Measuring the quality of nursing care: a consideration of different approaches.

This paper argues that a preoccupation with cost-effectiveness threatens to swamp nurses' traditional concern with quality of care, and underlines the importance of clinical nurses becoming familiar with the complexities of quality measurement. Terminology widely used in the nursing literature is clarified and research studies that address the quality of nursing care are reviewed. It is suggested that whilst some of these have provided important theoretical insights into quality issues, the qualitative research methods employed have so far failed to provide a practical alternative to the more 'objective' measures of quality currently adopted by clinical nurses and their managers. Generic measures of quality are identified and categorized and it is suggested that most of these are in need of extensive validity testing in relation to the concepts of quality that they purport to measure. The measures of quality themselves may be less important than the content in and process by which they are applied. 'Top-down' and 'bottom-up' approaches to measurement are discussed in relation to the notion of facilitative leadership. The value of top-down approaches is questioned on the grounds that they may violate the integrity of the quality-assurance cycle and prevent clinical nurses from making the commitment that is necessary in order to assess and improve the quality of their nursing practice.