Research on the Quality of Abdominal Surgical Nursing Care: A Scoping Review

characteristics, patients’ characteristics, nurses’ characteristics, nursing care needs, and nursing documentation. Further research should be focused on the measurement and evaluation of the quality of abdominal surgical nursing care from nurses’, patients’ and their relatives’ perceptions by using nonexperimental and experimental study designs for gaining the knowledge how to improve the quality in practice.


Introduction
According to statistics of different countries, the number of patients in need of abdominal surgery has increased during the last 10 years, leading to higher rates of these surgical procedures (1,2). Abdominal surgical procedure is one of the most common surgical procedures in Europe and the United States (1,3). In Lithuania, abdominal surgery ranked second among all surgical procedures in 2009 (1226 procedures per 100 000 population), following surgeries of the musculoskeletal system (1463 procedures per 100 000 population) (4). Because so many patients need abdominal surgery, it is important to measure and improve the quality of abdominal surgical nursing care in order to achieve high-quality health services, to shorten patient hospitalization period, and to have economically more effective health care system.
Abdominal surgery (major and minimally invasive) is a conceptually unique health intervention due to the signifi cant risk of death, the likelihood of pain and other distressing symptoms, the possibility of disability, and the planned nature of procedure (5). It is vitally important that a nurse who takes care of a patient preoperatively, intraoperatively, and postoperatively 24 hours per day could provide him/her with high-quality nursing care. The quality of surgical nursing care around the world depends on skills and knowledge of surgical nurses. They usually have specifi c expertise in a specialty service (6). As a large number of nurses are involved in this area, it is economically important to have a highly skilled professional (7).
Various defi nitions of the quality of health care have been proposed from different perspectiveshealth care providers and customers -over the years (7)(8)(9)(10)(11). Several studies related to the quality of health care have been focused particularly on patient satisfaction (10). Patient-perceived quality has been reported to be a subjective, dynamic patient perception of the extent to which expected health care is received (11). High-quality care is the right of all patients and the responsibility of all nurses (12) and could be defi ned as care that is provided according to hospital standards and job requirements (13).
The measurement and improvement of the quality of nursing care is a process, when the attitudes of all health care providers (nurses, physicians, other specialists), patients and their relatives are impor-tant (14)(15)(16)(17)(18). It is a core concern for health care providers and consumers (19). Various health care measures have been identifi ed as indicators of the quality of health care over the years (20). However, studies evaluating the quality of nursing care among different patient groups are scarce (21,22). Patients undergoing abdominal surgery may be a group that has different views, needs, expectations, and evaluation of the quality of nursing care.
This scoping review focused on the quality of abdominal surgical nursing care from patients' and nurses' perceptions and factors related to the quality of nursing care. The aim of this article was to analyze the methodological characteristics and main fi ndings of studies in the fi eld of the quality of abdominal surgical nursing care with the ultimate goal to gain the knowledge about the quality of abdominal surgical nursing care for developing recommendations for further nursing research, education, and practice and for improvement of the quality in practice.
The following research questions will be responded: "What are the methodological characteristics of studies?" and "What are the main fi ndings of studies?"

Material and Methods
Methods. Data collection procedures included literature search in the MEDLINE (Ovid), PsycInfo (Ovid), CINAHL, and Cochrane databases using the following key words in various combinations: quality of nursing, surgical or perioperative, abdominal or abdomen. These databases were selected because of their comprehensiveness (23)(24)(25). Studies addressed to research questions were included if they met the following inclusion criteria: human studies, published in electronic format (on-line), focused on the quality of abdominal surgical nursing care or on the quality of surgical nursing care including abdominal surgical nursing care, peer-reviewed, written in English ( Fig.).
Screening. A total of 161 articles were screened based on their titles ( Fig.). In this scoping literature review, analysis was carried out on a fi nal sample of 17 articles, which were obtained in full text. The exclusion and inclusion criteria were not based on the quality of the studies, but on relevance (26,27). The data were extracted onto a standardized form. All data from the included studies were charted, and themes and key issues were identifi ed.  The analyzed studies (n=17) were conducted in different countries from three continents (Table 1)

Methodological Characteristics of the Studies
Aims of the Studies. The aims of the studies included were classifi ed by their content analysis into the main 5 categories ( Table 2). The most common aim of studies was to analyze the quality of nursing care in association with patient outcomes (28)(29)(30)(31)(32)(33)(34).
Other studies aimed to describe the quality of nursing care from patients' or/and nurses' perspective and/or to compare their perceptions (11,16,19,(35)(36)(37). The studies aiming to develop specifi c instruments for the evaluation of the quality of care (18,38) or to develop and evaluate the special preceptorship programs (39) as well as studies focusing on the measurement of quality indicators were analyzed (40).
Study Design. Frequently, a nonexperimental design was used by authors in their studies (Table 1).
One study was carried out by using a quasi-experimental design (39); all other used a descriptive design (41). A secondary analysis of the data, which were collected earlier, was carried out in two studies (31,34). Three studies were carried out by using a cross-sectional design (28,32,33). The descriptive correlational design was used in two studies (30,40) as well as comparative design in fi ve studies (16,19,31,32,34).
Sample. The analyzed studies enrolled patients and nurses (Table 1). A total of 6836 patients were involved in 12 studies (mean, 570; range, 96-1470); the total sample of nurses from 11 studies was 32 011 (mean, 2910; range, 24-10 319). The study population comprised both nurses and patients in 7 studies (16,18,19,32,36,37,40). The sample of patients comprised medical-surgical patients including patients after abdominal surgery. The staff nurses were recruited in 11 studies with nurse managers in two of them. The authors also explored inpatient medical records and daily staffi ng data (29,40).
Instruments. Various instruments were employed to measure the quality of nursing care in the studies (Table 1). In this review, the instruments can be classifi ed by three criteria: 1) patient perceptions of the quality of nursing care were evaluated using the scales measuring patient satisfaction; 2) scales based on the conceptualization of care quality from nurses' perspectives; and 3) scales developed with some patient input. A structured questionnaire, developed earlier and modifi ed for a particular study, as an instrument was frequently used (n=13). More than one questionnaire was used in 10 studies. The instruments developed for that particular study were applied in 9 studies (n=9). Interview (n=1) and medical records (n=1) were other data collection methods used in the studies. The indicators of nursing care quality, developed by the American Nurses Association, were evaluated in two studies. Some instruments for the measurement of the quality of nursing care were used more than in one study: the Good Nursing Care Scale (GNCS, Leino-Kilpi, 1990; Leino-Kilpi and Vuorenheimo, 1994 [9,42]) was used in three studies; Patient's Assessment of Quality Scale -Acute Care Version (PAQS-ACV, Lynn and McMillen, 1999 [37]) was used in three studies as well; and the Maslach Burnout Inventory (Maslach, 1986) as an additional instrument was used in two studies.
Data Analysis. Data analysis (Table 1) included descriptive statistics (n=16), correlational analysis (n=11), and combinations of more than 2 statistical data analysis methods (n=9). The inductive content analysis was conducted as well (11). The reliability and validity of instruments were evaluated in the studies (n=13) by using the Cronbach alpha coeffi cient, validity methods, and content validity index (CVI).
Level of the Quality of Nursing Care. The quality of nursing care, evaluating it from patients' and/ or nurses' viewpoint, was rated as high in 11 studies (Table 3). However, in the study by Aiken et al. (28), the quality of nursing care was assessed as fair/poor by one-third of nurses, and 40% of them reported that the quality of care in their hospital deteriorated during the past year. Furthermore, nurses were more critical in the assessment of the quality than patients (16,37), but not in the study by Zhao et al. (19) and Al-Kandari and Ogundeyin (36). To investigate patient outcomes in relation to selected patient characteristics, patient care processes of perceived nursing care quality, and coordination of care

Discussion
The research in the area of the quality of abdominal surgical nursing care is limited. There are no studies with a special focus on the quality of abdominal surgical nursing care as well as literature reviews. It is a new scoping review in the fi eld of the quality of medical-surgical nursing care with the focus on the quality of abdominal surgical nursing care. The fi ndings may be useful for nursing research, nursing education, and nursing practice with implications for nursing management.
Methodological Characteristics of the Studies. The studies included in this review analyzed different aspects of the quality of nursing care involving patients who undergo abdominal surgery, but no studies investigating characteristic features of the quality of abdominal surgical nursing care were found. Various methods for quality measurement were used in studies such as Leinonen et al. (43), and sometimes not all methodological issues were clear for identification and synthesis.
The quality of nursing care in the analyzed studies was evaluated from patients' and/or nurses' perspectives. Patients are frequently chosen as participants probably because of the importance of their opinion and the interrelationship between patient satisfaction with health care and treatment outcome as mentioned in earlier studies (10,19,38,43,44). Gunther and Alligood (14) proposed that the nursing profession has been unable to articulate clearly what comprises high-quality nursing care because we have been defi ning it as a product viewed from the patient's perspective rather than a service offered by the profession.
There are no instruments developed and psychometrically assessed for the measurement of the quality of abdominal surgical nursing care. However, the combination of some instruments could be useful for the measurements of the quality of nursing care in this area (43) including cognitive/technical and affective/interpersonal aspects of nursing quality (22). According to Radwin et al. (21), the instruments for the measurement of the quality of nursing care could be classifi ed by three criteria: patients' perceptions of the quality of nursing care were measured using patient satisfaction scales (29,39,40), scales based on the conceptualization of care quality from nurses' perspectives, and scales developed with some patient input (16,18,32,37). The evaluation of the quality of abdominal surgical nursing care requires high-quality instruments, preferably with some interventions in order to have a broader view of quality. The statistical data analysis, carried out almost in all studies, provides the capability to process large samples as easy as small ones, especially when questionnaires are used. Nurse researchers have applied the newest statistical data analysis methods and presented the reliability and validity of used tools.
Main Findings of the Studies. The evaluation of the quality of health care from three aspectsstructure, process, and outcomes -suggested by Donabedian (8) is still helpful to defi ne the quality. However, the Donabedian's model focuses on health care, not nursing care; his defi nition of the quality of care that individual practitioners provide care to individual patients was useful in defi ning the quality of nursing care at individual versus organizational level (22). Patient outcome is more preferable in the studies on nursing quality from patients' perspectives usually based on patient satisfaction with nursing care, although nursing processes and activities are the key elements in the studies evaluating nursing quality from nurses' perspectives (14). The components of quality such as environment, individualized care of a patient, patient safety (45), and cooperation with relatives are important for defi ning the quality of nursing care from both patients' and nurses' perspectives. The defi nition of the quality of nursing care is not constant and tends to change depending on many factors such as time, place, perspective, etc. The meaning of quality as it pertains to nursing remains elusive because the frameworks used to defi ne the concept and develop theories emerge from the perspective of people other than those in the nursing profession (14).
There is a lack of studies that measured the level of the quality of abdominal surgical nursing care. However, it is becoming more and more important to ensure and maintain a high level of quality in nursing care as economic pressure is increasing and personnel is being reduced, and the need for the assessment of the quality of nursing in abdominal surgical area is obvious. Usually, patient-oriented nursing care is associated with high-quality nursing care (46). However, the quality of nursing care cannot be evaluated only from patients' perspective as mentioned previously (14)(15)(16)(17)19); nurses must be involved in this process. High-quality nursing care entails the use of nursing knowledge, and nursing knowledge resides in the discipline's published conceptual models and theories (14).
There is a need to explore the factors that may infl uence the quality of abdominal surgical nursing care. Patients' variables such as age, gender, education, marital status, previous experience of surgery, etc. should be taken into consideration. For example, younger patients tend to be more critical in their evaluation probably because of higher levels of knowledge and less practical experience. It is critically important that surgical nurses would be able to identify patients' informational needs and fi nd ways to meet these needs especially with the aging population, new/advanced surgical procedures, vulnerability/poverty, and literacy level of patients (47). Nurse managers and educators should pay attention to the relationship between the quality of abdominal surgical nursing care and nurse staffi ng, nursing documentation, and unmet nursing care needs. Several studies (29,32,34) have shown that a nurse who has enough time to take care of a patient, to complete the adequate documentation, and to perform other activities such as an update of nursing care plans, teaching of patients and family, which are important, but usually left unfi nished because of lack of time, can provide high-quality nursing care.
Limitations. The search of articles was limited because of the electronic access only to the latest publications. It is possible that several relevant studies published earlier in paper format were left inaccessible and were not included in this scoping review. The literature review encompassed the references selected by searching in four databases using the explode commands; therefore, not all relevant studies were included in this review. However, the chosen databases are most comprehensive and useful for nurse researchers as mentioned previously (23)(24)(25). The description of the quality of nursing care in this review is oriented to specifi c aspects of abdominal surgery; however, as empirical research on this topic is limited, the quality of nursing care is described in general as it was reported in studies. Inductive content analysis provides a broad picture of the content of the studies, although the used methods do not necessarily capture all possible contents and details.
Future Directions of Research. Future research in the area of abdominal surgical nursing care needs to provide more information on the quality of nursing care. In particular, more information on the effectiveness of methods to evaluate and improve the quality of abdominal nursing care and the establishment of the roles of nurses, patients and their relatives in this process is needed. The quality of abdominal surgical nursing care should be systematically and constantly evaluated, measured, and monitored from patients' and nurses' perspectives by using various methods and complex interventions.

Conclusions
Many references dealing with the quality of nursing care were found. However, there is a lack of studies that aimed to highlight specifi c aspects of the quality of abdominal surgical nursing care. The quality of abdominal surgical nursing care is an important aspect for nursing theory and practice development, patients' satisfaction, and nurses' job satisfaction as well as for nurse managers/administrators and other health care providers who are interested in improving the quality of health care and economic situation.
Nursing educators should include the subjects, refl ecting characteristic features of abdominal surgical nursing care, in nursing programs in order to improve the quality of nursing care and nurse competence. Further research on nursing should be focused on the measurement and evaluation of the quality of abdominal surgical nursing care from nurses', patients' and their relatives' perspectives by using nonexperimental and experimental study designs for gaining the knowledge how to improve the quality and what economic, social, and well-being benefi t may be obtained.