Relationships, trust, decision-making and quality of care in a paediatric intensive care unit

Objective  To assess the care-giving practices of health-care practitioners in the paediatric intensive care unit (PICU) through their qualitative insights, reflections and experience in participatory action research. Design and methods  Qualitative research in the form of ‘participatory action research’ was used to gather data from three sources within the unit: focus groups within disciplines, observations within the PICU, and semi-structured interviews. All staff members were active collaborators and equal stakeholders in the decision-making process, research and feedback. Setting  The paediatric intensive care unit (PICU) of the Red Cross War Memorial Children’s Hospital (RCWMCH). Participants  All staff members from various disciplines working in the PICU. Results  Staff members described problems with respect to relationships, trust and decision-making within care-giving practices. Conclusion  The study qualitatively describes how poor communication amongst staff members in respect of relationships and decision-making impacted on trust and how this tended to compromise care-giving practices in the PICU. The data suggested that this was more evident in informal rather than formal clinical decision-making procedures. The strength of the study was that the participatory action design in the research allowed staff members to address the very dynamics that they themselves cited as problematic.     

Changes in usual source of care and perceptions of health care access, quality, and use

OBJECTIVE: We sought to evaluate the extent of changes in usual source of care and associations with perceived health care access, quality, and use. RESEARCH DESIGN: We collected cross-sectional data on adults from the 1998 to 1999 Community Tracking Household Survey (n = 48,720). Linear and logistic regressions accounted for survey design and possible confounders. RESULTS: Eleven percent of respondents reported a change in usual source of care in the last 12 months; 14% reported no usual source. After adjustment, respondents with a change in usual source reported more unmet needs than those with no usual source or a continuous usual source (13%, 10%, and 7%, respectively), whereas respondents with a change in usual source or no usual source reported lower satisfaction with health care than respondents with a continuous usual source (52%, 51%, and 68%, respectively). However, respondents with a change in usual source were more likely to see a physician in the last 12 months than those with no usual source or a continuous usual source (91%, 46%, and 83%, respectively). CONCLUSIONS: Persons who experience a change in usual source of care more closely resemble persons who have no usual source in perceptions of access and quality but resemble persons who have a continuous usual source in use. Although we cannot determine whether the change in usual source caused these variations in perceived access, quality, and use, these data suggest that there are important and unrecognized differences in interactions with the health system among individuals who report a usual source of care at a single point in time.     

Opinions of families,staff, and patients about family participation in care in intensive care units

PurposeThe aims of the study were to assess opinions of caregivers, families, and patients about involvement of families in the care of intensive care unit (ICU) patients; to evaluate the prevalence of symptoms of anxiety and depression in family members; and to measure family satisfaction with care.Materials and MethodsBetween days 3 and 5, perceptions by families and ICU staff of family involvement in care were collected prospectively at a single center. Family members completed the Hospital Anxiety and Depression Scale (HADS) and a satisfaction scale (Critical Care Family Needs Inventory). Nurses recorded care provided spontaneously by families. Characteristics of patient-relative pairs (n = 101) and ICU staff (n = 45) were collected. Patients described their perceptions of family participation in care during a telephone interview, 206 ± 147 days after hospital discharge.ResultsThe numbers of patient-relative pairs for whom ICU staff reported favorable perceptions were 101 (100%) of 101 for physicians, 91 (90%) for nurses, and 95 (94%) for nursing assistants. Only 4 (3.9%) of 101 families refused participation in care. Only 14 (13.8%) of 101 families provided care spontaneously. The HADS score showed symptoms of anxiety in 58 (58.5%) of 99 and of depression in 26 (26.2%) of 99 family members. The satisfaction score was high (11.0 ± 1.25). Among patients, 34 (77.2%) of 44 had a favorable perception of family participation in care.ConclusionsFamilies and ICU staff were very supportive of family participation in care. Most patients were also favorable to care by family members.     

Nurse staffing, care delivery model, and patient care quality

Little research has been conducted examining the linkages between nurse staffing and care delivery models in relation to patient care quality. Nurses in this study perceive that an all-RN staffing model is associated with better quality outcomes for patients, and that staffing models that include professional and unregulated staff may pose a challenge for unit-based communication and the coordination of care. Patient care delivery models were also important predictors of the quality outcomes studied.     

Effects of resident-oriented care on quality of care, wellbeing and satisfaction with care

In a resident-oriented care model applied in nursing homes, the residents are assigned to primary nurses. These primary nurses are responsible for the total care of the residents assigned to them. The purpose of the present study, using a pretest, post-test and control group quasi-experimental design, was to evaluate the effects of the implementation of resident-oriented care on the following aspects of quality of care: coordination of care, instrumental aspects, expressive aspects, resident wellbeing and satisfaction with care, and family satisfaction with care. The study was carried out on somatic and psycho-geriatric wards in three nursing homes in the Netherlands. Data were collected by questionnaires, interviews and observations. The results of the study showed that the intervention was partly successful in the experimental group. Some aspects of the resident-oriented care model were not clearly evident. Moreover, the effects on quality-of-care aspects were limited. The results revealed that the 'coordination of care' increased on half of the experimental wards. Furthermore, there was an indication that 'expressive aspects' changed in favour of the experimental wards. The implementation of resident-oriented care had no effect on resident wellbeing and satisfaction or on family satisfaction. Finally, the results are discussed in the light of some methodological limitations that often go together with intervention studies in the real world.     

Agonizing care: care ethics,agonistic feminism and a political theory of care

'Care' is central to nursing theory and practice, and has been described in a variety of ways. Intense conversations about care have been developing in other fields of study as well, from the social sciences to the humanities. Care ethics has grown out of intellectual exchange between feminist thought, moral theory and the critique of traditional western political philosophy. However, care ethics is not without its critics, as these accounts of care have also sparked vigorous challenges. This paper traces the construct of care through nursing theory, care ethics, feminist critiques of moral and political theory and agonistic feminism to outline a set of problematics that a political theory of care should engage. It discusses how care is conventionally posited in more or less essentialist, universalizing and naturalizing terms. It introduces the ideas of feminist theorists who resist dichotomizing care and the political, and situate care in the context of power and politics. The tensions between care feminism and agonistic feminism are highlighted in order to explore the potential of theorizing both care and nursing in political terms.