OLDER PEOPLE

A Qualitative study explaining nurses’ perceptions of quality care for

older people in long-term care settings in Ireland
Kathy Murphy BA, MSc, PhD NUI, RGN, RNT
Head of Nursing and Midwifery, NUI, Galway, Ireland

Submitted for publication: 21 March 2005

Accepted for publication: 4 November 2005

Correspondence: MURPHY K (2007) Journal of Clinical Nursing 16, 477–485

Kathy Murphy A qualitative study exploring nurses’ perceptions of quality care for older people in
Department of Nursing and Midwifery long-term care settings in Ireland
Aràs Moyola
Aim. The aim of this research was to explore nurses’ perceptions of the attributes of
St. Anthony’s campus
quality care and the factors that facilitate or hinder high-quality nursing care in
NUI, Galway
Ireland
long-term care.
Telephone: +0 0353914 93940 Background. The quality of care for older people living in long-term care has been
E-mail: kathy.murphy@nuigalway.ie identified as an issue of concern in many nursing research studies. While many
factors have been identified, it is difficult to determine key factors from current
research.
Method. The study was a qualitative exploration of nurses’ perceptions of quality
care for older people and the factors that facilitate or hinder quality care. It
involved 20 interviews with nurses. Respondents were asked to illustrate their
accounts with examples from practice. This phase of the research was guided by
the principles of hermeneutic phenomenology and the analysis process by Van
Manen.
Findings. The findings indicated that nurses perceived quality care for older
people in Ireland as holistic, individualized and focused on promoting inde-
pendence and choice. The research revealed, however, that care in many practice
areas was not individualized, patient choice and involvement in decision making
was limited and some areas engendered dependency. While staffing was identified
as a factor which had an impact on the provision of patient choice, other issues,
such as the motivation of staff, the role of the ward manager and the dominance
of routine were also highlighted.
Conclusion. There is a need to review organizational approaches to care, develop
patient centred approaches to care and provide educational support for manag-
ers.
Relevance to practice. This research focuses on care for older people; it helps
practitioners identify key factors in the provision of quality care for older people
living in long-term care.

Key words: factor analysis, long-term care, mixed methods, nurses perceptions of
quality, quality care

 2007 Blackwell Publishing Ltd 477

doi: 10.1111/j.1365-2702.2005.01526.x
K Murphy
Introduction
Within health care there has been a shift away from an
illness-oriented service to one that is more health focused
and person centred (An Bord Altranais 1994, Commission
on Nursing 1998, Department of Health and Children
2001). Health care documents and policies have increasingly
emphasized the need for high-quality care (McQueen 2000).
Quality is a term that is used increasingly when describing
services within health care (Attree 2001, Department of
Health and Children 2001). However, a review of the
literature revealed that there was little consensus on what
quality is and, while most authors agree that it is an
important concept, it remains, on the whole, nebulous,
diverse and lacking in specificity.
Background
The word quality is derived from the Latin word qualitas,
from qualis’ of what kind, of such a kind’. It is defined as the
degree of excellence of something as measured against other
similar things, degree or grade of excellence or a distinctive
attribute, special feature or characteristic (Oxford English
Dictionary 2004). Redfern and Norman (1990) suggested
that quality was something to strive towards, an aspiration to
be achieved. Quality is also context specific and related to
your perspective as a stakeholder (Donabedian 1990, Attree
1996, Timpson 1996, Huycke & Allen 2000, Gunther &
Alligood 2002). Timpson (1996) and Donabedian (1990)
suggested that perspectives on quality changed over time as
they were shaped by the prevailing philosophies of health
care, changing priorities within health care and the economic
and political climate.
Donabedian (1966) conceptualized quality into three
dimensions: structure, process and outcome. Structural
aspects related to the health care organization and were
required for the delivery of quality. Process aspects were
related to the process of care giving. Outcome aspects
were the outcomes you could expect if quality was delivered.
Many studies have used these three dimensions to describe
quality (Hogston 1995, Attree 1996, Langemo 1997,
Campbell et al. 2000) and provide a framework for analysis.
Some researchers have focused specifically on nurses’
perceptions of quality care (Leino-Kilpi & Vuorenheimo
1994, Hogston 1995, Williams 1998, Luker et al. 2000) and
a few have focused on nurses’ perceptions of quality in long-
term care (K.M Hudson, University of Virginia, Virginia,
unpublished results, Philp et al. 1991). Hudson (1991) found
that nurses identified: a home like atmosphere, the capacity
for residents to have personal belongings, the need for good
478  2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 477–485
clean facilities, a philosophy of care, socialization, a sup-
portive atmosphere and positive staff attitudes as important.
Hudson (1991) also found that: resources, equipment,
staffing levels, skill mix, staff education, staff retention,
personality characteristics of staff, personality characteristics
of residents, a lack of gerontological education and experi-
ence and regulations and policies within the home were
mediating factors of quality care for older people living in
long-term care.
Care of older people
Over the last 60 years there has been a fundamental change
in approaches to care for older people internationally and
within Ireland. These changes have been shaped by health
care policy about older people, international perspectives on
care for older people and changing ideologies about nursing
in general. McCormack (2003) and Davies et al. (1999)
suggest that care for older people should be person-centred
and holistic, based on autonomy, respect, choice and the
promotion of independence.
However, the evidence from many studies (Wells 1980,
Wade 1983, Waters 1994, Koch et al. 1995) is that care is
not yet person centred. Studies have consistently found that
care for older people continues to be dominated by routine
(Norton 1967, Wells 1980, Evers 1981, Waters 1994), does
not focus on the individual needs of the patient (Wade
1983, Koch et al. 1995) and engenders helplessness with
nurses doing for the patient what they could do for
themselves (Waters 1994). As numbers of older people
increase and the quality of life of older people in long-term
care is in question, it is important to examine factors that
contribute to the quality of care for older people living in
these settings.
The study
There were two aims of this study; the first was to determine
nurses’ perceptions of the attributes of quality care. The second
was to identify the factors that facilitated or hindered high-
quality nursing care for older people in long-term care settings.
Design
An across method sequential exploratory research design
was used to explore nurses’ perceptions of quality care.
The first phase was a qualitative exploration of nurses’
perceptions of quality care for older people and the factors
that facilitated or hindered quality in long-term care
settings.
Older people
Phase one approach
Phase one of the study was guided by the principles of
phenomenology as the focus was on nurses’ perceptions and
experiences of providing quality care for older people. While
this study was not phenomenology per se, the design was
influenced by phenomenological methods in three ways. First,
there was an attempt to describe phenomena as they were
experienced by nurses and to identify the similarities and
differences in the ways in which phenomena were conceptu-
alized and apprehended. Second, the subjectivity of the
researcher was recognized, prior assumptions were identified
and an attempt to identify and work with biases and use
experience was made by reflecting throughout the data
collection phase of the study. Third, the analysis steps which
were used within phase one of the study were adapted from
Van Manen (1990).
Sample selection
The study population was nurses working in long-term care
settings in a health board in Ireland. Participants had to be
a registered nurse, involved in direct care and have at least
six months experience of working with older people.
Respondents worked in one of three types of long-term
care units; Long-Stay Geriatric Hospital, Community Nur-
sing Unit or District General Hospital. Respondents were
chosen at random from Health Board lists and invited to
participate. Twenty interviews with registered nurses were
conducted; the sample was stratified as 15% of registered
nurses were managers. Of the 20 interviews, three were
with managers and 17 other registered nurses. Table 1
outlines the age range.
Data collection and analysis
Interviews were held in or near to the respondents’ work-
place. An interview guide was used, which was generated
from an examination of the literature. The questions were
broad and holistic, to allow respondents to describe their
perceptions in depth. Interviews, which were between
40 minutes and one hour, were tape recorded, transcribed
Table 1 Age range of respondents
Age range No of respondents within each age range
21–30 1
31–40 4 home (Respondent 15).
41–50 8
> 50 7
 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 477–485
Quality care for older people in long-term care settings in Ireland
and coded. Data analysis was guided by the work of Van
Manen (1990) and involved the following stages: initial
descriptive coding, interpretative coding, identification of
categories and identification of themes.
Rigour
Four criteria were used to ensure rigor: credibility, audita-
bility, confirmability and applicability. Respondents were
sent a copy of findings for their comment, an experienced
qualitative researcher reviewed transcripts and a reflective
dairy was maintained throughout the time that interviews
were conducted and data analysed.
Ethical considerations
Ethical approval for the study was sought and given by a
clinical ethics committee. Consent in writing was sought from
all participants 24 hours in advance of the interview.
Confidentiality was ensured by the removal of all identifying
material.
Findings phase one: interview findings
Three major themes were identified from an analysis of coded
data: it should be like home, striving for excellence and making
a difference. Each theme is presented in two parts, the first part
outlines nurses’ perceptions of quality care, the second, the
factors which were perceived to hinder quality care.
Theme one: it should be like home
This was a major theme raised by all respondents and it
brought together many elements within the care environment
which were considered by respondents as essential to the
creation of environments, which were relaxed, flexible and
social. Respondents suggested that making the environment
like home was not just about the structural components of
the care environment but included the interpersonal environ-
ment, the general atmosphere and the development of an
ethos of patient inclusion. Some respondents described the
ideal care environment as one that was like home from home:
It’s their home and it has to be treated as their home. But we should
make the environment as natural as possible. For them to know that,
that they’re there, not because there’s no place else for them, not
because they’re in some kind of an institution but because it’s their
Homeliness also included such things as being welcoming to
families visiting. One respondent described how her own
479
K Murphy
family were involved in creating the homely atmosphere of
her unit:
Well we try to emphasise the family – that there’s no restriction on
the family visiting, a homely environment. Even last night, I brought
my children into the unit because it was Halloween, and the first
surprise I got was a new, one of those gas fires, it was like we’d been
trying for that for so long and the next thing it was there. And they
were all there sitting around like, I’ve worked in nursing homes
where they’re sitting in rows of chairs all squashed together, and here
everybody’s laughing and joking and we’d fruit cake and you know, a
few hot whiskeys (Respondent 19).
Respondents also suggested that wearing their own clothes
gave patients a sense of identity and that having some personal
belongings helped to give a patient a sense of belonging:
I feel they settle in here and that they are happy and they do get that
sense of belonging but I don’t think it gives them a feeling of home to
home, we don’t encourage enough of personal belongings. I mean
when you consider they come in with maybe two bags and that’s their
whole life packed into that. Even if it was only to bring your chair so
they can say, ‘that is my chair’…We don’t go into that enough, I feel
we should be really (Respondent 10).
The interpersonal environment
All respondents suggested that a homely environment was
one where nurses were caring, friendly, kind and gentle.
Respondents suggested that caring included such things as
kindness, feeling for, listening, thoughtfulness and empathy:
There is the thoughtfulness, the kindness, its about caring, I mean
really caring for people. I mean just last week one patient died and
the amount of staff that wept, I mean wept openly (Respondent 19).
Respondents stressed the complexity of working with older
people and suggested that nurses could use their full range
of nursing skills in care giving. They suggested there was a
need for nurses to be positive about working with older
people.
Organisational flexibility
Most respondents linked the creation of a home-like envi-
ronment to flexibility in care giving routines, choice, ade-
quate time for care giving and good leadership. Flexibility in
care giving routines was perceived key as this offered patients
the possibility of choice about many aspects of their care,
including the time at which they got up or went back to bed.
Some respondents were very clear about the link between
quality care and choice:
Well, I think it’s (quality is) about having choices and I think it’s
about time (Respondent 16).
480  2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 477–485
Time for care giving
Many respondents raised the issue of time for care giving.
Some respondents linked time and quality directly and argued
that time was crucial in the delivery of individualized care,
ensuring emotional needs were met and in maintaining a
patient’s independence.
Good leadership
Respondents, when highlighting the need for organizational
flexibility, suggested that an ethos of choice and flexibility, in
care routines were most likely to be initiated by the ward
leader:
It has to come from the top down, like everything else. It has to be
people willing to change from the top down and then obviously every
start has its ups and downs but simple things can make such a
difference, you know like break our routine of having everybody up
at a certain time, having meals at a certain time (Respondent 10).
Staffing levels and skill mix
All respondents identified the importance of adequate staffing
levels as a prerequisite to the delivery of quality care and
creating relaxed, ‘homely’ environments.
Respondents identified two elements of staffing as import-
ant in the provision of quality care: having sufficient staff and
having the right mix of staff. Respondents suggested that it
was important in the delivery of quality care to have the right
skill mix in the team and that team members were appropri-
ately educated and focused on the care of the patient.
Structural aspects of the facilities
Respondents suggested that it was important in ‘homely
environments’ to have facilities such as a day room, a dining
area and a relative’s room. These facilities allowed patients to
socialize with other patients and created the potential for
activities to occur. Respondents highlighted many important
changes that had taken place to enhance care facilities and
suggested that these changes had made a difference:
There has been a lot invested in the line of making it brighter, making
it more cheerful, using light that kind of thing, bathroom updates,
stuff like those chair lifts for hoisting people into the bath and it does
make a huge difference, it really does, it makes a big difference
(Respondent 10).
Factors which impacted on the creation of home like
environments
Six factors were perceived to impact on ‘homely’ environ-
ments: an inability of staff to change, a lack of perceived
value in working with older people, the dominance of
Older people Quality care for older people in long-term care settings in Ireland

routine, a lack of staff, a lack of leadership and poor promote change is a big thing. But we have to change if we’re going
structural facilities. to give better quality care (Respondent 4).

While respondents articulated a need to change, they iden-

Inability of staff to change
tified a complex range of issues that made changing organ-
Many respondents suggested that there was a need to move
izational practices difficult.
away from the rigid care routines of the past to a more
flexible system driven by patient choice. Some respondents
A lack of leadership
identified an inability to change as a key barrier to quality
Many respondents suggested that good leadership was an
care:
important factor in achieving organizational flexibility.
The inability of people to change…ourselves, we’re our worst enemy Respondents, who were working in clinical units where sig-
most of the time, a lot of the time. Particularly maybe the nurses that nificant organizational changes had been implemented, sug-
have been in the profession for years, they are less willing to change gested that the ward managers’ role was crucial to the success
than we would be (Respondent 10). of these changes. Other respondents suggested, however, that
the lack of leadership had resulted in a failure to change.
Some respondents, however, while highlighting the difficul-
ties of change suggested that things were changing; however,
Lack of staff
implementing change was sometimes seen as standing against
Most respondents identified staffing as a key factor in the
the norm. Respondents were concerned that educational
provision of quality care. Respondents suggested that suffi-
opportunities had not always been available and they felt the
cient staff was necessary to deliver quality care and the lack
lack of opportunity had a negative impact upon staffs’
of staffing often limited care provision. It was evident from
motivation to change. They suggested that all staff should
many respondent accounts that they perceived that it was
have opportunities for further education.
staffing levels which dictated the time at which patients were
got up and put back to bed:
Lack of perceived value in working with older people
Some respondents were concerned that there was a percep- At 2 they’re (the patients) all started to be put back into bed.
tion that working with older people lacked value and status Sometimes patients don’t want to go to bed, but it seems to be a
within nursing and society. Some respondents suggested that routine thing, they have to go. Part of it is that that’s the best time to
others did not always view working with older people to be put them in, the other part is that nurses don’t want to leave them to
very important: the other shift, the next shift start again at 6 to 9 it’s a spilt shift.
There are only two nurses on, so the patients are put back into bed
Even to tell people you’re working in elderly care, you often can get a
(Respondent 6).
non-verbal message you know that well kind of it’s not terribly
important and I would like to think it’s very important (Respondent 5).
Poor structural facilities
Respondents therefore suggested that there was a need to Many respondents’ highlighted improvements that had been
promote working with older people positively. made over the last few years to the structural elements of
buildings; examples included new dining room facilities and
Dominance of routine, which limited choice the upgrading of bathrooms. However, some respondents also
Many respondents described inflexible care routines and an highlighted the lack of some vital facilities, which they sug-
inability within the present system to facilitate patient choice gested had an impact on the ‘homely’ environment of care:
or individualized care. They suggested that there was a need
Then lunch time comes and they have lunch by their bedside because
for radical change in the way care was conceptualized and
we don’t have a sitting rooms for them and it’s you know this is a
delivered at present and that change was crucial to a quality
hindrance to care…that they must sit and everything happens at their
focused system.
bedside, their meals, their ablutions of whatever…which isn’t correct
Many respondents described care routines, which required
(Respondent 4).
work to be done in a certain way and within a set timescale:
Respondents suggested that the lack of these facilities had an
I think what has hindered us a lot is custom and practice, what has
impact on the social dimensions of care as eating together or
always been done. And like why are you changing that I mean we
having a common dayroom were important to encouraging
always did that here and I think that’s a big problem. You know,
social interaction.
people don’t want to change, that’s a big thing. And trying to

 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 477–485 481
K Murphy
Theme two: striving for excellence
This theme brought together care processes, which were
perceived by respondents as aspects of care needed to achieve
excellence in care. Respondents suggested that excellent care
was holistic, individualized and family centred and their
accounts often recounted how they were trying to ensure that
these components were embedded into practice.
Holism
Holistic care included a focus on physical, psychological,
social and spiritual needs of patients and respondents sug-
gested that all these dimensions of care were important to
ensuring that the patients’ needs were identified and planned
for. Many respondents suggested that holistic care was an
important dimension of quality care:
Holistic care, care of the body, the mind, the soul, you know just
being totally there, for the elderly you know (Respondent 15).
Respondents also suggested that the importance of physical
care should not be underestimated as it was important to a
patients self-worth and esteem that they were clean and
physically well cared for:
For their own self worth if they are dressed properly and we are very
careful to attend to hygiene needs and with bed linen, people like to see
fresh sheet on the bed. I feel hygiene is very important (Respondent 11).
For respondents, holistic care was the kind of care all nurses
should aspire to and that which they would have liked to give
in an ideal world.
Emotional care
Many respondents singled out emotional care as a vital com-
ponent of quality care for older people. They perceived emo-
tional care to be part of holistic care but as something to be
delivered if there was time to do so. They suggested that
emotional care was crucial to older people as many were suf-
fering significant losses in their lives. Respondents suggested
that it was the talking to patients that helped make a difference:
Sometimes, just sometimes by talking to them, there are often some
patients, sometimes they’re difficult, they can be very difficult, but
you usually find with difficult patients if you sit down and talk to
them then they tend to become less sort of difficult and they start to
trust you I suppose as well (Respondent 6).
Knowing the person
Many respondents identified the need to ‘know the person’ as
an important prerequisite to emotional care. Knowing the
patient as a person enabled staff to respond to their
482  2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 477–485
individual needs and to try and bring a personal dimension to
care. Many respondents described examples of care that in-
volved doing something for a patient that was important to
them individually; an example included bringing a retired
farmer to visit his lands. The humanity and kindness of nurses
was evident throughout their accounts of care.
Individualizing care
Many respondents suggested that quality care and individu-
alized care were synonymous. Individualized care was per-
ceived as an ideal, something that you should strive for:
Individualised care, definitely. That the person would be seen as an
individual and that the person, and that her needs or his needs would
be met as an individual not in bulk like what’s good for one is good
for all, I think individualised care is the way forward (Respondent 4).
Family centred care
Many respondents perceived family centred care as an
important component of care for older people. Respondents
stated that involvement of the family was an important
dimension of care for all patients but was particularly
important when an older person was not able to participate
in decision making. Some respondents suggested that it was
important that the family were perceived as part of the care
team and that there were facilities for families to visit. Some
respondents suggested that it was important that ward ethos
was one that welcomed families and actively sought feedback
from relatives about care.
Factors, which impacted on the provision of holistic,
individualized and family centred care
This section outlines the factors which were perceived to have
an impact on the provision of holistic care. Two factors are
described: the burden of emotional care and a lack of time to
implement individualized care.
The burden of emotional care
Some respondents described caring for older people as emo-
tionally challenging and exhausting. They differentiated be-
tween care on a medical ward in which patient turn over was
high and care on a long-stay ward where patients lived. Many
respondents described the work as physically and mentally
draining. One respondent described the impact of caring for
patients day after day:
They take a lot from you; they can actually be very consuming of
everything because they become so focused on themselves because
they are in an institutionalized environment (Respondent 16).
Older people
Lack of time or staff to implement individualized care
Many respondents highlighted the link between time for
care giving and individualized care. They suggested that
the overall busyness of wards gave little time to focus
on the individual needs of patients and they suggested
that this impacted on the provision of individualized
care:
To concentrate on individual needs, which I know is concentrated on
to some extent but there often is not much time to talk to the patient
as an individual (Respondent 5).
Theme three: making a difference
This theme focused on care activities which respondents
identified as activities which helped make a difference to the
day-to-day lives of patients. All respondents emphasized the
importance of social activities in maintaining patients’
physical and mental well being. Social activities brought
laughter to people and kept them connected to the world.
Activities directed at maintaining independence ensured that
a patient’s potential was realized giving dignity and purpose
to his/her life. The provision of activities varied greatly within
different clinical areas. In some long-term care settings,
activities were very much part of the every day care, while in
others it was an added on extra, done if there was time.
Respondents suggested that activities were important in
maintaining a person’s interest in life, in stimulating the
mind and in maintaining social contact:
Activities motivate – well one patient that comes to mind – that loves
music – so you just put on a tape of Irish music and she’s absolutely in
another world and I think the other patients love it as well
(Respondent 13).
Some respondents highlighted the importance of patients
maintaining social contact with family, friends and people
outside the hospital setting and having opportunities for
social contact within clinical settings.
Respondents reported that teaching patients often
focused on re-educating patients about their activities of
daily living, in particular, washing, walking and dress-
ing and that this was an essential part of promoting
patients independence. One respondent described how she
worked with a patient to help develop his social skills
further:
He has very few social skills. I was teaching him to use the
shower, to be able to turn it on and off. I would say are you not
able to do that? And he would say ach no. A lot of teaching then,
because he is well able but he is just not able to cope with life
(Respondent 11).
 2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 477–485
Quality care for older people in long-term care settings in Ireland
Some respondents described examples of care, which had
included a co-ordinated multidisciplinary approach which
had made a real difference to a patient:
Multidisciplinary teamwork and resources
All respondents identified the importance that physiotherapy
and occupational therapy were available for patients who
required these therapies to maintain independence. They
described instances when physiotherapy and occupational
therapy had made a difference to patients.
The physiotherapist used to do an exercise class and it made
such a difference for a while. The patients were so excited to go
down into the day room. They had a big class and they were
doing these exercises and that was a lot of stimulation (Respond-
ent 6).
Factors which impacted on social activities and
maintaining independence
Two factors were identified that impacted on this theme: a
lack of multidisciplinary resources and a lack of time for
patient education and assessment.
A lack of multidisciplinary resources
All respondents highlighted that multidisciplinary therapies
were not available for patients in long-term care and
that this lack of provision impacted significantly on
maintenance or recovery of independence. Respondents
described the difficulty of accessing multidisciplinary
resources:
I suppose the multidisciplinary resources are very limited for the
patients that are here. There is physiotherapy but there is no
occupational therapist. It’s very difficult to get a speech therapist
to come in, so the supports are just not there (Respondent 6).
Multidisciplinary resources were perceived as an integral part
of helping a patient regain independence and to maintaining a
worthwhile life.
Lack of time for patient education and patient assessment
Many respondents while stating that assessing what a patient
could and could not do for themselves and patient education
were vital components of care, suggested that the pace of
work was such that it was quicker to do something for a
patient than let them do it for themselves:
We tend to take over do things for them, out of the goodness of our
heart. I suppose we are quicker and then again it gets us places a lot
faster, we get our work done quicker and it gives us time to move on
to the next thing (Respondent 10).
483
K Murphy
Discussion
Respondents in this study identified three themes relevant
to quality care, it should be like home, striving for
excellence and making a difference. There was support
within the literature for many of the elements of quality
care identified by this research. Redfern and Norman
(1999) identified the promotion of patient autonomy, good
leadership, attitudes and sensitivity and a philosophy of
individualized care as indicators of high-quality care, while
Luker et al. (2000) and Clarke et al. (2003) identified
knowing the patient as important, Attree (1996) identified
the importance of structural elements such as organization
of care, facilities, skill mix and staffing levels; Irurita
(1996) and Fosbinder (1994), the importance of interper-
sonal elements and emotional care, Williams (1998) the
need for sufficient time for care giving and Gjerberg (1995)
the need for choice.
In this study, however, respondents suggested that there
were other attributes of quality relating specifically to older
people in long-term care that were important: those that
related to making the environment like home and those
which focused on helping patients maintain an interest in
life.
Respondents’ honest accounts, however, of the extent to
which they were able to deliver quality care revealed a
divergence between what respondents felt care should be and
the actual care that was given. A lack of choice and time for
care giving, a focus on physical care and a lack of patient
inclusion in decision making were identified as problems.
Respondents suggested that routine often dominated and that
a lack of staffing was a problem. Respondents also identified
the inability of staff to change as a key issue.
Other researchers have identified resistance to change as a
key barrier to change (Curtis & White 2002, Tingle 2002).
Tingle (2002) found that the factor that was most frequently
cited as inhibiting change was a lack of receptivity of staff
who were ingrained in the old way of doing things. Curtis
and White (2002) identified stress, self-interest, denial, lack
of understanding and trust, motivation and uncertainty as
reasons why people resist change. They suggested that the
way change is introduced has a major impact on the extent of
resistance. Inclusion, participation, education and facilitation
were identified as strategies which can help facilitate change.
This was supported by Bennebroek Gravenhorst et al. (2003)
who investigated factors which hindered change and found
that resistance to change was directly linked to the manage-
ment of the change process. The education of staff, the way
organizational change is managed and the inclusion of staff in
identifying the need for change are clearly crucial.
484  2007 Blackwell Publishing Ltd, Journal of Clinical Nursing, 16, 477–485
The findings of phase one of this research and analysis of
literature were used to develop a questionnaire which was
distributed to the population of nurses working in long-term
care in one Health Board. These findings will be reported in a
statement paper.
Acknowledgements
I would like to express my appreciation and thanks to all the
nurses who participated in the interviews, pilot studies and
survey. Dr Diarmuid O Donovan who supervised the
research. I would also like to acknowledge the support and
funding provided for the research by the Nursing and
Midwifery Planning and Development Unit. Thanks also to
Ms Gloria Avalos, Ms Joan Kavanagh, Ms Adeline Cooney,
Ms Deirdre Kerans for their help during the study.
Contributions
Study design: KM; data collection and analysis: KM; manu-
script preparation: KM.
A qualitative study exploring nurses’ perceptions of quality
care for older people in long-term care settings in Ireland.
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