Factors Impacting on Nursing Care Quality


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Nurses play an indispensable front-line role in patient care within the NHS. However, issues such as role ambiguity, management concerns, training deficiencies, and a limited evidence-base raise serious questions about the quality of health care nurses dispense. This essay considers some of these issues.

Role Ambiguity

Although nurses offer a wide variety of patient care services, there is considerable ambiguity about specific work responsibilities in some areas of nursing (Goll-McGee, 1999; Rask & Hallberg, 2000; Hinsby et al, 2004; Dickens et al, 2005; Needham et al, 05; Sekula, 2005). Forensic psychiatric care is a good example. In a comprehensive survey of nurse’s views about their job responsibilities, Rask and Hallberg (2000) found significant differences between licensed mental health nurses and registered nurses in the emphasis attached to key nursing roles, such as assessment, medical tasks (e.g. giving medication), and actions relating to patients ‘daily living activities’. Nurses often feel uncertain about whether they can undertake certain tasks autonomously without incurring the wrath of doctors. For example, much has been written about nurse-initiated thrombolysis for cardiac patients (Rawles, 1994; Smallwood, 2000; Smallwood et al, 2004; Kelly, 2004). Patients presenting at an A & E unit with cardiac symptoms may benefit from nurse-administered thrombolysis prior to formal medical screening. This would include performing an electrocardiogram and administering a thrombolytic agent via a standard protocol. Although nurse-induced thrombolysis may significantly reduce door-to-needle times, until recently there was no precise definition of this role in nursing literature. Nurses are often unsure precisely what roles they are expected to perform to deal with problems like teenage pregnancy and STD transmission (Campbell, 2004). This situation is confounded by the fact that sexual health needs vary considerably across specific patient groups (e.g. HIV incidence is significantly high and access to health access seemingly more limited amongst African/immigrant communities) (DOH, 2001, 2002; 2005a, 2005b; also see Erwin et al, 2002). The net effect of this haziness is that nurses may not always be entire certain of their role at critical moments, or may feel too stressed out, in situations where immediate patient care is paramount.

Workload, Time Management & Training Issues

The issue of work-related stress (Ewers et al, 2002) is directly implicated in workload time management. It is no secret that nursing staff in the UK can be overworked at times (Kilfedder et al, 2001; Hinsby & Baker, 2004; Hughes & Umeh, 2005). A major reason for this is the severe time constraints created by the multiplicity of tasks nurses are required to perform. The Nursing Stress Scale (Plant et al, 1992; Tyler & Cushway, 1995), a standard measure of work stress experienced by nurses incorporates workload as one of several separate and distinct sources of stress, highlighting the importance of this factor in nursing care. The workload problem was emphasised in a recent article about school nursing (Martell, 2005). School nurses are heavily under resourced but yet face an arduous workload, more so for those working in the pubic sector. Staff shortages and a multiplicity of responsibilities means that not enough time is spent on health promotion and in the classroom. More than half of school nurses report feeling ‘emotionally drained’, and work excess hours on a daily basis, several times a week. The level of stress seems to vary considerable across different nursing fields. A recent study found that registered nurses report higher levels of stress compared with psychiatric nurses especially in the absence of social support (Hughes & Umeh, 2005). Then there is the issue of training. Nurses in the UK receive extensive training before being employed to work on the ‘frontline’ (Campbell, 2004). However, questions have been raised about the adequacy of existing nursing education in various aspects of patient care. For example, although it has been suggested that nurses can play a crucial role in evaluating and caring for victims of sexual assault, nurses in the UK currently receive no formal training in this area (Dinsdale, 2005). Another area of training deficiency is in HIV prevention. Although the Nursing and Midwifery Council (NMC) approves specific training courses for nurses in this area, universities and colleges are not compelled to offer them, “”Pre-registration training for nurses does not include mandatory education relating to sexual health services. Nurses working in sexual health gain post-basic education in an ad-hoc manner – through working in the specialty, and by undertaking specialist post-registration courses” (Campbell, 2004, p.169). Nurses often receive limited (if any) training in the care of specific patient groups. For example, few nurses have special knowledge of the health care needs of ethnic minorities communities (DOH, 2000b; Andalo, 2004). Those who by chance spend some time working in such communities may gain some of the necessary expertise, but otherwise most nurses may be uninformed in this area. School nursing is another area in which training needs are not being met (Harrison, 2004; Martell, 2005). Martell (2005) reports that school nurses often have limited access to essential training for their role.

Research & Evidence-based practice

As with other branches of health care there is increasing emphasis in nursing care on evidence-based practice (Lewis & Latney, 2003; Thompson et al, 2004; Ring et al, 2005). Feasible evidence-based practice requires an adequate evidence base (Lewis & Latney, 2003). However scientific literature in certain areas of nursing care is often patchy, delaying the development of appropriate ‘best practice’ statements that will ensure consistency in the quality of care nurses dispense across all sectors of the NHS and private sector (Hoskin’s, 2000; Serrant-Green, 2004). The importance of evidence-based ‘best practice’ guidelines cannot be overstated. The Nursing and Midwifery Practice Development Unit (NMPDU) emphasises their importance in achieving consistent care delivery across nursing sectors. Unfortunately, even where best-practice guidelines have been widely developed for nursing care, as is the case with NHS Scotland, implementation is often slow and inconsistent (Ring et al, 2005). Nurses rarely refer to an evidence base when making decisions about patient care (Thompson et al, 2004). For example, midwifes often fail to offer antenatal HIV testing to women for ethnic minority backgrounds, to avoid appearing discriminatory (Gibb et al, 1998), even though such testing is a standard recommendation of the National Institute for Clinical Excellence (NICE), DOH, and Nurse Agencies National Minimum Standards (DOH, 1994, 2000a). Guideline execution can be hampered by many factors including resource deficiencies, lack of training, resistance to change, lack of emphasis or prioritisation, absence of local nurse ‘leaders’ who can champion best-practice ideology, and resistance to change. Fulbrook (2003) notes that nursing knowledge and care often derives from more experiential and in-depth one-to-one interactions with patients, rather than formal scientific doctrine. Thus, it is questionable whether existing best practice statements, which are rooted in positivist literature, are indeed appropriate for nursing care.


The quality of nursing care patients receive may often be compromised by workload issues, training deficiencies, a paucity of an adequate research evidence base, inconsistent implementation of clinical guidelines, and poorly defined job responsibilities. It appears these problems are rather more pressing in the public compared with private sector. A recent study of the work-related perceptions of nurses working in non-NHS facilities found that nurses in this sector reported greater levels of support, cohesion, job clarity and physical comfort (Dickens et al, 2005). However, they also indicated greater work pressure. There appears to be significant variation across various nursing specialties in the importance attached to key aspects of nursing care, such as patient assessment. Furthermore, certain nursing domains, for example school nursing, suffer from severe staff shortages, a multiplicity of responsibilities, and significant training issues. Overall, nursing care in the UK appears to lack the support it needs to meet expectations.


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