In,. ,. ,%urs. Stud.. Vol. 29. No. 3. PP. 231436. Prmtcd ,n Great Bntam
I992
Nursing evaluation: purposes, achievements and opportunities DAVID MARSLAND Director
CONOR GISSANE Research Officer, Centre for Evaluation Research, Department of Health and Paramedical Studies, West London Institute of Higher Education, Isleworth. Midd1esc.u TIC’7 5 DU, U.K.
Abstract-Evaluation has become a powerful, specialized discipline in recent decades, with its own sophisticated conceptual and technical apparatus. Evaluation of nursing has benefited strongly from these developments, as examples of cogent, recent evaluations demonstrate. Evaluation is already proving an indispensable practical tool for raising the quality of health care, and for advancing professional nursing standards. Nonetheless, there is room for further improvement. Neglected areas of nursing should be brought under the spotlight of evaluation, conceptual and methodological rigour should be strengthened, and training in research skills should be extended.
Introduction
According to Striven (1991) the primary origins of modern evaluation research are to be found in the wave of large-scale educational programmes funded by governmentsparticularly in the U.S.A.-during the 1960s. Evaluation of these huge public investments was required by law. Naturally enough, evaluation flourished. In the years since then, evaluation has spread rapidly from education into other fields, including not least health care. It has expanded into a large-scale discipline in its own right (Patton, 1982). From the beginning of this process of rapid development of evaluation, applications in health care have played a significant part. More recently health care world-wide has become a major arena of systematic evaluation research. This was reflected by the 231
232
D. .\I.4 RSLAiVD
A,VD C. GISSA.1%
publication in 1981 of the WHO’s influential “Health Programme Evaluation: Guiding Principles” (WHO, 1981). While the WHO’s guiding principles were inevitably couched at a broad and programmatic level, they did draw explicitly and intelligently on the developing general literature and practice of evaluation. In particular they served to direct health care evaluation wisely and well by their emphasis on the importance of: Systematic information. Valid indicators and well-founded criteria. The distinctions between relevance, adequacy, impact.
progress, efficiency, effectiveness, and
In Britain, concern with evaluation in health care has come increasingly to the fore since the beginning of the 1980s (see for example Jenkins, 1991). For several distinct reasons it seems likely to increase further in coming years: The current far-reaching reforms of health care, with their emphasis on consumer satisfaction and their radical re-organization of management and delivery. The current rapid rate of technological, pharmacological, and therapeutic innovation in health care. The current evident increase in the population’s interest in health matters, including diet, fitness, and alternative medicine. The increasing costs of health care, and the consequent problems of determining priorities and auditing for efficiency. Each of these four influences is a source of continuing pressure for increased and more effective evaluation in the nursing sphere specifically, as well as in health care as a whole. For example, we may expect more consumer satisfaction studies of patients’ reactions to the technical and human relations performance of nurses; further use of evaluation research as a systematic source of adjudication between different modes of organizing nursing teams; carefully designed studies of the nurse’s public image in the context of a wider market of health care providers; and widespread investigation of the costs and benefits of utilizing nursing personnel where cheaper and less skilled health care workers might serve. Over and above the effect of these four influences, the current phase of rapid development in the nursing role and nurse education is increasing pressure for evaluation still further. In the hospitals and in the community alike, the work of nurses is being radically transformed, with new tasks, new responsibilities, and new modes of organization being introduced year by year. Project 2000 is revolutionizing initial training. New programmes providing joint training for hitherto entirely specialized community nurses are being established. Bachelors and Masters courses in Nursing Studies and in specialist nursing fields are multiplying. All of these exciting developments in nursing and in nurse education require systematic evaluation. State of the
art
As of 1992, considerable progress is already being made on the lengthy evaluation agenda established by the contemporary revolution in health care as a totality and in nursing specifically.
EVAL fJAT1O.V: PURPOSES,
ACHIEVEMENTS
A.vD
OPPORTUNITIES
233
Progress is certainly less well advanced in Britain than in the U.S.A., where evaluation research is an altogether bigger, better funded, and more confident enterprise (Harman, 1987). Nonetheless, a considerable body of high quality evaluation research on nursing has been and is being undertaken. Some examples are to be found in the articles in this special issue of the International Journal of Nursing Studies. Much else besides would need to be included in any comprehensive, systematic account: for example the high quality evaluation of many aspects of nursing either completed or under way in the growing Centres of Nursing Research and in the expanding Departments of Nursing Studies and Health Studies in universities, colleges, and medical schools right across Britain. If achievements in the evaluation of nursing are considerable, there are also evident limitations and inadequacies. For example: Is there enough evaluation research under way ? Is evaluation perhaps too much concentrated on the more fashionable areas of nursing, and especially on nurse education? Are less popular services such as mental health care and care of the elderly perhaps also Cinderellas as far as evaluation is concerned? Are there sufficient large-scale evaluation studies under way? How much danger is there that incorrect lessons may be learned from a multiplicity of small-scale investigations? Can we be confident that the strongest and most appropriate research designs are being used? Perhaps there are too many one-shot case studies, and too few investigations designed longitudinally or in such a way as to incorporate relevant, considered comparisons? How adequate is the quality of the information, indicators, and data in nursing evaluation studies? Is sufficient attention being paid to the rules of measurement? Is nursing evaluation as tough as it should be? Are the criteria adopted for success and effectiveness pitched sufficiently critically to identify real weaknesses? How adequately are evaluation researchers succeeding in winning the enthusiastic backing of the nurses and other health care personnel in the systems evaluated? How far are they enabled to believe that evaluation belongs to them rather than to “expert outsiders”? How often and how adequately are the lessons learned from evaluation research implemented in improved practice? Is attention to ethical issues -which are peculiarly serious in evaluation research-adequate? How well are operational and research personnel in nursing being trained in the specific methodologies and skills of evaluation research? In the next section we turn to a brief consideration in more concrete terms of achievements in nursing evaluation and of opportunities for improvement. Achievements and opportunities The crucial benchmarks of excellence in evaluation seem to be as follows: Clarity and significance of objectives. Adequacy of scale. Appropriacy and power of research design. Adequacy of data quality. Effectiveness of data analysis. Relevance and force of criteria. Self-discipline and plausibility of interpretation. Indications for implementation.
23-I
D. MA RSLAND
AVD
C. GISSA:VE
Of many recent important studies, we have chosen two to illustrate successful achievement and opportunities for improvement in nursing evaluation. Characteristic of the best recent evaluation research is MacGuire’s study of the impact of primary nursing on the quality of care for the elderly (Mac&ire, 1991). It is modestly focused on assessing the effectiveness of Senior Monitor as a tool for evaluating changes in the quality of care. It is designed carefully to incorporate relevant comparisons and crucially, measures of change over time. Data collection and analysis are careful and thorough. The author’s conclusions are in the modestly cautious vein appropriate to any evaluation research: “It would appearthat where wards are closely matched in terms of size, patient population, acuity, staffing level, skill mix and support services, the very process of being assessed is a powerful incentive to improve practice. Commensurate improvement in the quality of care as a result of such re-appraisal may be achieved
irrespective
of whether
the ward is organized
along primary
nursing lines”.
While this may appear disappointing to some, it exemplifies admirably the modest but secure steps by which evaluation research can assist practice. It illustrates perfectly the extent to which any such advance presupposes careful conceptualization, accurate measurement, sophisticated research design, and systematic analysis. A similarly important and interesting, if perhaps less sophisticated, example of the best recent nursing evaluation research is provided by Whelan’s (1988) study of the impact of management styles on quality of care. The management styles of Sisters on 16 oncology wards were empirically classified in terms of the three dimensions of socio-emotional orientations, task orientations, and patterns of decision making. Quality of care was assessed, less than adequately in the author’s own admission, in terms of nurses’ confidential ratings. Measurement, design and analysis were for the most part appropriately complex and thorough, allowing effectively for the partialling out of confounding influences other than management style. Overall, the study seems to suggest that management styles do substantially affect, or at least are significantly correlated with, quality of care. In particular, variations in ward sisters’ socio-emotional orientations and task orientations (but not, interestingly, in the democratism of their decision making) are apparently associated with significant quality differences. The study thus lays the basis for larger-scale and more precise investigations of a potentially key influence on the delivery of quality care-front-line leadership. Both the strengths and the scope for improvement in studies such as these by Mac&ire and by Whelan are graphically and persuasively indicated in Thomas and Bond’s important 1991 review of research on the effectiveness of primary nursing (Thomas and Bond, 1991). The authors argue, on the basis of careful examination of most of the recent published research, that more powerful research designs are required. Even more importantly, they conclude that more precise conceptualization of such “global concepts” as “primary nursing” (and, one might add: “management style”), including tight operational definitions, is essential. If we are to avoid the unsatisfactory situation identified by Thomas and Bond in the area of primary nursing-“The vast majority of studies are flawed . . . findings have little validity and cannot be generalized”, their rigorous methodological challenge will need to be addressed positively.
EVALUATION:
PURPOSES,
ACHIEC’EzbfENTS
A.VD OPPORTUNITIES
235
It will not be adequate simply to move investigations onto a larger scale than the-in this respect typical-studies by MacGuire and Whelan. It will not be enough to attend to problems in measurement (as by Whelan) or even to efforts at improving its precision (as by Mac&tire), valuable though the best endeavours in this direction are (Harrison, 1991). Nor, of themselves, will improvements in design or in analysis ensure that the problems identified by Thomas and Bond are addressed adequately (Miller, 1991). Only rigorous conceptual analysis, clarity of operational definitions, and precise specification of research objectives can clear the way for reliable, determinate findings in evaluation, such that implementation of improvements to practice become feasible.
Towards a balanced,
realistic programme
of nursing evaluation
On the other hand, where evaluation is underdeveloped, as it clearly still is in nursing (and indeed in health care generally), we probably have to take some risks which are not fully justified in methodological terms. For example, the important study of general management in the NHS carried out recently by Pollitt and his colleagues (Pollitt et al., 1991; Harrison et al., 1989) might be accused of dealing in just the sort of “global concepts” against which Thomas and Bond’s magisterial warning is directed. No doubt the complex of structures and processes encompassed by the concept of “general management” needs careful unpacking if its effects are to be assessed precisely and authentically. In the meantime, however, Pollitt and Harrison have at least taken the issue beyond the realm of mere conjecture, and provided a valuable basis for further, more adequate studies. Thus, before the rigorous standards quite properly demanded by Thomas and Bond can be achieved, before even the less ambitious principles set out earlier in this paper can be insisted on, there are many areas of nursing-where evaluation has scarcely begun at allwhich should be attended to modestly rather than not at all. For example, as relatively recently as 1984, Long and Wilkinson were still busily enunciating a theoretical framework to provide the basis, the merest conceptual infrastructure, for evaluation in occupational health nursing (Long and Wilkinson, 1984). There, as in many other fields of nursing, evaluation research is still in its infancy. Achievements to-date in nursing evaluation are considerable. The methodological route towards upgrading its quality are well established. In our judgement, the period up to the year 2000 should see:
Neglected fields brought firmly Training in evaluation research All nursing evaluation brought insistence on theoretical clarity
under the spotlight skills substantially up to and beyond and methodological
of evaluation. strengthened. the highest current standards by rigour.
References Harman. J. et al. (1987). Progratn Evaluarion Kir. Sage. Harrison, A. (1991). Assessing patients’ pain: identifying reasons for error. J. Adv. Nun. 16, 1018-1025. Harrison, S. er al. (1989). General Monagetnenr in the National Health Service. Nuffield Institute Report Number 2. Jenkins. R. (1991). Outcome indicators of mental health. In fndicotorsfor.Clentol He&h (Jenkins, R. and Griffiths. S.. Eds). Department of Health, HMSO. Long, R. J. and Wilkinson, W. E. (1984). A theoretical framework for occupational health program evaluation. Occupa!. Hlrh Nurs.. May.
236
D. MARSLAND
AND C. GISSA.VE
%lacGuire, J. (1991). Quality of care assessed: using the senior monitor index in 3 wards for the elderly before and after a change to primary nursing. J. Adv. 12iurs. 16. 51 l-520. Miller, D. C. (1991). Handbook of Research Design and Social Measurement (5th edn) Sage. Patton, M. Q. (1982). Practical Evaluation. Sage. Pollitt, C. (1991). General management in the NHS: the initial impact. Public Administrafion 69. Striven. M. (1991). T/theEvaluation Thesaurus. Sage. Thomas, L. H. and Bond, S. (1991). Outcomes of nursing care: the case of primary nursing. Int. J. Nurs. Stud. 28, 291-314.
Whelan, J. (1988). Ward Sisters’ management styles and their effects on nurses’ perceptions of quality of care. J. Adv. Nurs. 13. 125-138. WHO (1981). Healfh Programme Evaluation: Guiding Principles. World Health Organization.
I992
Nursing evaluation: purposes, achievements and opportunities DAVID MARSLAND Director
CONOR GISSANE Research Officer, Centre for Evaluation Research, Department of Health and Paramedical Studies, West London Institute of Higher Education, Isleworth. Midd1esc.u TIC’7 5 DU, U.K.
Abstract-Evaluation has become a powerful, specialized discipline in recent decades, with its own sophisticated conceptual and technical apparatus. Evaluation of nursing has benefited strongly from these developments, as examples of cogent, recent evaluations demonstrate. Evaluation is already proving an indispensable practical tool for raising the quality of health care, and for advancing professional nursing standards. Nonetheless, there is room for further improvement. Neglected areas of nursing should be brought under the spotlight of evaluation, conceptual and methodological rigour should be strengthened, and training in research skills should be extended.
Introduction
According to Striven (1991) the primary origins of modern evaluation research are to be found in the wave of large-scale educational programmes funded by governmentsparticularly in the U.S.A.-during the 1960s. Evaluation of these huge public investments was required by law. Naturally enough, evaluation flourished. In the years since then, evaluation has spread rapidly from education into other fields, including not least health care. It has expanded into a large-scale discipline in its own right (Patton, 1982). From the beginning of this process of rapid development of evaluation, applications in health care have played a significant part. More recently health care world-wide has become a major arena of systematic evaluation research. This was reflected by the 231
232
D. .\I.4 RSLAiVD
A,VD C. GISSA.1%
publication in 1981 of the WHO’s influential “Health Programme Evaluation: Guiding Principles” (WHO, 1981). While the WHO’s guiding principles were inevitably couched at a broad and programmatic level, they did draw explicitly and intelligently on the developing general literature and practice of evaluation. In particular they served to direct health care evaluation wisely and well by their emphasis on the importance of: Systematic information. Valid indicators and well-founded criteria. The distinctions between relevance, adequacy, impact.
progress, efficiency, effectiveness, and
In Britain, concern with evaluation in health care has come increasingly to the fore since the beginning of the 1980s (see for example Jenkins, 1991). For several distinct reasons it seems likely to increase further in coming years: The current far-reaching reforms of health care, with their emphasis on consumer satisfaction and their radical re-organization of management and delivery. The current rapid rate of technological, pharmacological, and therapeutic innovation in health care. The current evident increase in the population’s interest in health matters, including diet, fitness, and alternative medicine. The increasing costs of health care, and the consequent problems of determining priorities and auditing for efficiency. Each of these four influences is a source of continuing pressure for increased and more effective evaluation in the nursing sphere specifically, as well as in health care as a whole. For example, we may expect more consumer satisfaction studies of patients’ reactions to the technical and human relations performance of nurses; further use of evaluation research as a systematic source of adjudication between different modes of organizing nursing teams; carefully designed studies of the nurse’s public image in the context of a wider market of health care providers; and widespread investigation of the costs and benefits of utilizing nursing personnel where cheaper and less skilled health care workers might serve. Over and above the effect of these four influences, the current phase of rapid development in the nursing role and nurse education is increasing pressure for evaluation still further. In the hospitals and in the community alike, the work of nurses is being radically transformed, with new tasks, new responsibilities, and new modes of organization being introduced year by year. Project 2000 is revolutionizing initial training. New programmes providing joint training for hitherto entirely specialized community nurses are being established. Bachelors and Masters courses in Nursing Studies and in specialist nursing fields are multiplying. All of these exciting developments in nursing and in nurse education require systematic evaluation. State of the
art
As of 1992, considerable progress is already being made on the lengthy evaluation agenda established by the contemporary revolution in health care as a totality and in nursing specifically.
EVAL fJAT1O.V: PURPOSES,
ACHIEVEMENTS
A.vD
OPPORTUNITIES
233
Progress is certainly less well advanced in Britain than in the U.S.A., where evaluation research is an altogether bigger, better funded, and more confident enterprise (Harman, 1987). Nonetheless, a considerable body of high quality evaluation research on nursing has been and is being undertaken. Some examples are to be found in the articles in this special issue of the International Journal of Nursing Studies. Much else besides would need to be included in any comprehensive, systematic account: for example the high quality evaluation of many aspects of nursing either completed or under way in the growing Centres of Nursing Research and in the expanding Departments of Nursing Studies and Health Studies in universities, colleges, and medical schools right across Britain. If achievements in the evaluation of nursing are considerable, there are also evident limitations and inadequacies. For example: Is there enough evaluation research under way ? Is evaluation perhaps too much concentrated on the more fashionable areas of nursing, and especially on nurse education? Are less popular services such as mental health care and care of the elderly perhaps also Cinderellas as far as evaluation is concerned? Are there sufficient large-scale evaluation studies under way? How much danger is there that incorrect lessons may be learned from a multiplicity of small-scale investigations? Can we be confident that the strongest and most appropriate research designs are being used? Perhaps there are too many one-shot case studies, and too few investigations designed longitudinally or in such a way as to incorporate relevant, considered comparisons? How adequate is the quality of the information, indicators, and data in nursing evaluation studies? Is sufficient attention being paid to the rules of measurement? Is nursing evaluation as tough as it should be? Are the criteria adopted for success and effectiveness pitched sufficiently critically to identify real weaknesses? How adequately are evaluation researchers succeeding in winning the enthusiastic backing of the nurses and other health care personnel in the systems evaluated? How far are they enabled to believe that evaluation belongs to them rather than to “expert outsiders”? How often and how adequately are the lessons learned from evaluation research implemented in improved practice? Is attention to ethical issues -which are peculiarly serious in evaluation research-adequate? How well are operational and research personnel in nursing being trained in the specific methodologies and skills of evaluation research? In the next section we turn to a brief consideration in more concrete terms of achievements in nursing evaluation and of opportunities for improvement. Achievements and opportunities The crucial benchmarks of excellence in evaluation seem to be as follows: Clarity and significance of objectives. Adequacy of scale. Appropriacy and power of research design. Adequacy of data quality. Effectiveness of data analysis. Relevance and force of criteria. Self-discipline and plausibility of interpretation. Indications for implementation.
23-I
D. MA RSLAND
AVD
C. GISSA:VE
Of many recent important studies, we have chosen two to illustrate successful achievement and opportunities for improvement in nursing evaluation. Characteristic of the best recent evaluation research is MacGuire’s study of the impact of primary nursing on the quality of care for the elderly (Mac&ire, 1991). It is modestly focused on assessing the effectiveness of Senior Monitor as a tool for evaluating changes in the quality of care. It is designed carefully to incorporate relevant comparisons and crucially, measures of change over time. Data collection and analysis are careful and thorough. The author’s conclusions are in the modestly cautious vein appropriate to any evaluation research: “It would appearthat where wards are closely matched in terms of size, patient population, acuity, staffing level, skill mix and support services, the very process of being assessed is a powerful incentive to improve practice. Commensurate improvement in the quality of care as a result of such re-appraisal may be achieved
irrespective
of whether
the ward is organized
along primary
nursing lines”.
While this may appear disappointing to some, it exemplifies admirably the modest but secure steps by which evaluation research can assist practice. It illustrates perfectly the extent to which any such advance presupposes careful conceptualization, accurate measurement, sophisticated research design, and systematic analysis. A similarly important and interesting, if perhaps less sophisticated, example of the best recent nursing evaluation research is provided by Whelan’s (1988) study of the impact of management styles on quality of care. The management styles of Sisters on 16 oncology wards were empirically classified in terms of the three dimensions of socio-emotional orientations, task orientations, and patterns of decision making. Quality of care was assessed, less than adequately in the author’s own admission, in terms of nurses’ confidential ratings. Measurement, design and analysis were for the most part appropriately complex and thorough, allowing effectively for the partialling out of confounding influences other than management style. Overall, the study seems to suggest that management styles do substantially affect, or at least are significantly correlated with, quality of care. In particular, variations in ward sisters’ socio-emotional orientations and task orientations (but not, interestingly, in the democratism of their decision making) are apparently associated with significant quality differences. The study thus lays the basis for larger-scale and more precise investigations of a potentially key influence on the delivery of quality care-front-line leadership. Both the strengths and the scope for improvement in studies such as these by Mac&ire and by Whelan are graphically and persuasively indicated in Thomas and Bond’s important 1991 review of research on the effectiveness of primary nursing (Thomas and Bond, 1991). The authors argue, on the basis of careful examination of most of the recent published research, that more powerful research designs are required. Even more importantly, they conclude that more precise conceptualization of such “global concepts” as “primary nursing” (and, one might add: “management style”), including tight operational definitions, is essential. If we are to avoid the unsatisfactory situation identified by Thomas and Bond in the area of primary nursing-“The vast majority of studies are flawed . . . findings have little validity and cannot be generalized”, their rigorous methodological challenge will need to be addressed positively.
EVALUATION:
PURPOSES,
ACHIEC’EzbfENTS
A.VD OPPORTUNITIES
235
It will not be adequate simply to move investigations onto a larger scale than the-in this respect typical-studies by MacGuire and Whelan. It will not be enough to attend to problems in measurement (as by Whelan) or even to efforts at improving its precision (as by Mac&tire), valuable though the best endeavours in this direction are (Harrison, 1991). Nor, of themselves, will improvements in design or in analysis ensure that the problems identified by Thomas and Bond are addressed adequately (Miller, 1991). Only rigorous conceptual analysis, clarity of operational definitions, and precise specification of research objectives can clear the way for reliable, determinate findings in evaluation, such that implementation of improvements to practice become feasible.
Towards a balanced,
realistic programme
of nursing evaluation
On the other hand, where evaluation is underdeveloped, as it clearly still is in nursing (and indeed in health care generally), we probably have to take some risks which are not fully justified in methodological terms. For example, the important study of general management in the NHS carried out recently by Pollitt and his colleagues (Pollitt et al., 1991; Harrison et al., 1989) might be accused of dealing in just the sort of “global concepts” against which Thomas and Bond’s magisterial warning is directed. No doubt the complex of structures and processes encompassed by the concept of “general management” needs careful unpacking if its effects are to be assessed precisely and authentically. In the meantime, however, Pollitt and Harrison have at least taken the issue beyond the realm of mere conjecture, and provided a valuable basis for further, more adequate studies. Thus, before the rigorous standards quite properly demanded by Thomas and Bond can be achieved, before even the less ambitious principles set out earlier in this paper can be insisted on, there are many areas of nursing-where evaluation has scarcely begun at allwhich should be attended to modestly rather than not at all. For example, as relatively recently as 1984, Long and Wilkinson were still busily enunciating a theoretical framework to provide the basis, the merest conceptual infrastructure, for evaluation in occupational health nursing (Long and Wilkinson, 1984). There, as in many other fields of nursing, evaluation research is still in its infancy. Achievements to-date in nursing evaluation are considerable. The methodological route towards upgrading its quality are well established. In our judgement, the period up to the year 2000 should see:
Neglected fields brought firmly Training in evaluation research All nursing evaluation brought insistence on theoretical clarity
under the spotlight skills substantially up to and beyond and methodological
of evaluation. strengthened. the highest current standards by rigour.
References Harman. J. et al. (1987). Progratn Evaluarion Kir. Sage. Harrison, A. (1991). Assessing patients’ pain: identifying reasons for error. J. Adv. Nun. 16, 1018-1025. Harrison, S. er al. (1989). General Monagetnenr in the National Health Service. Nuffield Institute Report Number 2. Jenkins. R. (1991). Outcome indicators of mental health. In fndicotorsfor.Clentol He&h (Jenkins, R. and Griffiths. S.. Eds). Department of Health, HMSO. Long, R. J. and Wilkinson, W. E. (1984). A theoretical framework for occupational health program evaluation. Occupa!. Hlrh Nurs.. May.
236
D. MARSLAND
AND C. GISSA.VE
%lacGuire, J. (1991). Quality of care assessed: using the senior monitor index in 3 wards for the elderly before and after a change to primary nursing. J. Adv. 12iurs. 16. 51 l-520. Miller, D. C. (1991). Handbook of Research Design and Social Measurement (5th edn) Sage. Patton, M. Q. (1982). Practical Evaluation. Sage. Pollitt, C. (1991). General management in the NHS: the initial impact. Public Administrafion 69. Striven. M. (1991). T/theEvaluation Thesaurus. Sage. Thomas, L. H. and Bond, S. (1991). Outcomes of nursing care: the case of primary nursing. Int. J. Nurs. Stud. 28, 291-314.
Whelan, J. (1988). Ward Sisters’ management styles and their effects on nurses’ perceptions of quality of care. J. Adv. Nurs. 13. 125-138. WHO (1981). Healfh Programme Evaluation: Guiding Principles. World Health Organization.
