Tài liệu Current situation and effectiveness of chief nurse capacity improvement intervention from 2010 - 2013 in nghe an province

1 INTRODUTION: 1. Urgency of theswas: In our country, Chief Nurse System (CNS) is the first management level of the hospital. Chief Nurse is responsible for implementing the medical command of doctor, management of human resources and department administration. Efficient quality of care, patient service, use of resources depends significantly on CNS. According to survey in year 2007 of the Viet Nam Nursing Association, Chief Nurse has had generally intermediate level 84.8%, College 7.2%, University 7.8% and postgraduate 0.2%. Have been trained the nursing management with the rate of 37.8%, the effectiveness of executive leadership, participation in the activities of training, guidance and specialization guidance has been only done good 33.7% [42], [43]. In Nghe An (2008), Number of Chief Nurse has been more than 400 people, intermediate professional qualification has been 91.9%; college 8.1%; Trained on nursing management 19.2% [71], [95]. In recent years, Nghe An has gradually strengthened and perfected the nursing management system. However in fact revealed a certain number of limitations, such as low-level professional qualification, management capacity was not effective, management system was insufficient, has been influenced on the quality of patient care. With the challenges in health care, hospital overcrowding has increased the shortage of nursing manpower, limitation of proficiency was barrier in whole patient care. This was that the role and responsibility of the Chief Nurse became very important in the planning, coordination of the work, the thesis was the key to solve the above challenges, became more urgent and meaningful practice. Proceeding from the above requirements we have carried out implementation of the project: Status and effect of Chief Nurse ability intervention in Nghe An province with the goals: 1. Describe the situation and factors that has affected the ability of Chief Nurse at the hospitals in Nghe An province in 2010 - 2011. 2. Evaluate capacity improvement intervention effect of Chief Nurse at the hospitals studied in 2011-2013. 2. New contributions of the thesis: - Describe the task performance capacity status for the management of Chief Nurse in the hospital - Nghe An province. - Identify the factors affecting to the task performance capacity for the management of Chief Nurse in the hospital - Nghe An province. - Consider about the task performance capacity status for the management of the hospital of Chief Nurse in the hospital - Nghe An province. - Proven intervention activities raised Nursing Management Capacity for Chief Nurse. 2 - Strengthen capacity of health systems (building the technical management system, records and report system) to contribute improvement of the nursing care service quality in the hospitals - Nghe An province. 3. Layout of thesis: Including 125 pages, Introduction 2 pages, Overview for document 40 page, object and methodology 18 pages; Research Results 40 pages, Discussion 22 page, Conclusions 2 pages and Recommendations 1 page. There were 18 sets, 17 figures, 02 diagrams and 159 references (Vietnamese: 110, English: 49). Chapter 1. GENERAL 1.1 Concepts and relevant definitions: - Management capacity has been evaluated based on the ability to apply knowledge and skills in management operations: including knowledge for the skills and management content. Perform proficiently management processes and attitudes before the assigned work in a spirit of responsibility, solidarity, self-dwascipline, sacrifice for the community [74]. - Nursing Management Capacity (NMC) has been expressed on the ways of knowledge, practices and attitudes: the nursing dean (ND) has had the excellent technical expertwase, both have has good management skills and seriousness and responsibility before actions. However, the application of the preeminent quality management system, supporting Manager would increase management efficiency [46], [47], [74], [91]. 1.2. Nursing management capability: 1.2.1 Nursing management competency assessment skills: Based on the knowledge and practice of the nursing management skills, including 16 following skills [16], [14], [20], [30], [40], [95]: Organizing wholly care for patients; Directing the hygiene work; Human resource management; Asset - Materials Management; Participation in training, scientific research; Planning; Plan performance organizations; Evaluation; Supportive supervision; Application of information technology; Decwasion making; Problem solving; Organization of meetings; Time management; Administrative documents and drafting method of text and Records Management. 1.2.2 Nursing Management Capacity Method: - Periodical, regular evaluation; - Extraordinary evaluation; - Periodical evaluation interposed extraordinary [6], [10], [11], [39], [95]. 1.2.3 Factors affecting the Nursing management capability: Factors have affected nursing capacity, including: - NURSE Qualifications was low [127], [129]. - The administration and documentation works of nurse occupy percentage of time equivalent to the direct time for patient care (CP) (28%). Meanwhile, each activity, work had not guidelines, procedures work to help management methodically and unified [94]. 3 - Awareness of staff, the low self-esteem, the complacent of the medical staff for nursing person have affected to some extent the management operation and covering and extending level of whole patient care (WPC) in the hospitals. The hegemony of doctor, the coordination between the nurse and each other [79]. - The Nursing person (Nurse) has had often passive and dependent behavior, they have taken the initiative in the struggle for the branch. Internal branch was often not united. - Lack of educational opportunities, re-training for specialization and management. - In addition, low-income, large number of patients, lack of equipment and coordination of the patient and family were also factors affecting not less the quality of nursing work. 1.3 Research for Nursing Capacity: 1.3.1 In the world: For scientific research in the nursing, according to Tiran and colleagues at the University of Greenwich London has shown lack of head to promote as well as instruct the research, this was one of the reasons causing non-clinical nurse not or reduced research capacity [154]. Research on knowledge, practice, attitudes of nurses, Chief Nurse of Pamela Duffy and colleagues in the United States has shown that there was a difference in practice perception of provincial hospital before and after training. For skills before training rate of Nurse, Chief Nurse having confidence in clinical practice was 46%, after training was 60% (p = 0.018), the attitude was also similar difference (p = 0.046) [140]. According to Roderick’s researchers at the United States for improvement of the patient care quality (PC) [147] has shown that the patients’ satisfaction proportion for the doctor was the higher than Chief Nurse, Nurse in intensive clinic department, but in obstetrics satisfaction for Nurse, Chief Nurse was 73%, for the doctor 71%. 1.3.2 In Viet Nam: * For nursing management: According to the survey results of the Vietnam Nursing Association in 2007 has shown that levels of Chief Nurse in hospitals in Vietnam have had professional qualifications limited intermediate 90.6%, below the age of 35 accounted for 23, 9%. Rate of Chief Nurse not trained about management was still high (62.2%) [42]; Pham Duc Muc’s research [59], to investigate systems and human resource for Chief Nurse in central and provincial hospitals in 2007 shown: Trained for Nursing management was 63.3%. Implementing authorities tasks: Organizing and directing the implementation of whole patient care (WPC): good 72.3%; medium 22.1%; poor 4.1%; no done 1.5%. Speech, check the implementation in accordance technical procedures hospital regulations: Good 4 90.0%; Average 3.2%; poor 5.2%; no done 1.5%. Organize training and rawasing the level: good 62.4%; Average 22.5%; poor 9.2%; no done 5.9%. Join practice guide for pupil - student: Good 35.8%; Average 31.4%; poor 26.6%; no done 6.3%. Procurement planning, test use and preservation: good 48.0%; Average 31.4%; poor 26.6%; no done 6.6%. Check the hygiene, infection protection: Good 88.2%; Average 5.5%; poor 5.2%; no done 1.1%. Join the organization, recruitment work: Good 60.5%; Average 24.0%; poor 12.5%; no done 3.0%. Participation in scientific research: Good 38.0%; Average 22.1%; poor 34.7%; no done 5.2%. Participation in guidance of branch: Good 45.8%; Average 20.3%; poor 22.8%; no done 5.2%. Sum up partially, generally: good 62.0%; Average 27.5%; poor 8.0%; no done 2.5%. Participation in propose ideas regarding the nursing policies: good 77.9%; Average 17.0%; poor 4.1%; no done 1.1%. According to Do Dinh Xuan’s research (2007) [107], has shown that 6,787 Chief Nurse were working in the public hospitals in the country, including: Nurse 78.4%, Midwife 7.4%, Medical Engineering 8.2%, 6.0% Chief Nurse with no professional qualification was nurse participating in nursing management (doctors, pharmacists). Regarding the capacity status of Chief Nurse Dean: 84% Chief Nurse Dean have assessed themself that they were able to complete from more fairly in the contents: patient care organization; Sanitation work guideline of departments; rooms; human resource management; asset and materials management. Only 54.5% Chief Nurse Deans jointed in the courses for management, in training, scientific research and direction of branch, with 61.40% gain from the good level and more, especially, 20.20% Chief Nurse Deans were weak in scientific research work. Weak implementation or no organization of scientific meetings accounted for 24.40%. Still 21.10% Chief Nurse Deans have achieved an average or less within the formulation, organization and maintenance of wholly care work. Chief Nurse Dean was weak or may not participate in the selection of new employees for 24.40%. * For affected factors: Do Dinh Xuan’s research (2007) [107], indicating that the factors such as age, sex, equipment and working conditions, the coordination of patient families and doctors as well as the work overload, etc were considered as relevant factors and influenced directly the ability of Chief Nurse Dean. Very little themes research factors affecting nursing capacity, might have re-statwastic some related factors directly affecting the quality of professional management. No analytical research has evaluated the affecting factors to give solution to effective interventions. * For the document, form of nursing management: According to Vo Thi Dinh , the record, storage of document, form were pretty good, record status surpluses or deficits, duplicate information stipulated by the Ministry of Health that also occurred [32]. Nguyen Thi Thanh Mai said that recording the developments of patients recently being in the department 5 were less than 5%, average 73%, rather 22%; developments in the treatment process were less 4%; average 78%, rather 18%; handling care were less 6%; average 75%, rather 19% [55]. * For satisfaction of patient: According to Vuong Kim Loc, research for the situation of nursing management work at Saint Paul hospital in 2007, patient’s satisfaction results have reached 55% [52]. Le Thi Binh’s research (2008), the Central Hospital was very satisfied by people 42.1%; satisfied 48.2%; Provincial/ citify hospitals very satisfied 62%, satisfied 36% [2]. Ha Thi Soan’s research (2007) has assessed the satisfaction of patients and their family for the medical staff about attitude >90% satisfied, specialization >90%, patients boards 94%. However, 10-12% non-satisfied were mainly on administrative procedures, made the test but not explain, no dietary guidelines, patients have had to buy more medicines outside [71]. Survey results of Nguyen Thi Ngoc (2005) at the General Hospital Thong Nhat, Dong Nai, the average satisfaction rate was 45.3% primarily not satisfied with guidance, explanation and health education yet thoughtful [64]. Hoang Thu Nga’s research said: satisfaction rate for attitude of service 87.8%; guidance in hospitalization 87.1%; mode of hygiene 84.8%; facilities, equipments 80.1%; security 62.9% and expertwase 93.7% [63]. 1.3.3 In Nghe An: Research in 2009, Nursing staffs, midwives in Nghe An has had 1,735 workers, mostly women 84.5%. In which university degrees, college was 11.7%, foreign language level A was 12.3%, Office informatics were 24.8%, trained nursing Management 38.5% [72]. According to the 2008 survey in Vinh City shown: Chief Nurse has had intermediate level about 91.9%; Average age of 35-55 accounted for 78.8%; not trained nursing management about 76.8%, capable of office computing and foreign language level A accounted for 54.5 - 62.6% [96]. In recent years, although there have been many positive changes in the domains of nursing, patient care in Nghe An. However, the nursing scientific research has had still many limitation because the force of nurse, midwife and technicians were mainly intermediate, an knowledge for research design and methods of scientific research was weak. The major topics has used the description method, bringing the summarization, report, very little research analysis titles, content focuses mainly on human survey, conducted nursing technical procedures, understanding patient service attitude. Especially intervention research for Chief Nurse capacity did not have any topic. 6 Chapter 2. OBJECTS AND RESEARCH METHOD 2.1 Research objects: - Chief Nurse was working at the hospital in Nghe An province. - Management staff of department, research hospitals. - The system of records, books, management forms of research hospitals; - Patients who were inpatients in the departments, research hospitals. 2.2 Capacity investigation location of Chief Nurse: at 40 public hospitals and private in Nghe An. 2.3 Research time: Research time was conducted from 2010 to 2013, divided into 2 stages. 2.4 Research Methodology: 2.4.1 Research design: Cross-sectional descriptive research analysis in combination of control intervention research. 2.4.2 Research sample sizes: Stage 1: Current status and factors affecting the status of Chief Nurse capacity. 2.4.2.1 Quantitative Research: Chief Nurse object: Thus, the research samples of Chief Nurse object were 403. Records, books, saving reports: Analysis of records, books and reports related to the nursing care and nursing management works of the years 2009 - 2013, including: case history, monitoring sheet, care vote, the management books of materials, manpower, plans, preliminary reports and summarization ... Patients’ inpatient treatment: Thus, the samples have selected to research of patient object were 400. 2.4.2.2 Qualitative Research: - Depth interview: Director/Vice Director of the hospitals: 8 persons. - Discussion under groups: 02 groups, each group was 8 head or deputy department. Stage 2: Evaluation of effectiveness of intervention "improvement of Chief Nurse capacity". 2.4.2.3 Intervention research: Total of Chief Nurse required to research 100 (Intervention group 100 and control group 100). 2.4.4 Research sample selection method: 2.4.4.1 Cross-sectional descriptive research: - For the Chief Nurse: Choose whole Chief Nurse working in 40 public hospitals, non-public in Nghe An province. - For inpatients: Select samples with 02 stages: 7 - Stage 1: Divise the provincial, district, citify hospitals into two ecoregions (advantages and disavantages). - Stage 2: Each ecoregion randomly has selected in proportion, disavantage 3/12 hospital and advantage 7/28 hospital to conduct an investigation, in each hospital investige 40 patients. 2.4.4.2 Qualitative Research: Intentionally select 8 above research hospitals: Depth interviews with 8 Director/ Vice Director. Organize Discussion into 2 groups, each has been 8 head or deputy department[84]. 2.4.4.3 Intervention research: Step 1: Select the research locations: Select 21 hospitals/ 32 public hospitals randomly assign the intervention group and control group. Step 2: Pre-intervention assessment: Assess capacity of Chief Nurse; The success indexes before the intervention: Step 3: Implement intervention situations to improve the capacity of Chief Nurse: * Develop a plan of implementation, inspection and evaluation; * Carry out the service supply and longitudinal inspection of research indexes during the intervention time, was 02 years (24 months): - Implement training solutions in Nursing Management [17], [106]: Training Program: issued by Ministry of Health attaching the Text No. 5909/YT-K2DT dated 16/08/2004 of the Ministry of Health, including 16 skills for nursing management [104], [105]; Develop and use procedures, guidelines and forms for nursing management. - Organize the application of knowledge, skills and forms of Nursing Management in daily activities of Chief Nurse. - Implement periodic supervision: 1 month/time to support supervision, 3 months/time meetings, learn from experience. Step 4: Collect, process data, and post-intervention effectiveness. - Collect post-intervention data. - Evaluation in comparison with post-intervention: Two intervention and non-intervention groups was initially the same (ptct and ptc), any difference (the index) was later through the horizontal invertigation in psct and psc that could relate the impact of intervention method. + The result index of intervention group = (psct - ptct )/ptct x 100% + The result index of control group = (psc - ptc)/ptc x 100% + Effective intervention = The result index of intervention group - The result index of control group In which: The result index: Performance Index; ptct: The pre-intervention research index of intervention group; psct: The post-intervention research index of intervention group; ptc: The pre-intervention research index of control group; psc: The post-intervention research index of control group. 8 The result index of intervention group > 0 and Intervention result = The result index of intervention group - The result index of control group > 0, so the intervention was effective. 2.5 Data collection and processing method: 2.5.2 Data processing: - Quantitative data processing: software EpiData 3.1 software and SPSS 16.0 with the test t; test 2. + Comparison 2 rates: If 2 calculation > 2 table, so there was different between the two rates (index), means statistical significant at level p < 0.05 or 0.01. + Comparing two average values: Testing test t, no duplex, independent observation, homogeneity variance and net distribution [86]. + Influencing factors: Recurrent analysis of logistis to analysis of multivariate relationship, based on a stepwise process. The dependent variable, independent variables have brought into the binary variable form. Chapter 3. RESEARCH RESULT 3.1 Status and factors affecting the Chief Nurse management capacity: 3.1.1 Characteristics of the research subjects: Results for General Information about Chief Nurse: Sex: Mostly female (81.6%); under age 40 was 57.1% higher; Main ethnic was Kinh (95.1%); Main professional qualifications was Intermediate (62.9%); Nursing specialization accounted for 68.4%; trained nursing management was 25.7%; Foreign language levels were mainly A, B (58.0%); Computer levels A, B (70.6%) and overseas study tours most (98.3%) have not been away. 3.1.2 Management capacity status of Chief Nurse: 3.1.2.1 Chief Nurse’s management knowledge: Classification of Chief Nurse’s management knowledge under the qualification: The results have shown that 412 Chief Nurse, the rate of general management knowledge graded fair, good 72.5%; in the group from College degree and more account for 26.4%, Intermediate group 46.1%. According to the provincial and district branches: General management knowledge rate grades fairly, good at provincial group was 29.4% ( x = 65.43), the district group was 43.2% ( x = 64.32). According to public hospitals and private: rate of general management knowledge grades fairly, good in public group was 65.1% ( x = 66.22), non-public group was 7.5% ( x = 57.16). According to the disadvantage and advantages regions: rate of general management knowledge grades fairly, good in disadvantage regions was 23.5%, advantages was 49.0%. Grade point average for general management knowledge according to qualification: of 153 Chief Nurse having college degree or more was 65.36 (standard deviation = 15.2), of 259 Chief Nurse having intermediate degree was 64.73 (standard deviation = 15.7). The results have shown that the college degree or more higher than intermediate degree was 0.63 with confidence 9 intervals 95% (-2.49 to 3.74). This difference did not mean the statistics with p = 0.693. According to the provincial and district branches: Grade point average for general management knowledge of 173 Chief Nurse in provincial branches was 64.32 (standard deviation = 15.2), the 239 Chief Nurse in district branches was 65.43 (standard deviation = 15.8 ). The results shown that the provincial branches were lower than district branches, was 1.10 with confidence intervals 95% (-4:16 to 1.94). This difference did not mean the statistics with p = 0.476. According to public, non-public: Grade point average for general management knowledge of 355 public Chief Nurse was 66.22 (standard deviation = 14.7), of 57 non-public Chief Nurse was 57.16 (standard deviation = 18.3). Public > nonpublic was 9.06 with confidence interval 95% (3.99 to 14.14). This difference meant the statistics with p = 0.001. According to the disadvantage and advantage regions: Grade point average for general management knowledge of 121 Chief Nurse in disadvantage regions was 69.14 (standard deviation = 14.6), of 291 Chief Nurse in advantage region was 63.23 (standard deviation = 15.6). Disadvantage region higher than advantage region was 5.91 with confidence interval 95% (2.65 to 9.17). This difference meant the statistics with p = 0.0001. 3.1.2.2 Chief Nurse’s management Practices: Research results classify Chief Nurse’s management practices according to qualification: rate of general management practices was classified fair, good accounting for 72.5%; at group from college degree or more (26.4%), intermediate group (46.1%). Head under the provincial and district branches: the rate of general management practices was classified average in provincial branch group was 19.7%, and in district branch group was 17.0%. According to public and non-public: In 412 Chief Nurse, the rate of the general management practices have classified average in the public group was 34.0%, non-public group was 2.7%. According to disadvantage, advantage regions: The rate of general management practices was classified average in disadvantaged regions was 11.4%, advantage regions 25.2%. Research result of grade point average for Chief Nurse’s management practice under qualification: of 173 Chief Nurse having college degree or more was 64.4 (standard deviation = 17.4), of 239 having intermediate degree was 64.5 (standard deviation = 16.1). Results shown that the college degree or more and intermediate degree were approximately equivalent with confidence interval 95% (-3.51 to 3.28). This difference did not mean the statistics with p = 0.945. According to the provincial and district branches: Grade point average for management practices of 173 Chief Nurse in provincial branches was 69.78 (standard deviation = 16.3), the 239 Chief Nurse in district branches was 60.64 (standard deviation = 15.7). The results shown that the provincial branches were higher than district branches, was 9.14 with confidence interval 95% (6.01 to 12.27). This difference has meant the statistics with p = 0.0001. According to Public, non-public hospitals: Grade point average for management practices of 10 355 public Chief Nurse was 65.39 (standard deviation = 16.9), of 57 non-public was 58.77 (standard deviation = 13.4). The results shown that the public group higher non-public group was 6.62 with confidence interval 95% (2.66 to 10.58). This difference had meant the statistics with p = 0.001. According to the disadvantage and advantage regions: Grade point average for management practices of 121 Chief Nurse in disadvantage regions was 63.21 (standard deviation = 17.79), the 291 Chief Nurse in advantage region was 65.01 (standard deviation = 16.04). The results shown that disadvantage regions lower than advantage region was 1.80 with confidence intervals 95% (- 5:49 to 1.89). This difference did not mean the statistics with p = 0.337. Classification results of Chief Nurse’s Management Capacity shown that the fair, good rate for general management knowledge was 72.6%; x = 64.97 (Std: 15.5); Fair, good rate for general management practices was 0%, average 36.6%; x = 64.48 (Std: 16.6); Fair management capacity was 13.8%, mainly average (67.7%); x = 129.44 (Std: 23.2). 3.1.2.4 Satisfaction assessment of patient for Chief Nurse: Assessment of patients by satisfaction, very satisfaction with Chief Nurse capacity at a high level. However, there were still dissatisfaction, very dissatisfaction for professional performance planning and effective 25.6%; Speech 23.6%; Gesture 23.5%; Examination procedures and hospitalizations 23.1%. 3.1.2.5 Factors affecting the ability of DDT: Factors related to the management capacity of Chief Nurse in the univariant model: The Chief Nurse respond to be supported the factors so the nursing management capacity was higher than of Chief Nurse who were not supported this: Direction table, scheme (1.98 times); Workflows (0.28 times); Discussion with colleagues (2.25 times). Table 3:13: Factors affecting the Chief Nurse’s ability after bring into a multivariate model to adjust jammed control: Affecting factors OR 95% CI p Scheme instruction 1.67 1.11 2.74 p = 0.12 Workflows 0.29 0.13 0.63 p = 0.002 Discussion with colleagues 1.65 0.80 3.42 p = 0.177 Re-trained 1.32 0.67 2.62 p = 0.423 Comment: In a logistic multivariate regression model to control jamming factors, the results shown that factors supporting profession has helped really Chief Nurse, was factor of Workflows. The Chief Nurse had answered to be supported for the Workflows have had capacity less greater than 0.29 times the Chief Nurse being not supported this. That was more supported for workflows, the Chief Nurse has had higher capacities. 11 3.2 Evaluate the effectiveness of interventions: 3.2.1 The assessment results before and after training: Chief Nurse’s knowledge assessment before and after training: After training, Chief Nurse’s knowledge met requirement (100%) higher than before training. Effective training = 42.1 Effective intervention. 3.2.2 Chief Nurse’s management knowledge: Evaluation of Chief Nurse’s management knowledge before and after intervention: Before intervention Chief Nurse’s management knowledge between two intervention groups (good, fair 7.5%) and controls (good, fair 5.2%) have not had differences with p > 005. After intervention Chief Nurse’s management knowledge of intervention group (good, fair 48.0%) > control group (7.9%), the difference has meant the statistics with p <001. Result Index of intervention group = 540%; Result Index of control group = 50%; Intervention efficiency = 490%. So, intervention was effective. The discussions under group has shown also a similar opinion, knowledge for nursing management of Nursing deans has had limited, often done under medical command and made administrative duties of the department mainly, the deployment tasks through content of meetings. After a period trained about nursing management, still be perplexed at first, subsequently be monitored and supported so Chief Nurse understant now the concepts, contents of management activities process. Opinions of hospital managers have given more positive comments. Generally, the assessment for Chief Nurse’s management knowledge has been recognizes well by the hospital managers/ departments, complete assigned works with better quality. Thus, assessment of intervention activities was effective initially have contributed to improving the quality of healthcare services. 3.2.3 Chief Nurse’s management skills practices: Assessment of Chief Nurse’s Management Practice: Before intervention assessment for Chief Nurse’s management practice between the two groups of intervention (good, fair 5.7%) and control (good, fair 7.5%) have not had the differences with p > 0.05. After intervention, Chief Nurse’s management practices of intervention group (good, fair 41.5%) higher than the control group (good, fair 4.8%), the difference has meant the statistics with p < 0.001. Result index of intervention group = 630%; Result index of control group = - 40%; Intervention result = 670%. So intervention was effective. The opinion for depth interviews and group discussions also have turned around comments on nursing management skills of Chief Nurse was clearly improved. Thus, for the management skills of Chief Nurse has been highly appreciated by the hospital managers/ departments, the significant improvement for the quality and effectiveness of patient care. 3.2.4 Chief Nurse’s management capacity: Table 3.16: Assessment for Chief Nurse’s management capacity: 12 Management capacity Knowledge Practice Good Fair Average Poor Good Fair Average Poor Good Fair General capacity Average assessment Poor Pre-intervention Intervention Control group group p n = Rate n = Rate 117 % 112 % 7 3.1 6 2.6 10 4.4 6 2.6 0.765 49 21.4 46 20.1 51 22.3 54 23.6 5 2.2 7 3.1 8 3.5 10 4.4 0.060 36 15.7 50 21.8 68 29.7 45 19.7 6 2.6 1 0.4 2 0.9 13 5.7 0.005 48 21.0 37 16.2 61 26.6 61 26.6 After-intervention Intervention Control group group p n = Rate n = Rate 117 % 112 % 63 27.5 11 4.8 0.00 0 47 20.5 7 3.1 5 2.2 81 35.4 2 0.9 13 5.7 46 20.1 5 2.2 0.00 0 49 21.4 6 2.6 20 8.7 89 38.9 2 0.9 12 5.2 63 27.5 7 3.1 0.00 0 45 19.7 11 4.8 8 3.5 84 36.7 1 0.4 10 4.4 Comments: Before general management capacity intervention of intervention group (good, fair 3.5%) lower than the control group (good, fair 6.1%), the difference has meant the statistics with p < 0.005. After the general management capacity intervention of Chief Nurse in the intervention group (good, fair 47.2%) higher than the control group (good, fair 7.9%), the difference has meant the statistics with p <0.001. Result index of intervention group = 1250%; Result index of control group = 30%; intervention result = 1220% → intervention was effective. The depth interviews and concentrated group discussions have confirmed that: To improve the quality of patient care, strengthening nursing management capacity, overcoming the existence of the actual management status, we have had to pay attention synchronously to conditions: Material basic, medical equipment; Improving the quality of professional qualifications, attitudes, responsibilities and professional conscience of Chief Nurse. Thus, to improve the nursing management capacity, education in improving, training, updating knowledge, skills, dissemination for medical ethics for Chief Nurse was necessary. 3.2.5 Documents, form of nursing management: The pre-intervention research results of current documents, forms of nursing management of intervention group (good, fair 20.5%), control group (good, fair 20.1%), the difference between the two groups did not mean statistics with p> 0.05. post-intervention current document, forms of nursing management of intervention group (good, fair 44.1%) higher than the control group (good, fair 22.8%), this difference has meant statistics with p <.05. 13 Result index of intervention group = 120%; Result index of control group = 10%; Intervention result = 110% → intervention was effective. For the storage condition, the hospital managers said that the storage situation was in confusion, unscientific, the classification of document list, the time helps to manage, search, lookup if necessary were having many difficulties. To meet the demand for improving the quality of health care, should have the right solution, scientific, safety, quality and efficiency in document work and management forms. 3.2.7 Satisfaction of patient: Before the intervention, the patient's satisfaction with Chief Nurse between the two groups of intervention and control: difference (Regarding gestures; Respond immediately; Visit, encourage; Professional knowledge, Professional Engineering; examination procedures and hospitalization; Implement the profession successfully and efficiently with p < 0.05); no difference (For speech; Consulting, health education: care layout method, treatment with p > 0.05). After the intervention, patients' satisfaction for Chief Nurse in intervention group was higher than control group; This difference has meant the statistics with p < 0.001. Chapter 4. DISCUSSION 4.1 Status and factors affect Chief Nurse’s management capacity: 4.1.1 Chief Nurse’s management knowledge: In accordance with research results showing that good classification rate for patient care knowledge was 68%; hygiene work (54.6%); Asset management (65.5%); Investigation - scientific research, directing the branch (18.0%); human resource management (61.4%); rate of general management knowledge grades fair, good accounting for 72.5%. According to Pham Duc Muc’s research (2007) [59] patient care in good (72.3%); hygiene work (88.2%); asset management (90.0%); Investigation scientific research, directing the branch (35.8 to 45.8%); human resource management (60.5%). Do Dinh Xuan (2007) [107] research on 6787 Chief Nurses for the public hospitals in the country (914 Nursing Deans) shown that 84% Nursing Deans were able to completion of works from fair level or more. Pamela Duffy and colleagues’ research in the United States shown that there was a difference in perception of the practice of provincial hospitals before and after training. For pre-training skills rate of Nurse, Chief Nurse having confidence in clinical practice was 46%, after training was 60% (p = 0.018), for the attitude was also similar difference (p = 0.046) [140]. Dao Thanh’s research (2007) has shown that the implementation of scientific research experience was weak, in which 7.7% did not perform this task [77]. Tran Thi Chau's research (2007) has suggested that Chief Nurse was trained about nursing management 41.6%, performing main function for administrative management [26]. 14 our research results were lower than with above researchs. Nghe An was North Central provincial region, social - economic conditions have had still more to differences than the national average. On the other hand, rate of Chief Nurse has had intermediate degree as a proportion of 62.9%, higher than the country (59.7%) [59]. Meanwhile nursing management training organization in the recent years has had developed but the results have not been lot (25.7%). Therefore, lower knowledge for nursing management reflects reality. According to professional qualifications classification of the general management knowledge for 412 Chief Nurse (Table 3.2), results in groups from colleges or more rate of management knowledge grades fair, good (26.4%), intermediate degree (46.1%). Grade point average of management knowledge (Figure 3.1) of 153 Chief Nurse having intermediate degree or more was 65.36, of 259 Chief Nurse in intermediate degree was 64.73. The results have shown that the grade point average for knowledge of Chief Nurse having colleges or more higher than intermediate degree was 0.63 with confidence intervals 95% (-2:49 to 3.74). This difference did not meant the statistics with p = 0.693. Between the two groups by this qualification no difference in knowledge was due not trained, familiar with the nursing management skills. Therefore, management knowledge did not depend on professional qualifications. So implementation of nursing management training plan was a very important and necessary issue. Management knowledge in accordance with district and provincial branches (Table 3.3), the rate of general management knowledge grades fair, good in group of provincial branches 29.4%, in group of district branches 43.2%. Grade point average (GPA) of management knowledge (Figure 3.2) of 173 Chief Nurse in provincial branches was 65.43; of 239 Chief Nurse in district branches was 64.32. The results have shown that GPA of management knowledge of Chief Nurse in provincial branches higher than district branches was 1.10 with confidence intervals 95% (-4:16 to 1.94). This difference did not mean the statistics with p = 0.476. Comparison of knowledge between provincial and district branch, at first sight could show that provincial branches would have higher knowledge than district branch but in our research there was no difference between the two groups under branches. The reason to explain about this problem not to training for nursing management training remains highly (74.3%). In Table 3.4 the results have shown the percentage of general management knowledge grades fair, good in public group was 65.1%, and non-public group 7.5%. GPA of general management knowledge (Figure 3.3) of 355 public Chief Nurse was 66.22; of 57 non-public Chief Nurse was 57.16. The results shown that GPA of general management knowledge of public Chief Nurse higher than non-public was 9.06 with confidence interval 95% (3.99 to 14.14). This difference has meant the statistics with p = 0.001. In fact, the amount of Chief Nurse working in the area of non-public hospitals were recruited from two new sources of and recruitment of retirees. This force was not trained on nursing 15 management; on the other hand they were interested mainly in profession and in management under boss model. The research results in Table 3.5 has shown that the proportion of general management knowledge grades fair, good in disadvantage regions was 23.5%, in advantage regions 49.0%. GPA of management knowledge (Figure 3.4) of 121 Chief Nurse in disadvantage regions higher than in advantage regions was 69.14; of 291 Chief Nurse in advantage regions was 63.23. GPA of general management knowledge of Chief Nurse in disadvantage regions higher than in advantage regions was 5.91 with confidence interval 95% (2.65 to 9.17). This difference has meant the statistics with p = 0.0001. this difference could be caused by differences in professional qualifications, in disadvantaged regions with rate of Chief Nurse with intermediate accounts for 17.2%, in advantage regions was 45.6%. Besides, in Nghe An Chief Nurse with intermediate degree was the majority (62.9%), meanwhile the amount of Chief Nurse in the advantage regions was 291 people more large than in disadvantaged regions (121 persons). According to Do Dinh Xuan (2007) [107], GPA of management under the branches (oscillating from 72.64 ± 18.29 to 95.90 ± 7.55) and under region (oscillating from 80.19 ± 13.08 to 89.15 ± 11.28). Meanwhile our research results achieved only GPA of lower management knowledge (oscillating from 63.23 ± 15.6 to 69.14 ± 14.6). However, GPA of regional management knowledge of our research in disadvantage regions was higher than the advantage regions, this difference means the statistics. Thus, generally our research data compared with some other researchs was lower. Explanation for this problem was due to regional characteristics, working conditions and improvement learning in Nghe An was still limited compared to the country. On the other hand, maybe due to our research was the direct interviews, other researchs were maieutic method so research result was somewhat different. On the advantage regions GPA of general knowledge lower than the disadvantage regions was due to partition plans. Thus, the general knowledge results reflecting actual were appropriate. Through the research results have suggested that Chief Nurse’s management knowledge in Nghe An was lower than the national average level. To improve the quality of management in particular, the quality of medical services in general, the health branch should have a training plan, knowledge improvement of nursing management. On the other hand the work of managing staff planning, recruitment, appointment should be considered, based on Nursing management training certificate. 4.1.2 Chief Nurse’s management practices: Research results in Table 3.6 have stated that the rate of fair classification for patient care practice was 40.3%; Hygiene work (35.7%); Asset management (33.0%); Investigation - scientific research (2.9%); human resource management (3.5%); rate of general practices grades average accounting for 36.7%, poor (63.3%). 16 In 412 Chief Nurse, rate of general management practices grades fair, good (0%), average 36.7%. GPA of management practices (Figure 3.5) of groups from colleges or more was 64.4; Intermediate group was 64.5. groups from colleges or more and Intermediate group were approximately with confidence interval 95% (-3.51 to 3.28). This difference did not mean the statistics with p = 0.945. Thus, management practices assessment of Chief Nurse has given also result as same as management knowledge. There was no difference between the two groups according to professional qualifications. For the classification of practice under provincial and district branches, the research in Table 3.7 has indicated that the rate of general management practice classified average in the provincial branch group was 19.7%, and in district branch group 17.0%. GPA of management practices (Figure 3.6) in provincial branch was 69.78, district branch was 60.64. Provincial branch higher than district branch was 9.14 with confidence interval 95% (6.01 to 12.27). This difference has meant the statistics with p = 0.0001. This difference could be explained that Chief Nurse in the provincial branch although untrained nursing management as in district branch, but in the provincial branch has had many conditions contacted experiential management personnel, learned through a variety of information channels. From real-life experience provided the more experience for Chief Nurse in management, better thinking in management skills practice. The rate of general management practices (Table 3.8) has classified average in the public hospital group was 34.0%, and in the non-public group 2.7%. GPA of management practices of the public hospital group (Figure 3.7) was 65.39; Non-public group was 58.77. Public group higher non-public group was 6.62 with confidence interval 95% (2.66 to 10.58). This difference has meant the statistics with p = 0.001. Interpretation of this result was similar to knowledge assessment. Chief Nurse in non-public hospitals have had little opportunity to exchange to learning, exchange of experiences, they have focused on fulfilling their professional duties, the management work was little interest. Research (Table 3.9) has shown that the rate of general management practice has classified average in disadvantaged regions was 11.4%, in the advantaged regions 25.2%. GPA of practice (Figure 3.8) of disadvantaged regions was 63.21; advantaged regions 65.01. Disadvantaged regions lower than advantaged regions was 1.80 with confidence interval 95% (- 5:49 to 1.89). This difference did not mean the statistics with p = 0.337. For the practice, there was no difference between the two ecoregions. In the same conditions of health organization system, the same continuous training conditions, the same implementation of the sector policy. So generally there was not a lot of different on qualifications, policies for training and updating knowledge. They have varied a little in economic - social conditions, traffic, etc. Thus, reinforces recommendations to improve the knowledge and practice of Chief Nurse need to implement continuous training organization for nursing management. 17 For the classification of Chief Nurse’s management capacity (Table 3.10), the proportion of fair accounts for 19.8%, average (65.5%), still poor (14.6%) with grade point average of capacity was x = 129.44 (Std: 23.2). Compared to some researches, such as Pham Duc Muc (2007) [59], Do Dinh Xuan (2007) [107]; Nguyen Thi Nhu Tu [93] and some other researhes, we did not have a basis for comparison. Because nursing management capacity researchs have based mainly on assessment of trained professional qualifications, information technology, foreign languages and a number of nursing technical processes, referring to knowledge, skills of management process, but not sufficient compared with provisions of nursing management training program [16] and the functions and duties of Chief Nurse [23]. The information collection method was also different, was based mainly on maietic methods, depth interviews. Meanwhile our research uses a checklist and evaluation of practice results through direct observation or indirect management practices; combine information collection through documents, books, records of storage management. We found that the Chief Nurse’s practice classification was low-level, no kind of fair, good. This could be understood that as Chief Nurse was trained the nursing management with low proportion (25.7%). The daily management activities were carried out according to experience. So Chief Nurse should be well schooled in the nursing management, prior to appointment should have standard on basic of Nursing management Certificate. At the same strengthening and developing the storage work of records and management forms. 4.1.3 Factors affecting the management capability of Chief Nurse: Research result has shown that there was especial relationship between Chief Nurse’s management capabilities and instructions, scheme (2 = 1.98, p = 0.05); Workflows (2 = 0.28, p = 0.01); Discuss with colleagues (2 = 2.25, p = 0.05). In table 3.12 Hosmer and Lemeshow Test (Hosmer and Lemeshow 2 = 4.219, p = 0.75) shown that multivariant regression model was significant. When logwastic regression analysis has analyzed that the relationship of these factors with the Chief Nurse’s management capacity dependent variant and independent variant were brought in binary form. Table 3.13 has indicated that: The analysis results shown that this model was fully comfortable to multivariate analysis between factors such as individuals, families and agencies with Chief Nurse’s nursing management capacity. Workflows have associated closely with the Chief Nurse’s management capacity, workflows of management capabilities were better than 0.28 times (p <0.01) in comparison with workflow after adjustment for other factors. This result has eliminated some factor as compared with multivariate analysis as the jamming factors were eliminated. Thus, for the management work, Chief Nurse in the thinking were seriously to follow, less creative or fearful. In fact, Chief Nurse forces were mainly intermediate level so following the technical process more than the creation was easily understandable. On the 18 other hand due to limitation for funding conditions, time and sample size, the results did not reflected clear relationship of some other factor. From the above analysis, It was necessary to the next research to depth analysis of factors affecting the nursing management capacity of Chief Nurse to propose appropriate solutions contributing to improvement ofthe management capacity to meet performance of function, protective duty, care and people's health growth. According to Do Dinh Xuan’s research (2007) [107], the factors such as age, sex, equipment and working conditions, the coordination of patient families and doctors as well as the work overload, etc were considered as the relevant factors and directly affecting the management capacity of Nursing Dean. According to Nguyen Thi Nhu Tu (2007) [93], factors have affected the management capacity of Chief Nurse that leaders have underestimated the patient care work, imbalance in the number of patients and the nursing manpower; weak, low qualification; not involved Council for reward, dwascipline, recruitment, appointment, transfer. In Ho Chi Minh City, Tran Thi Chau's research (2007) has suggested that low qualifications (Intermediate level 78.3%); untrained nursing management (59.4%) were also the factors contributing to affect the ability of Chief Nurse [26]. Our research results have shown that the factors affecting Chief Nurse’s management capacity was somewhat different from previous researches. The reason for this difference could be due to affect the customs, habits, different conceptions between regions. Besides, due to the research design also has made different results. Until now, very little topics study factors affecting the nursing capacity or could re-statistize some related factors directly affecting the quality of profession and management through the interviews. It needs the depth analysis researches to assess the affected factors to provide effective intervention methods. Thus, capacity management of Chief Nurse has affected a lot of factors, depending on each local, the specific object of the influence of different factors. 4.1.4 Satisfaction of patients: Research results (Figure 3.15) have shown that: Patients have satisfied, very satisfied with speech 76.3%; Gesture 76.4%; Respond immediately upon request accounted for 77.8%; Visit and encourage 79.1%; Consultant, health education 86.1%; Professional knowledge 78.1%; Professional engineering 79.1%; Examination procedures and hospitalizations 76.8%; The layout of care and treatment work 83.1%; Professional performance planed and efficiency 74.4%; However there were still dissatisfaction, very dissatisfaction for professional performance planed and effective 25.6%; Speech 23.6%; Gesture 23.5% and examination procedures and hospitalizations by 23.1%. Roderick research in the United States for improving the quality of patient care [147] has stated that the satisfaction rate of the patients for the doctor was higher than Chief Nurse in intensive clinical department, whereas in 19 obstetrics satisfaction for Chief Nurse was 73 %, for doctors 71%. According to Vuong Kim Loc (2007), studying the situation of nursing management at SaintPaul hospital, patient’s satisfaction results have reached 55% [52]. Le Thi Binh’s research (2008), the Central Hospital was very pleased by people 42.1%; satisfied 48.2%; Provincial/ citify hospital were very satisfied 62%, satisfied 36% [2]. According to a Nguyen Thi Ngoc’s research result (2005) at General Hospital Thong Nhat, Dong Nai, satisfaction rate of average level for Chief Nurse’s capacity accounted for 45.3% mostly not satisfied with instructions, explanations, health education not yet thoughtful [64]. Ha Thi Soan’s research (2007) [71] has assessed the satisfaction of patients and families for the medical staff about altitude > 90%, patients boards 94%. However, 10-12% were dissatisfied mainly on administrative procedures, the test not explain, no dietary guidelines, patients should buy medicines outside. According to Hoang Thu Nga said: satisfaction rate for mental attitude of service 87.8%; guidance for hospitalization 87.1%; hygiene mode 84.8%; facilities, equipments 80.1%; security 62.9% and specialization 93.7% [63]. Comparing these results with previous researchs, our research has given the same result, although in different conditions in the socio-economic, customs and traditions, but the general doctors, Chief Nurse in particular were devotion to the patient, sacrifice, dedication to the job, devoted care, service to the patient. On the other hand patients often have complained about spirit, service attitude, behavior. Through the research results, the managers were helped to know the requirements, the desire, the factors have related to patient satisfaction. 4.2 Evaluate the effectiveness of interventions to improve management of Chief Nurse: 4.2.1 Chief Nurse’ Management Knowledg: Research results at Figures 3.16 and 3.17 have indicated that Chief Nurse before training cognite about 16 skills of nursing management were still limited (11/16 skills did not meet). After training, knowledge of 100% Chief Nurse met requirement. GPA before training was 36.7; after training was 77.9. Training effect = 42.1. Thus, training interventions were effective. Through these results, we known that the role of training work has had an important position, but in order this result were sustainable development, shall plan to strengthen supportive supervision for the knowledge became really skill, competence. Table 3.14, before intervention the management knowledge of Chief Nurse of intervention group (good, fair 7.5%) and control groups (good, fair 5.2%), the two groups did not differed with p > 0.05. After the intervention the management knowledge of Chief Nurse of intervention group (good, fair occupies 48.0%) higher than the control group (good, fair 7.9%), the difference between the two groups have meant the statistics with p < 0.01. Intervention result = 490%. Before intervention the assessment was the same between the two groups, after intervention the intervention group has had higher knowledge than the control group, so the intervention was effective. This issue was as to 20 compliance as explanation the nursing management so initial assessment in GPA of knowledge before training was low ( x = 36.7), after training knowledge was significantly improved ( x = 77.9). The results shown that interventions were effective (interventions result = 490%); simultaneously during task execution, the Chief Nurse has applied the learned nursing management skills in specific conditions, within learning and working, combines the supportive supervision so awareness was much improved. Whereby this has indicated the nursing management training organization for Chief Nurse force or person in planning was a very important contributing to improving management capacity. Strengthen supportive supervision was also very important to contribute improvement of capacity. The depth interviews for management staffs and group discussions given also similar opinion, knowledge for nursing management of Nursing dean was limited, usually done under medical command and mainly done the administrative responsibility of department, the tasks were implemented through meetings content. After intervention training solutions for nursing management, still has confused at first, later to be monitored so Chief Nurse understook the concepts, processes, content of management operation process now. The opinions of hospital managers were more positive comments. 4.2.2 Practice of Chief Nurse’s management skills: Before the intervention (Table 3.15) have evaluated the management practices of Chief Nurse in the intervention group (good, fair 5.7%) and control groups (good, fair 7.5%), the two groups did not differed with statistically significant with p > 0.05. Research results after intervention Chief Nurse’s management practice of intervention group (good, fair occupies 41.5%) higher than the control group (good, fair 4.8%), this difference was statistically significant with p < 0.001. Intervention result = 670%; results reflect effective intervention. Before the intervention, Chief Nurse’s management practice in the intervention group and control group were differences, after the intervention Chief Nurse’s management practice of the intervention group was higher than the control group. The reason for this difference was due to the intervention group was applied the direct work instruction measures, construction and application of management skills process, strengthen inspection and supervision in place for Chief Nurse. After 24 months of intervention, assessment for Chief Nurse’s management practices of intervention group was higher than the previous 35.8%. This result was evidence to mark the interest in leadership of department/hospital for nursing management forces, the efforts of the Chief Nurse, the support and assistance of supervision staffs. So, to maintain the intervention results in a sustainable way, the Chief Nurse was required to further study and improve the knowledge and management skills. On the other hand it was necessary to strengthen the supportive supervision and exchange of experience through meetings, cross-check between departments, learn from experienced, overcome and repair to meet well the requirement of task execution.