerging themes (Gray, McCance and Brown, 2021; Hadi and José Closs, 2016). It is, however, important that researchers incorporate inter-rater code testing to ensure they cover all reliability angles to ensure consistency in the identification of KPIs judgments and themes before any form of interpretation can be deduced from the final data set (Roberts, Dowell and Nie 2019). In this regard, the researchers ensured some level of reliability by ensuring consistency of judgment in the absence of secondary data while also ensuring the same across the various contributors to eliminate any disagreements and ensure the provided themes are agreed upon across all participants. This research approach also enables the researchers to critically countercheck information provided by organisations vis-à-vis clinical leaders to establish themes central to identifying appropriate KPIs and, alternatively, emerging challenges in their identification and implementation.
FINDINGS
In the first phase, 15% of the organisations identified responded to the questionnaires creating a response spread that reflected the target population. The responding institution jointly listed 1058 data items in response to the KPI questionnaire but not all the documented data items could be categorised as KPIs (Gray, McCance and Brown, 2021). One reason pointed out by the researchers is that some of the data sets were opinions. In other cases, the feedback consisted of care planning tools and reporting methods, indicating that the organisations and their respective nurses and midwives were unaware of what exactly constitutes KPIs. However, in this phase, the researchers identified 40 KPIs significant to nursing and midwifery practices, but, significantly, the lack of a defining measurement in establishing the KPIs affected response rates and the ability of the participants to accurately point out KPIs (Gray, McCance and Brown, 2021; O’Connor et al., 2018). At the organisational level, 11 KPIs were identified as specific to nursing and midwifery practices, while five were identified as specific to clinical nursing and midwifery practices. On the other hand, while not all the data sets provided on KPIs were insufficient, some were categorised as quasi-KPIs, with four quasi-KPIs identified under nursing and midwifery organisations and a further 11 under clinical nurse and midwifery (Gray, McCance and Brown, 2021). Specific to the field, 9 KIPs were identified to be specific to midwifery.
In the second phase, quantitative documentation was provided based on responses received from directors and nursing and clinical managers. Two main themes emerged from the interviews; leadership challenges in developing KPIs and the need to take action to improve the institution of KPIs. On the leadership challenge, over 87% of organisations used the cited KPIs with a percentage of KPI processes, roughly over 50% incorporating data collection. Pressure ulcer was the most cited KPI that participants claimed to be of value in determining a patient’s quality of care, but the lack of international consensus on how best to approach data collection in improving KPIs was cited as a major challenge (Gray, McCance and Brown, 2021; O’Connor et al., 2018). On the second theme, taking action, participants claimed that clinical leaders must be at the forefront of directing KPI action to establish ownership and maintain checks and balances. Henceforth, this finding, and the article as a whole, is beneficial not only to nurses and midwifery nurses but also to organisations as it points out the disparities in knowledge about KPIs and how clinical leaders and nursing directors can take action to facilitate organisations and individual ownership of KPIs. The authors, therefore, recommend the importance of teamwork in discussing which KPIs to be identified through shared learning and engagement in decision-making to improve the management of KPI data (Gray, McCance and Brown, 2021). However, it is important that in future, such research should engage the input of registered nurses working at the ward level to gain more perspectives on the need for KPI data understanding among nurses and midwives.
APPLICATION TO PRACTICE
The article in this appraisal incorporates a mixed methods approach which is significant in enabling the researchers to draw the importance of qualitative and quantitative methods in uncovering diverse perspectives and underlining relationships. The researchers aim to explore the scope of KPI and its application and importance in nursing and midwifery. In this regard, the approach used is significant in attaining these objectives since it would be difficult to quantify the exploration without understanding previous challenges and emerging facets that shape KPIs (McCance et al., 2012; Wilson, Brown and McCance, 2021). As the researchers point out, the lack of knowledge and understanding of KPIs on the part of nurses and midwife affects quality care and, most notably, organisational operations on strategic approaches to quality care (Gray, McCance and Brown, 2021; McCance et al., 2012). It is, therefore, crucial to have firsthand understanding from clinical leaders who are key informants in this research and organisations through nurses and midwives to understand better how KPIs are integrated. The mixed research method adopted in this article is therefore valuable in answering the research and meeting the research aims and as a means of weighing the different perspectives given using different research approaches. It is for these reasons that the findings provided in this research are vital in advancing KPI knowledge in the U.K. and ROI by underlining the issues affecting the adoption or implementation of KPIs among nurses and midwifery and how best hospitals and clinical leaders can navigate the challenges through training, education, awareness creation and teamwork. The findings also expose the importance of engagement between clinical staff and service providers at all levels to strengthen the identification of KPI indicators in primary care, therefore, helping to advance community and patient care (Gray, McCance and Brown, 2021 4914; Wilson, Brown and McCance, 2021). The findings also provide perspectives on the importance of collective leadership in advancing quality improvement, as reported in phase 2 of the findings. Therefore, improving quality is significant in creating a cohesive team and decisions that translate into actionable parameters that advance patient-centred care. The study has also identified a large number of KPIs in use in the U.K. and the Republic of Ireland but, at the same time, lays bare the lack of strategic overview nationally and at the organisational level (Gray, McCance and Brown, 2021). At this juncture, it is important to note the importance of having a national platform that guides nurses, midwives and clinicians to identify appropriate and strategic mechanisms to eliminate any negative impacts that might arise, such as increased workload, negative patient care outcomes and increased health costs (McCance et al., 2020). Henceforth, this article points out the importance of establishing measures based on care aspects to inform KPIs and ensure the measures identified are also appropriate for nurses and their patients (McCance et al., 2012; Bail and Grealish, 2016). However, the findings in this research paper indicate that this is not the case, and nursing leaders and organisations must ensure consistent leadership to facilitate successful practice improvements through KPIs.
Conclusion
The research has identified several themes central to this exploration of KPIs, the most significant being factors that influence organisational KPI selection that include the availability of data collection tools and methods, reporting behaviours and the involvement of clinical leads and how nurses and midwives view the link between KPIs and quality care. The other key theme entails the existing leadership challenges mostly influenced by the lack of a cohesive national approach. Accordingly, this has been blamed on the lack of adequate resources to improve data collection. The solution lies in offering training and education and creating a national platform and initiatives.
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