The analysis identified two categories and four sub-categories that resonated across all participants, both managers and staff in individual and focus group interviews. The categories are labeled “professional issues: more than firefighting” (subcategories professional pride and competence) and “patient-centered approach: more than covering basic needs” (subcategories dignity and continuity).
When analyzing data, the categories for managers and staff were similar, but with some variations in the content of the sub-categories and codes. For example, when managers talked about competence they talked about deviation, reporting system, and education. In contrast, the staff talked about updated and regular information about new procedures, patients and organizational issues, time, equipment and training opportunities. There was general agreement among our participants, though we have included some quotes to show that there are slightly different views and divergences between Norway and the Netherlands.
The following sections present the two categories, with their corresponding sub-categories and codes (Table 2).
Professional issues: more than putting out fires
This study shows that the participants conceptualized quality as more than putting out fires, focusing on ongoing processes related to professional pride and competence. They illuminated that poor quality was often associated with a sense of being under pressure from external demands and cited several times when they had acted on these demands to remain professional and to offer the best quality of care to the patients, for instance by making time for them to have their hair and nails done.
The participants identified professional pride as an important dimension of quality in primary healthcare. The nurses were proud of their ability to offer high-quality care to each patient. They described quality as good when they took responsibility for their work and had time to exchange ethical reflections with their colleagues. These reflections were, for example, related to patient care, cooperation with next of kin and the resolution of dilemmas about scarce resources and insufficient time for each patient. The staff reported that professional pride was important for providing high-quality care and equated with being a good “fellow human.” The managers cited professional pride as giving care of highest quality, professionalism and having enough staff to attend to patients. The motivation of managers and staff resulted from providing patients with the extra service. This was at the heart of their conceptualization of “quality work.” In the words of one manager:
“Quality is not just firefighting, it is when we do this extra for the patient, then I am proud of my work” (Manager, Norwegian NH, M4).
Managers talked about being a good motivator for the staff, to have enough staff at work, and manage periods with sick leave as prerequisite for providing care quality to their patients. They also highlighted the importance of spending more time with and being visible to their staff. Managers argued the patients would benefit from better care as a result of this leadership approach. Moreover, they argued that checklists and reporting on indicators were mandatory activities, often without added value for the patient, hence it did not contribute to a sense of professional pride. Some talked about the benefit of not using time on completing checklists, because they preferred face-to-face time with the patients. One participant from the Netherlands commented that checklist registration is different from what staff are doing, because:
“the people who are working daily with the elderly people they do not always think about quality, but they are nevertheless doing quality work” (Quality manager, Dutch NH, M13).
Findings also indicate that when participants see the function of the checklist or indicator, they see the added value (e.g., medication safety). Other participants noted that quality of care improved when the staff customized tasks to their patients’ preferences.
Conceptualization of quality was closely related to professional competence. Both managers and staff talked about the importance of having the competence for the provision of quality care. Some managers talked about the challenges of sharing knowledge within the unit because there were so many part-time employees. The staff had a constant need for updating, learning and training on new procedures due to new and advanced treatment options for the patients treated in the municipalities.
Two examples are dialysis and immunotherapy. A few years ago, in Norway, only hospitals provided these treatments; today these are provided to patients at home or in nursing homes. These tasks require high nursing competence, the resources to use certain procedures, and compliance with procedures and regulation. Competence as a quality dimension, especially among managers, was linked to having the right professionals in the right place at the right time. There also had to be enough nurses to attend to patients with special needs. Moreover, the managers highlighted that staff needed to be empowered, independent, and “self-propelled.” According to a nursing home manager:
Quality of care depends on regulations being followed, and that we can trust the staff to follow the rules and procedures. (Manager, Norwegian NH, M2)
At the same time, the staff insisted that high quality of care was depended on them receiving sufficient training to meet requirements and understand new forms for treatment. In addition, the staff often needed more information to do a better job and to improve service quality.
Both managers and staff emphasized the need for higher competence in medication administration, check-list registration, documentation and nursing procedures such as nutrition guidelines. The staff was trained on new procedures, documentation systems, as well as the error reporting system to build competence. They cited the importance of training to be confident and to enjoy their work. It seemed important for the staff to trust their competence. This included updated and regular information about new procedures, patients and organizational issues. The staff asked for courses to maintain and develop their competence. Most of the participants talked about the necessity to report deviations not only regarding serious events but also near misses to improve quality in healthcare.
Participants from the Netherlands had several quality indicators, but this was less common among the Norwegian sample. All participants emphasized the importance of procedures with documentation and registration but complying with procedures and registration was not enough to ensure quality of care. One manager said:
“Quality cannot be measured on a tablet, it is not the basic functions and measurement that represent quality for a patient, but it is the dignity and empowerment that make the difference,” (Manager, Norwegian NH, M7)
The Dutch participants also mentioned the importance of staff having a sense of ownership of their work. They stated that each healthcare professional must know what to do and why in order to offer the best care to their patients.
Patient-centered approach: more than covering basic needs
The category patient-centered approach includes the sub-categories continuity and dignity.
The participants conceptualized quality in relation to the predictability and continuity of care. Continuity of care by ensuring a low staff-to-patient ratio was important, both for themselves and for the patients. Continuity of care contributed to their feeling of doing a better job for the patients.
Cooperation emerged from the data as an important dimension in the participants’ conceptualization of quality. All participants mentioned the importance of a collaborative workplace, where it was physically and socially easy to obtain help and support. They talked about cooperation intra-professionally within the nursing unit, and inter-professionally with physicians, physiotherapists, social workers, professionals, and politicians.
From the managers’ point of view, the quality of care depended on cooperation among professionals, exchange of experiences and professional support within and across units. For example, managers advocated for teamwork as essential in the “everyday rehabilitation” of patients. The quality of a patient’s rehabilitation was based on teamwork, because patients need to be as physically active as possible, implying the need for a shared understanding of sound care within the team, and a good dialogue between the professionals and the patients. Both managers and staff wanted to see more cooperation with the physiotherapist and the occupational therapist. As one manager said:
“I am not satisfied (happy) with the fact that physio and occupational therapists do not work shifts. That leads to poor quality.” (Manager, Norwegian HC, M9)
The healthcare staff supported each other and sometimes covered each other’s tasks at the busiest times. The cooperation made them feel more secure in their work, and they argued that it contributed to improving the quality of care. In the Netherlands, interprofessional teams in which each profession contributed supplementary knowledge and perspectives was highlighted as important for quality of care. Both managers and staff reported that interprofessional communication was associated with better quality. This was also evident in the Norwegian sample. In the words of a homecare manager:
… a culture to share experiences and learn from each other, we talk a lot about it, how can you learn from each other. What in the world are some doing since they manage to get patients on their feet, while others cannot? (Manager, Norwegian HC, M2).
Conceptualization of quality was also linked to cooperation in terms of common tools for documentation. The soundness of quality depended on the ability to use documentation systems between care levels and to secure medical records and discharge summaries at the time of transfer. All participants talked about incomplete or inaccurate medication lists, often resulting in the wrong pills and medication being dispensed to the patients. They asked for more reliable communication and cooperation. Some participants cited the usefulness of e-health and “mobile care,” which gave immediate answers to their questions.
Dignity was an important category in the conceptualization of care quality. The participants insisted that the quality of care depended on patients being treated with dignity. They stated that good quality care, or “personalized care,” puts patient first.:
“The patients should receive services with good and sufficient quality, and this should be provided with dignity.” (Staff, Norwegian NH, M2)
The staff articulated the need for giving the patients valuable treatment and care that protected patients’ dignity. In other words, patients should be able to choose their activities, nutrition and caregivers. Dignity also pertained to their intention of enabling patients to live meaningful lives. At the same time, healthcare staff were mindful of what is most clinically effective for their patients, which sometimes created professional dilemmas. For example, some patients preferred to stay in bed even though they would benefit from physical activity. Some managers in both countries talked about quality as something that was more than measurable or tangible:
It is not basic functions and measurements that represent quality for a patient in a long-term institution. To carry out one’s life, i.e. the end of life, with a dignity and a co-determination that makes you feel alive until the end. It’s not about your blood sugar or talking to a doctor or annual checkups and that kind of things. (Manager, Norwegian NH, M4).
In our organization, we think that patients’ well-being should be prioritized above all. This discussion is ongoing - over and over again, which risks can we take for the patients and their well-being [what is the consequence]. (Quality Manager Dutch HN, M11)
The participants also conceptualized quality in terms of the provision of “best practice,” meaning that they constantly needed to make many small changes to provide optimal care, because best practices change with time. Another way to put “the patients in the center” was to sit with them while they are and to keep their rooms tidy and welcoming.
We are really serious about putting the client in the center - we have to do this. We must do this. Otherwise we have to say the client has lost. (Quality Manager Dutch HC, M12)