Comparisons of the cost-effectiveness among hospital chronic care, nursing home placement, home nursing care and family care for severe stroke patients

AIM: This study compared the cost and effectiveness of long-term institutional care and home care for stroke patients with severe physical disabilities. BACKGROUND: Whether home care is more economical or effective than institutional care for patients with chronic illnesses remains controversial when the cost of family labour is considered. Thus, decisions concerning the appropriate type of care setting for patients with severe chronic illness remain difficult. METHODS: From November 1995 to March 1996, 313 hospitalized stroke patients with severe physical disabilities treated at one of five hospitals in the Taipei metropolitan area were followed from the day of hospital discharge until the third month after discharge. These 313 patients were divided into four groups as follows: (1) 106 who were admitted to a chronic care unit in a hospital, (2) 60 who were admitted to nursing homes, (3) 60 who received professional home nursing care and (4) 87 who returned home without receiving professional care. The change of physical functional status in the patient was examined as the difference between activities of daily living (ADL) scores measured at discharge and at the end of the third month after discharge. RESULTS: Information on family costs for caregiving, including pay for long-term services utilized, labour costs for caregiving and out-of-pocket expenditures for miscellaneous materials was obtained during a weekly telephone interview. The results indicated that caring for patients in their own homes was not only more expensive but was also less effective in improving ADL scores than caring for patients in nursing homes and in chronic care units of hospitals. CONCLUSIONS: The results suggest that caring for patients with severe physical disabilities in institutions is more appropriate than caring of them at home.     

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.     

Ageing,care dependency,and care for older people in Egypt: a review of the literature

Aims. The purpose of this study was to gain an overview of the current situation of ageing and elderly care in Egypt and to consider the ensuing socio‐economical problems, which provide the framework for the provision of care. Background. Recent discussions about demographic transition in developing countries suggest a change in their age group composition. Possible implications of this development for nursing care require closer examination. Method. Literature about ageing and elderly care in Egypt of the period from 1980–2004 was researched and reviewed. Results. Despite the scarcity of literature and the lack of precision in many cases, it is possible to outline an overall development. Ageing is a slowly emerging phenomenon in Egypt contributing to a change in the country's age group composition. The ensuing care dependency appears to become a problem especially for lower and middle class members due to economical restrictions and life‐style changes. In relation to the need, there is a shortage of care‐providing institutions. Furthermore, geriatric homes seem to differ in their quality according to the residents’ social status. Conclusion. The existing types of geriatric homes will serve as prototypes for future development. There is however, a need for additional homecare services to reduce care givers’ strain in the families.     

Health, economic evaluation, and critical care

In the past 2 decades, societal spending on health care has become an international concern. The United States currently spends more than 1.6 trillion dollars per year on health care--approximately 15% of the gross domestic product. The provision of care to critically ill patients accounts for a disproportionate share of these health care dollars--approximately 13% of hospital costs, 4% of national health expenditures, and 0.5% to 1% of the gross domestic product. This enormous investment necessitates careful evaluation of our interventions and their associated expense. Economic evaluation can aid policy makers and health care professionals in comparing the relative and incremental value of disparate and expensive therapies and also inform decisions about which interventions provide good value for the health care dollar. In this review, we will highlight landmark publications over the past decades that have helped to shape the field of economic evaluations for critical care medicine.     

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.     

Staff experiences,perceptions of care,and communication in the intensive care unit during the COVID-19 pandemic in Australia

BackgroundIn 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission.AimThe aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale.MethodsThis was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis.FindingsFour major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods.ConclusionThe results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.     

Family participation in essential care activities: Needs,perceptions, preferences,and capacities of intensive care unit patients,relatives, and healthcare providers—An integrative review

BackgroundFamily participation in essential care activities may benefit both patients and relatives.ObjectivesIn this integrative review, we aimed to identify needs, perceptions, preferences, and capacities regarding family participation in essential care in intensive care units (ICUs) from the patient's, relatives', and ICU healthcare providers' perspective.Review method usedAn integrative review method was used.Data sourcesPubMed, CINAHL, EMBASE, MEDLINE, Cochrane, Web of Science, and reference lists of included articles were searched, from inception to January 25, 2021.Review methodsWe included studies on family participation in essential care activities during ICU stay which reported associated needs, perceptions, preferences and capacities. Quality assessment was performed with the Kmet Standard Quality Assessment Criteria developed for evaluating primary research papers in a variety of fields, and an extensive qualitative thematic analysis was performed on the results.ResultsTwenty-seven studies were included. Quality scores varied from 0.45 to 0.95 (range: 0–1). Patients’ needs, perceptions, preferences, and capacities are largely unknown. Identified themes on needs and perceptions were relatives' desire to help the patient, a mostly positive attitude among all involved, stress regarding patient safety, perceived beneficial effects, relatives feeling in control—ICU healthcare providers' concerns about loss of control. Preferences for potential essential care activities vary. Relatives want an invitation and support from ICU healthcare providers. Themes regarding capacities were knowledge, skills, education and training, and organisational conditions.ConclusionsImplementation of family participation in essential care requires education and training of relatives and ICU healthcare providers to address safety and quality of care concerns, though most studies lack further specification.     

无缝隙护理在优质护理服务中的应用

目的 探讨无缝隙护理在优质护理服务中的应用,旨在为患者提供更人性化的护理,进而提高患者的满意度.方法 通过弹性排班,实行对患者包干到人的工作制度,加强护理的责任心,提高工作积极性.结果患者满意度较改革前提高8.2%,护理工作质量明显提高,护患关系更加和谐.结论 开展无缝隙护理是提供优质护理服务的重要手段,强调以患者为中心的整体护理理念,提高护理服务质量,提升医院的核心竞争力.     

Missed nursing care in the critical care unit,before and during the COVID-19 pandemic: A comparative cross-sectional study

ObjectivesTo describe and evaluate reported missed nursing care in the critical care context during different phases of the COVID-19 pandemic in Sweden.Research methodologyA comparative cross-sectional design was used, comparing missed nursing care in three samples: before the COVID-19 pandemic in 2019, during the second wave of the pandemic in spring 2020, and during the third wave of the pandemic in fall 2021.SettingThe study was conducted at critical care units at a university hospital, Sweden.Main outcome measuresThe MISSCARE Survey-Swedish version was used to collect data along with two study-specific questions concerning perception of patient safety and quality of care.ResultsSignificantly more overtime hours and number of days absent due to illness were reported during the pandemic. The nurse/patient ratio was above the recommended level at all data collection time points. Most missed nursing care was reported in items concerning basic care. The most reported reasons for missed nursing care in all samples concerned inadequate staffing, urgent situations, and a rise in patient volume. Most nurses in all samples perceived the level of patient safety and quality of care as good, and the majority had no intention to leave their current position.ConclusionThe pandemic had a great impact on the critical care workforce but few elements of missed nursing care were affected. To measure and use missed nursing care as a quality indicator could be valuable for nursing managers, to inform them and improve their ability to meet changes in patient needs with different workforce approaches in critical care settings.     

Quality of care: the need for medical, contextual and policy evidence in primary care

The increasing availability of medical evidence in clinical practice was expected to improve the quality of care. However, this has not been realized. A possible explanation is that quality of care is a complex concept and needs a wider scope. Starting from the Donabedian triangle of structure, process and outcome, a framework for the analysis of quality of care is presented. The need for three types of evidence is identified and discussed: medical, contextual and policy evidence. Although the body of medical evidence is increasing, it has major flaws and gaps hampering its applicability in primary care. There is also a need to focus on the context of the medical encounter, which has been shown to influence outcome, but is still not well researched. Finally, evidence on costs, cost utility and equity needs to be considered. Taking these different aspects of evidence into account, an agenda for research in primary care is set. The analytical framework may provide new insights in the quest for improving quality of health care.     

Patient-centered care,nurse work environment and implicit rationing of nursing care in Swiss acute care hospitals: A cross-sectional multi-center study

BackgroundPatient-centered care is a key element of high-quality healthcare and determined by individual, structural and process factors. Patient-centered care is associated with improved patient-reported, clinical and economic outcomes. However, while hospital-level characteristics influence patient-centered care, little evidence is available on the association of patient-centered care with characteristic such as the nurse work environment or implicit rationing of nursing care.ObjectiveThe aim of this study was to describe patient-centered care in Swiss acute care hospitals and to explore the associations with nurse work environment factors and implicit rationing of nursing care.DesignThis is a sub-study of the cross-sectional multi-center “Matching Registered Nurse Services with Changing Care Demands” study.SettingWe included 123 units in 23 acute care hospitals from all three of Switzerland’s language regions.ParticipantsThe sample consisted of 2073 patients, hospitalized for at least 24 h and ≥18 years of age. From the same hospital units, 1810 registered nurses working in direct patient care were also included.MethodsPatients‘ perceptions of patient-centered care were assessed using four items from the Generic Short Patient Experiences Questionnaire. Nurses completed questionnaires assessing perceived staffing and resource adequacy, adjusted staffing, leadership ability and level of implicit rationing of nursing care. We applied a Generalized Linear Mixed Models for analysis including individual-level patient and nurse data aggregated to the unit level.ResultsPatients reported high levels of patient-centered care: 90% easily understood nurses, 91% felt the treatment and care were adapted for their situation, 82% received sufficient information, and 70% felt involved in treatment and care decisions. Higher staffing and resource adequacy was associated with higher levels of patient-centered care, e.g., sufficient information (β 0.638 [95%-CI: 0.30–0.98]). Higher leadership ratings were associated with sufficient information (β 0.403 [95%-CI: 0.03–0.77) and adapted treatment and care (β 0.462 [95%-CI: 0.04–0.88]). Furthermore, higher levels of implicit rationing of nursing care were associated with lower levels of patient-centered care, e.g., adapted treatment and care (β −0.912 [95%-CI: −1.50–0.33]).ConclusionOur study shows a negative association between implicit rationing of nursing care and patient-centered care: i.e.the lower the level of implicit rationing of nursing care, the better patients understood nurses, felt sufficiently informed and recognized that they were receiving highly individualized treatment. To improve patient-centered care, the nurse work environment and the level of implicit rationing of nursing care should be taken into consideration.     

Knowledge,facilitators and barriers to the practice of person-centred care in aged care workers: a qualitative study

The current study describes aged care workers' interpretation of the concept of person-centred care; and identifies the barriers that exist to impede its practice, and the facilitators that encourage person-centred care practice. Data were collected from interviews with aged care workers from two residential aged care facilities providing both high and low care for residents with and without physical and psychological issues based in Australia. Data were analysed to identify and explore categories of meaning for barriers and facilitators. Analysis is grounded in Brooker's VIPS framework for person-centred dementia care which is utilised as a comparative tool for analysing participants' understanding of person-centred care. Findings revealed that aged care workers have a reasonable but incomplete understanding of person-centred care. Insufficient time and residents' dementia behaviours acted as barriers to care workers' provision of person-centred care. Teamwork was found to facilitate person-centred care by increasing instrumental and relationship resources     

Consistency of quality assessments in long-term care by the clients, family members and named nurses

Combining assessments by the clients, their family members and named nurses of the quality of long-term care leads to a more comprehensive picture of the quality of the service. Clients should be the primary source of information, but particularly when they are not able to express their opinion, other sources of assessment are needed. This study describes and compares the consistency of quality assessments of long-term institutional care for the elderly made by the client (n = 312), his/her family member (n = 312) and the named nurse (n = 312). Data were gathered in 2002 from service houses, nursing homes and health centres. The consistency of the assessments made by the different groups of respondents was measured by frequency distributions, the weighted kappa coefficient and exact agreement. Frequency distributions differed significantly between the respondent groups in almost every item. Family members were more critical in their assessments than the other two groups. The consistency of assessments was highest with regard to the items 'contact with significant others' and 'medication'. In general the consistency of assessments, measured by weighted kappa, was rather low, but it was fair for 'clothing' (clients/family members) and 'privacy' (clients/named nurses and family members/named nurses). The occurrence of the option 'not applicable' to certain items was quite high, but varied somewhat between the three respondent groups. The results of this study support the viewpoint that comprehensive information gathering from family members and named nurses is useful, but they should not replace clients' assessments.     

Teleological care and the last years of life

The final years of life present challenges for care. In middle‐/high‐income countries, the percentage of people of advanced age in the population is growing, and the dying process continues to become more complex and protracted. We propose that a new understanding of care, ‘teleological care’, be considered as an important response to the contemporary challenges of the final years of life. Teleological care is a philosophy of care built around the root idea of a telos (i.e. end) in three senses: (1) the end of life as a temporal limit; (2) the ends of life as the individual's purpose and meaning; (3) the end of life as the meaning of life as a whole. In its practice, teleological care adheres to principles of (1) fidelity of practitioner to patient; (2) generalism of practitioners; and (3) coordination of care within existing services. With this philosophy and practice, care is administered by generalist health care professionals arranging for flow between care that attempts to reverse, stop or slow the disease process when appropriate, with care to address symptoms, and with care that responds to the difficulties of dying. Teleological care involves already existing programmes in roughly their present forms, serving as an overarching layer of organization added to the existing systems. Teleological care refocuses the concept of care to the patient's perspective with emotional, spiritual and practical support for facing the end of life, and a space for narrative and reflection within a wider circle of care.     

A comparative study of nursing staff, care recipients' and their relatives' perceptions of quality of older people care

hasson h. & arnetz j.e. (2009)   A comparative study of nursing staff, care recipients' and their relatives' perceptions of quality of older people care. International Journal of Older People Nursing   5 , 5–15
doi: 10.1111/j.1748-3743.2009.00186.x
Background.  Comparisons of different stakeholders' ratings of the quality of older people care can help to drive quality improvement.
Aim.  The aim was to compare staff, older care recipients' and their relatives' quality of care ratings.
Design.  Cross-sectional questionnaire surveys in 2003 and 2004, using a repeated measures design on an organizational level.
Methods.  Nursing staff, care recipients and relatives in two older people care organizations were included. The ratings of an overall quality grade, information, activities, general care and staff skills were compared between the respondent groups.
Results.  Care recipients in both organizations rated the overall quality grade significantly higher than nursing staff and relatives. Staff ratings of the information given to care recipients were significantly more positive than care recipients' and relatives' ratings. All three groups gave lowest ratings to the quality of activities offered to care recipients, with lowest ratings from nursing staff.
Conclusions.  Concurrent measurements of staff, care recipients and relatives' care quality perceptions can provide a broad evaluation of an organization's strength and limitations.
Relevance to clinical practice.  Staff, care recipients' and relatives' perceptions can be useful for older people care organizations and decision makers in developing care processes and outcomes of care.     

癌症病人的临终关怀与护理

简要阐明了临终关怀护理的发展及其服务机构的形式 ,综述了癌症病人临终关怀护理的重点是控制症状、给予病人及其家属心理支持 ,提出护理人员有责任开展和宣传临终关怀的意义 ,提高临终关怀的护理质量。