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Quality assessment of pediatric oncology nursing care in a central American country: findings, recommendations, and preliminary outcomes.

Article Excerpt
Pediatric oncology in developed countries, such as the United States, has achieved remarkable success over the past 25 years. In the U.S., the 5-year survival rate among children improved from 58% for patients diagnosed from 1975 to 1977 to 79% for those diagnosed from 1996 to 2001 (Jemal et al., 2003). However, in developing countries, where 80% to 85% of all childhood cancer cases occur, the survival rate is often less than 10%. The International Outreach Program (IOP) at St. Jude Children's Research Hospital, established in 1993, strives to improve the worldwide survival rate of children with cancer and other catastrophic illnesses by transferring knowledge and technology to partner-sites established in developing countries. The provision of quality nursing care is essential to improving survival rates for these children.

The IOP Nursing Program was developed using strategic planning guidelines to promote a structured approach to meeting international nursing needs (Finkler & Kovner, 2000). The program's mission is to provide the highest quality of nursing care to patients and families at IOP partner-sites. Four broad goals were designed to create a synergy that supports the mission and include 1) developing a process for assessing and improving the quality of nursing care, 2) providing comprehensive pediatric oncology education and training to nursing staff by hiring partner-site nurse educators and creating regional training centers, 3) developing strong partnerships with nursing leaders and educators affiliated with international nursing, and 4) contributing to the international nursing body of knowledge though research. The nursing program's conceptual model is depicted in Figure 1. This article focuses on the nursing quality improvement component of the program and includes specific methods used to evaluate quality nursing care in a developing Central American pediatric oncology IOP partner-site. Findings, recommendations, and preliminary outcomes are also presented.

Evaluation Methods

In May 2006, IOP's Nursing Director and St. Jude's Standards and Practice Coordinator traveled to Central America to assess the quality of nursing care at an IOP partner-site. Standards of nursing care and nursing professional performance were evaluated using standards endorsed by Joint Commission International (JCI), a division of the Joint Commission. JCI standards are universally recognized as the gold standard for international accreditation and were developed to assess quality and safety of health care in a wide variety of health care settings. The standards were developed by an international task force consisting of members from Latin America and the Caribbean, Asia and the Pacific Rim, the Middle East, Central and Eastern Europe, Western Europe, and Africa, and have been validated through quality and safety studies by public agencies and health ministries outside the United States (Joint Commission International, 2002). The standards take into account that hospitals in many developing countries do not yet function at the level of U.S. hospital standards; therefore, they are less stringent in evaluation criteria (Marshall et al., 2006).

The standards have been adapted for the international community and are designed to be culturally applicable and compliant with laws and regulations outside the U.S. (Timmons, 2007). A set of standards this broad in nature cannot account for a country's unique characteristics; however, there is evidence that many quality concerns are universal. Aiken, Clarke, and Sloane (2002) noted that countries tend to believe problems with quality of care and nurse staffing are a result of unique circumstances. Yet, data from their study suggested that contrary to popular opinion, many hospital problems know no country boundaries.

[FIGURE 1 OMITTED]

Nursing quality was assessed using standards from six JCI quality domains:

* Access to Care and Continuity of Care.

* Assessment of Patients.

* Care of Patients.

* Patient and Family Education.

* Prevention and Control of Infections.

* Staff Qualifications and Education.

Only those standards with relevance to nursing were selected, and standards were evaluated from a nursing perspective. Standards and elements of performance for each domain used in the evaluation are included in Figure 2. The methods used to complete the evaluation included direct observation of nursing care and a review of medical records, policies, procedures, and job descriptions. Interviews with nursing staff and a tour of the site were also conducted. All nursing interviews were communicated to the evaluators through the use of a translator. Written documents were translated into English by a translator. Following the evaluation, a comprehensive report was prepared, including recommendations and proposed implementation plan.

Partner-Site and Nursing Overview

The partner-site was opened in 2000 with financial support from the country's Ministry of Health, a local non-governmental philanthropic foundation, and St. Jude Children's Research Hospital. The site, a pediatric oncology unit functioning independently within a much larger public hospital system, is located in a Central American country with a population of about 13 million. The primary language is Spanish, but 23 officially recognized Amerindian languages are also spoken. The literacy rate is approximately 70%,...

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