Travel: An exploration of how key performance indicators influence nursing practice
2016/65 - Olivia Gray
The overarching aim of the study being undertaken was to explore the influence of key performance indicators (KPI’s) on nursing and midwifery practice as perceived by nurses and midwives working in organisations across the United Kingdom and Ireland. Having a greater understanding of the positive and negative issues involved in the use of indicators (data collection, analysis and reporting), and importantly how nurses act on this data, will support future work to streamline KPI use to make it more effective and efficient. This report presents an account of the data collection process for the second phase of the research, which the travel scholarship supported.
Key Performance Indicators (KPI’s) can be found in almost every sphere of life and are, in essence, measurements. Collected over time these measurements will reveal trends indicating progress or a lack of it. A business will measure their monthly sales targets; social media will measure the number of “hits” on their websites; and individuals may count the number of steps they take in a day. A healthcare organisation will collect hundreds of these KPI’s measuring for example, financial costs, waiting times and infection rates, but the overarching aim is to provide a means of determining whether the level of care is safe and is of an acceptable standard.
Explicitly linked to the measurement of KPI’s is the understanding that the knowledge generated should lead to improvements in quality of care. In my nursing practice, part of my role involved asking busy ward sisters and team leaders to provide me with specific measurement data. I was often asked: “why do you need this information? It just means more work for me”. Explaining that it was a mandatory professional requirement did not necessarily make it easier to obtain this information. At a clinical level, patient care will always, quite rightly, take priority.
Gathering the information for these measurements was far down their list of priorities, yet information on performance and quality of care is important because, as nurses and midwives, we want to provide the best possible care for our service users. We need to know what we are doing well and what needs to be improved. Therefore, we need to measure.
So, what are the challenges that we face in using these KPI’s, what works well and do they improve practice? Is there anything we can do to make this measurement process easier and which would enhance KPI use to create better outcomes for our service users? To help answer these questions I travelled across the United Kingdom and Ireland, talking to nurses and midwives to gain a wide range of different perspectives on what they consider to be the benefits of KPI use and the related challenges.
Overview of Methods
Through the dissemination of a questionnaire to the directors of nursing across the United Kingdom (UK) and Ireland in phase one of this study, I obtained an overview of the KPI’s that were in use. I also gleaned some information on the processes involved in the management of KPI’s such as data collection, analysis and reporting. However, the questionnaire offered a limited understanding of how KPI’s are used in practice.
To gain a greater depth of understanding of KPI use and insight into how KPI’s influence nursing practice it was necessary to interview nurses and midwives. Therefore, the aim of the second phase of this study, which the travel scholarship supported, was to use face-to-face semi-structured interviews to explore the views of the nurses and midwives who use KPI’s within their practice.
Research ethics and governance approval was obtained from my university - regionally as per the requirements for each country and locally in the nine organisations I visited. As per my research protocol I met the participants at a place of their choosing. Being based in Belfast, I was able to travel by car to meet the Northern Irish participants. Over the course of ten journeys I conducted interviews in counties Armagh, Antrim, Down and Tyrone, and learnt to appreciate the distance and time involved in travel for community nurses and the benefit of Google maps. Train journeys took me to Dublin in the Republic of Ireland, for a further four visits. However, for the interviews in Great Britain, flights and overnight accommodation proved the most efficient use of time and funding. From one central base I was then able to use onward connections via trams, taxis and coaches. I conducted eleven interviews in Edinburgh, Liverpool, Surrey and the West Midlands. Travel to Wales proved more of a challenge because of limited flights from Northern Ireland, but the participants were very supportive and we set up visits which I could access from English airports with onward travel into Wales. For most of the trips to Great Britain I was able to arrange multiple interviews in each location, and for this a very big thank you goes not only to the participants for their willingness to work with me, but also to the local collaborators in each organisation. These collaborators helped me to identify participants and navigate my way around unfamiliar countries and organisations. Working together we co-ordinated interview times and venues that suited everyone.
In total I carried out 37 face-to-face interviews with nurses and midwives working at executive, senior management and clinical levels. These people worked in diverse fields of practice including the acute and community sector. I gained insight into how nurses use KPI’s working in areas such as dementia care, intensive care, children’s, midwifery-led units and district nursing. I spoke with senior managers involved in quality improvement and risk management to understand how KPI’s influence their work. I spoke with nurses and midwives who were either heads of departments or directors/chief nurses to explore how KPI’s provide assurance of the quality of care delivered in what can be extremely large organisations. From these participants I also gained a deeper understanding of the impact that meeting national KPI requirements has on organisations and how this influences the practice of executive nurses and midwives.
As the interviews continued until November 2016, analysis is still ongoing. However, various common themes are becoming clear as well as some issues pertinent to specific aspects of practice and healthcare policy. Early indications would suggest a number of areas requiring further development in relation to KPI use, particularly the need for:
- a greater understanding of KPI’s at clinical level in order to promote their use as tools to improve care;
- support to develop KPI’s specific to the needs of community practice;
- greater ownership of KPI’s relevant to individual practice;
- more streamlined systems for data collection and reporting to reduce workload and improve efficiency.
I feel very fortunate and grateful to have been awarded this scholarship. I have travelled across five countries, visited nine organisations and interviewed just under forty nurses and midwives in approximately eight weeks. This has been mentally and physically challenging but also very fulfilling. The funding has meant that visits could be tailored to meet dates, times and venues that fitted around the participants’ working day, and rescheduled if the unexpected happened. It has also helped me gain knowledge and experience in relation to the project management aspect of research, which I had not considered previously but which is an essential element of multi-site studies.
Normally I like to be in control of my working situations but have been surprised that I can adapt to live with uncertainty. I am now less likely to be fazed by difficulties and more inclined to adopt a pragmatic approach. I have dealt with unexpected situations as they arose during my visits, identifying quickly who might be able to help, readjusting travel and interview schedules and communicating changes to those who needed to know. In part, this capacity to be flexible is due to the Florence Nightingale Foundation funding. With careful financial management the funding provided a cushion which allowed me to make last minute changes when the unexpected occurred so that the research with each organisation could continue with minimal disruption. Following completion of the analysis and research, outcomes from this study will be published as several articles to inform the development of future KPI’s and the systems employed to support their use.
The author would like to thank the Sandra Charitable Trust, through the Florence Nightingale Foundation, for the generous travel funding provided during this second phase of data collection as part of a larger PhD study. A sincere word of thanks is also extended to the Health and Social Care Trusts and the Department of Education and Learning in Northern Ireland for their ongoing support. A particular note of thanks goes to the nurses and midwives, who cannot be named, but without whom this study would not have been possible.