The challenge of risk prevention in home healthcare—An interview study with nurses in municipal care

Background

Safety in home healthcare has garnered increased attention as more people are receiving care for complex conditions at home. The prerequisites for providing safe care at home differ from those in hospitals. Malnutrition, falls, pressure ulcers and inappropriate medication commonly follow poor risk assessments, causing unnecessary suffering and costs. Therefore, risk prevention in home healthcare needs to be prioritised and studied more closely.

Aim

To describe nurses' experiences of performing risk prevention in municipal home healthcare.

Methods

Qualitative inductive approach, using semi-structured interviews with 10 registered nurses in a municipality in southern Sweden. Data underwent qualitative content analysis.

Findings

The analysis resulted in three main categories and one overarching theme describing nurses' experiences of risk prevention in home healthcare. Getting everyone onboard comprises the categories: Managing safety while respecting the patient's self-determination, which covers patient participation, the strategic importance of respecting different views of risks and information and the fact that healthcare workers are guests in the patient's home. Finding ways to make it work touches upon the relational aspect, including next-of-kin and promoting a common understanding to prevent risks. Being squeezed between resources and requirements refers to ethical dilemmas, teamwork, leadership and organisational prerequisites.

Conclusion

Patient habits, living conditions and limited awareness of risks is a challenge in risk prevention in home healthcare, where patient participation plays a pivotal role. Risk prevention in home healthcare needs to be initiated at an early stage of disease and ageing and should be seen as a process where early health-promoting interventions can prevent the development and accumulation of risks over time. Long-term cross-organisational collaborations and patients' physical, mental and psychosocial conditions also need to be taken into account.     

Registered nurses’ perceptions of their professional work in nursing homes and home-based care: A focus group study

Background

In Sweden, as well as in most industrialised countries, an increasing older population is expected to create a growing demand for health care staff. Previous studies have pointed to lack of proficient medical and nursing staff specialised in geriatric care, which poses serious threats to the care of a vulnerable population. At the same time, there are studies describing elderly care as a low-status career choice, attracting neither nurses nor student nurses. Judging from previous research it was deemed important to explore how nurses in elderly care perceive their work, thus possibly provide vital knowledge that can guide nurse educators and unit managers as a means to promote a career in elderly care.

Objective

The aim of the present study was to illuminate how nurses, working in nursing homes and home-based care, perceived their professional work.

Method

This was a qualitative study using focus groups. 30 registered nurses in seven focus groups were interviewed. The participants worked in nursing homes and home-based care for the elderly in rural areas and in a larger city in southern Sweden. The interviews were analysed in line with the tradition of naturalistic inquiry.

Results

Our findings illustrate how nurses working in elderly care perceived their professional work as holistic and respectful nursing. Three categories of professional work emerged during analysis: (1) establishing long-term relationships, (2) nursing beyond technical skills, and (3) balancing independence and a sense of loneliness.

Conclusions

The findings are important as they represent positive alternatives to the somewhat prevailing view on elderly care as depressing and undemanding. Nurse educators might use the key aspects as good examples, thus influencing student nurses’ attitudes towards elderly care in a positive way. Elderly care agencies might find them helpful when recruiting and retaining nurses to a much needed area.     

Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital care: a qualitative study

Background

Patient safety culture emerges from the shared assumptions, values and norms of members of a health care organization, unit, team or other group with regard to practices that directly or indirectly influence patient safety. It has been argued that organizational culture is an amalgamation of many cultures, and that subcultures should be studied to develop a deeper understanding of an organization’s culture. The aim of this study was to explore subcultures among registered nurses and nurse assistants in Sweden in terms of their assumptions, values and norms with regard to practices associated with patient safety.

Methods

The study employed an exploratory design using a qualitative method, and was conducted at two hospitals in southeast Sweden. Seven focus group interviews and two individual interviews were conducted with registered nurses and seven focus group interviews and one individual interview were conducted with nurse assistants. Manifest content analysis was used for the analysis.

Results

Seven patient safety culture domains (i.e. categories of assumptions, values and norms) that included practices associated with patient safety were found: responsibility, competence, cooperation, communication, work environment, management and routines. The domains corresponded with three system levels: individual, interpersonal and organizational levels. The seven domains consisted of 16 subcategories that expressed different aspects of the registered nurses and assistants nurses’ patient safety culture. Half of these subcategories were shared.

Conclusions

Registered nurses and nurse assistants in Sweden differ considerably with regard to patient safety subcultures. The results imply that, in order to improve patient safety culture, efforts must be tailored to both registered nurses’ and nurse assistants’ patient safety-related assumptions, values and norms. Such efforts must also take into account different system levels. The results of the present study could be useful to facilitate discussions about patient safety within and between different professional groups.

     

“I see myself as part of the team” – family caregivers’ contribution to safety in advanced home care

Background

The use of medical technology and the various contributing and interdepending human factors in home care have implications for patient safety. Although family caregivers are often involved in the provision of advanced home care, there is little research on their contribution to safety. The study aims to explore family caregivers in Home Mechanical Ventilation (HMV) safety experiences and how safety is perceived by them in this context. Furthermore, it seeks to understand how family caregivers contribute to the patients’ and their own safety in HMV and what kind of support they expect from their health care team.

Methods

An explorative, qualitative study was applied using elements from grounded theory methodology. Data were collected through individual interviews with 15 family caregivers to patients receiving HMV in two regions in Germany. The audiotaped interviews were then subject to thematic analysis.

Results

The findings shows that family caregivers contribute to safety in HMV by trying to foster mutual information sharing about the patient and his/her situation, coordinating informally health care services and undertaking compensation of shortcomings in HMV.

Conclusion

Consequently, family caregivers take on considerable responsibility for patient safety in advanced home care by being actively and constantly committed to safety work.Nurses working in this setting should be clinically and technically skilled and focus on building partnership relations with family caregivers. This especially encompasses negotiation about their role in care and patient safety. Support and education should be offered if needed. Only skilled nurses, who can provide safe care and who can handle critical situations should be appointed to HMV. They should also serve as professional care coordinators and provide educational interventions to strengthen family caregivers’ competence.

     

Cancer patients' perceptions of quality‐of‐care attributes—Associations with age,perceived health status,gender and education

Aims and objectives

The aim of this study was to explore the associations between patients' gender, education, health status in relation to assessments of patient‐centred quality and individuality in care and trust in nurses for those <65 (working age) and ≥65 years (older people).

Background

Patients' assessments of the quality of care they receive are essential for the development of the provision of patient care and services. Previous studies have revealed age of the patient is associated with their assessment of care quality attributes.

Design

The study employed a cross‐sectional, multicultural comparative survey design.

Methods

The data were collected using questionnaires among hospitalised cancer patients (N = 876, n = 599, 68%) in four European countries: Greece, Cyprus, Sweden and Finland. The data were divided into two subgroups based on age (cut point 65 years) and were analysed statistically.

Results

Cancer patients' age, gender and level of education were not related to their assessments of care quality attributes: person‐centred care quality, individuality in care and trust in nurses. Subgroup analysis of the older adults and those of working age showed clear associations with patients' assessments of quality‐of‐care attributes and perceived health status. The lower the perceived health status, the lower the assessment of care quality attributes.

Discussion

The results suggest that the cancer itself is the strongest determinant of the care delivered, rather than any patient characteristics, such as age, education or gender. Perceived health status, in association with cancer patient assessments of care quality attributes, may be useful in the development of patient‐centred, individualised care strategies alongside a stronger focus on people instead of cancer‐care‐related processes and duties.

Conclusions

Health status was the only factor associated with cancer patients' assessments of care quality attributes. Cancer itself may be the strongest determinant of the care quality perceptions, rather than any patient characteristics.

Relevance to clinical practice

The findings of this study have implications for cancer care professionals in terms of patient assessment and care planning. The measures may be useful in assessing quality of cancer nursing care.     

Australia’s first Transition to Professional Practice in Primary Care Program: Qualitative findings from a mixed-method evaluation

Background

In Australia, there is an increasing demand for registered nurses in primary health care. Registered nurses graduating from university typically enter the workforce via supported transition to professional practice programs in acute-care hospital settings. A prospective strategy to create a sustainable primary health care workforce is to develop comparable transition programs in primary health care settings, such as general practice. We developed, implemented, and evaluated Australia’s first transition to professional practice in primary care program.

Patient safety culture in nursing homes – a cross-sectional study among nurses and nursing aides caring for residents with diabetes

Background

Due to the high morbidity and disability level among diabetes patients in nursing homes, the conditions for caregivers are exceedingly complex and challenging. The patient safety culture in nursing homes should be evaluated in order to improve patient safety and the quality of care. Thus, the aim of this study was to examine the perceptions of patient safety culture of nursing personnel in nursing homes, and its associations with the participants’ (i) profession, (ii) education, (iii) specific knowledge related to their own residents with diabetes, and (iv) familiarity with clinical diabetes guidelines for older people.

Methods

Cross-sectional survey design. The study included 89 nursing home personnel (38 registered nurses and 51 nurse aides), 25 (28%) with advanced education, at two nursing homes. We collected self-reported questionnaire data on age, profession, education and work experience, diabetes knowledge and familiarity with diabetes guidelines. In addition, we applied the Nursing Home Survey on Patient Safety Culture instrument, with 42 items and 12 dimensions.

Results

In general, those with advanced education scored higher in all patient safety culture dimensions than those without, however statistically significant only for the dimensions “teamwork” (mean score 81.7 and 67.7, p?=?0.042) and “overall perceptions of resident safety” (mean score 90.0 and 74.3, p?=?0.016). Nursing personnel who were familiar with diabetes guidelines for older people had more positive perceptions in key areas of patient safety culture, than those without familiarity with the guidelines.

Conclusions

The findings from this study show that advanced education and familiarity with current diabetes guidelines was related to adequate evaluations on essential areas of patient safety culture in nursing homes.

     

Understanding nursing scope of practice: a qualitative study

Background

The past decade has seen increased patient acuity and shortened lengths of stays in acute care hospitals resulting in an intensification of the work undertaken by nursing staff in hospitals. This has ultimately led to a reconsideration of how nursing staff manage their work.

Aim

The aim of this study was to understand how medical and surgical nurses from two Australian hospitals conceive their scope of practice in response to the available grade and skill mix of nurses and availability of unlicensed health care workers and other health care professionals. By exploring these meanings, this study aimed to build an understanding of how nursing work patterns were shifting in the face of changing patient acuity, patient profiles and nursing skill mix.

Method

A constructivist methodology, using critical incident technique (CIT) was used to explore nurses’ role and scope of practice. Twenty nurses, 16 registered nurses (RNs) and four enrolled nurses (ENs), discussed significant events during which they perceived they were undertaking either patient care activities they should be undertaking, or activities that should have either been delegated or undertaken by a higher level of care provider.

Findings

Five themes emerged from the data: (1) good nurses work in proximity to patients providing total patient care; (2) safeguarding patients; (3) picking up the slack to ensure patient safety; (4) developing teamwork strategies; and (5) privileging patients without mental illness or cognitive impairment. A pattern woven throughout these themes was the idea of negotiation. RNs were struggling with the notions that direct patient care was sometimes not the best use of their time, and delegation did not equate with laziness.

Conclusion

Negotiation has become a fundamental aspect of nursing practice given the variety of nursing care providers currently employed in acute care settings. Negotiation has allowed nurses to redefine appropriate nurse–patient proximity, promote patient safety and find innovative ways of working in nursing teams.     

Family involvement in timely detection of changes in health of nursing homes residents: A qualitative exploratory study

Aims and objectives

To explore family perspectives on their involvement in the timely detection of changes in their relatives' health in UK nursing homes.

Background

Increasingly, policy attention is being paid to the need to reduce hospitalisations for conditions that, if detected and treated in time, could be managed in the community. We know that family continue to be involved in the care of their family members once they have moved into a nursing home. Little is known, however, about family involvement in the timely detection of changes in health in nursing home residents.

Design

Qualitative exploratory study with thematic analysis.

Methods

A purposive sampling strategy was applied. Fourteen semi‐structured one‐to‐one interviews with family members of people living in 13 different UK nursing homes. Data were collected from November 2015–March 2016.

Results

Families were involved in the timely detection of changes in health in three key ways: noticing signs of changes in health, informing care staff about what they noticed and educating care staff about their family members' changes in health. Families suggested they could be supported to detect timely changes in health by developing effective working practices with care staff.

Conclusion

Families can provide a special contribution to the process of timely detection in nursing homes. Their involvement needs to be negotiated, better supported, as well as given more legitimacy and structure within the nursing home.

Relevance to clinical practice

Families could provide much needed support to nursing home nurses, care assistants and managers in timely detection of changes in health. This may be achieved through communication about their preferred involvement on a case‐by‐case basis as well as providing appropriate support or services.     

Professionals' experiences of supporting two-mother families in antenatal and child health care in Sweden

Background

In Sweden, antenatal and child health care are offered free of charge to all expectant and new parents. Professionals in antenatal and child health care play an important role in supporting parents. Previous research shows that same-sex mothers face heteronormative assumptions and insufficient support during their transition to parenthood.

Objective

To explore professionals' experiences of supporting two-mother families in antenatal and child health care.

Method

A qualitative method with focus group discussions was used. An interview guide was followed, and the discussions were held online. The data was analysed according to inductive content analysis.

Settings and participants

The participants were midwives (n = 8) and nurses (n = 5) in antenatal and child health care from different parts of Sweden. Participants were recruited through the coordinating midwives and child health care nurses in the different regions.

Findings

One main category was identified: Striving to be open-minded in supporting same-sex mothers. Health care professionals described meeting well-prepared mothers, with an equal commitment between each other, and mothers on guard against heteronormative views. Professionals provided support through empowerment by creating a safe environment and aiming at providing equal support to all parents or tailored support to same-sex mothers. Mothers described handling challenges, as a balancing act to acknowledge both mothers. Struggling with documents and communication and a lack of information were other challenges to be handled. Professionals reflected on their own professional competence and expressed that knowledge acquired through education, experience and personal interest all contributed to their competence.

Conclusions

Forms and documentation need to be updated to be gender neutral to be including to a variety of family constelleations. Health care professionals need time to reflect on norms and challenges to better support both mothers in a two-mother family.     

Rest break organization in geriatric care and turnover: A multimethod cross-sectional study

Background

Various determinants of nurses’ work motivation and turnover behavior have been examined in previous studies. In this research, we extend this work by investigating the impact of care setting (nursing homes vs. home care services) and the important role of rest break organization.

Objectives

We aimed to identify direct and indirect linkages between geriatric care setting, rest break organization, and registered nurses’ turnover assessed over a period of one year.

Design

We designed a multimethod cross-sectional study.

Setting

80 nursing units (n = 45 nursing homes, n = 35 home care) in 51 German geriatric care services employing 597 registered nurses.

Methods

We gathered documentary, interview, and observational data about the organization of rest breaks, registered nurses’ turnover, and additional organizational characteristics (type of ownership, location, nursing staff, clients, and client-to-staff-ratio).

Results

The findings show that the rest break system in geriatric nursing home units is more regularly as well as collectively organized and causes less unauthorized rest breaks than in home care units. Moreover, the feasibility of collective rest breaks was, as predicted, negatively associated with registered nurses’ turnover and affected indirectly the relation between care setting and registered nurses’ turnover. Care setting, however, had no direct impact on turnover. Furthermore, registered nurses’ turnover was higher in for-profit care units than in public or non-profit units.

Conclusions

This study reveals significant differences in rest break organization as a function of geriatric care setting and highlights the role of collective rest breaks for nursing staff retention. Our study underlines the integration of organizational context variables and features of rest break organization for the analysis of nursing turnover.     

Nurses’ competencies in home healthcare: an interview study

Background

Nurses working in Home healthcare (HHC) are facing major challenges since more advanced care and treatment are increasingly being carried out in patients’ homes. The aim of this study has been to explore how nurses experience their competencies in HHC situations.

Methods

This study has a qualitative and explorative design. Ten nurses were interviewed and data was analyzed using content analysis.

Results

The themes “Being a capable nurse”, “Being a useful nurse” and “Being a subordinate and dependent nurse” were identified. Nurses want to be capable of taking care of patients, to develop their competencies and to perform their duties in the way required. They also want their work to be useful and to provide good and safe HHC. Finally, nurses want to improve HHC care by applying their competencies. Simultaneously, they are subordinate and dependent in relation to their manager and also dependent upon their manager’s interest in encouraging nurses’ competence development.

Conclusions

Nurses in HHC are responsible for many seriously ill patients and they want to contribute to good and safe patient care. To maintain patient safety, reduce the risk for burnout and staff turnover as well as to contribute to a sustainable development of the work, strategies for transferring competencies between nurses and efforts for competence development are needed.

     

Safety of Care by Caregivers of Cancer Patients

ObjectivesTo describe common areas of threats to patient safety and quality of care when caregivers provide care. Recommendations for caregivers to enable them to provide safe care are included.Data SourcesResearch-based articles and reports.ConclusionThe literature is limited in discussion on home safety issues for caregivers. Non cancer-specific literature provides some direction for recommendations for nurses to guide caregivers.Implications for Nursing PracticeThe home environment is an unregulated and uncontrolled site, and the safety risks families take are unknown. Professionals should assess the caregiver's knowledge and ability when providing caregiving guidance to ensure the patient is receiving safe and quality care. Nurses need to stress the importance of providing safe quality care and provide education and community resources.     

Exploring the perceived changes and the reasons why expected outcomes were not obtained in individual levels in a successful regional palliative care intervention trial: an analysis for interpretations

Context

The Japan Outreach Palliative Care Trial of Integrated Model (OPTIM) study, a mixed-methods study to evaluate the effects of a comprehensive regional palliative care program, revealed that the program provided broad positive outcomes at the regional level: increased home death, palliative care use, patient- and family-reported qualities of care, and health care professionals’ difficulties. Not all participants however obtained positive outcomes and thus exploring the reasons why expected outcomes were observed in individual levels could be of value.

Aims

The primary aims were to explore why expected outcomes were not obtained in individual participants, and the perceived changes in daily practices of physicians and nurses were explored.

Subjects and methods

Postintervention questionnaire survey on 857 patients, 1,137 bereaved family members, 706 physicians, and 2,236 nurses were analyzed.

Results

The reasons for not achieving home deaths included unexpected rapid deterioration, caregivers unavailable, concerns about adequate responses to sudden changes, and physical symptoms uncontrolled, while lack of physician availability at home and lack of information from physicians were less frequently reported. The reasons for not receiving specialized palliative care services were the lack of recommendations from physicians and no information about palliative care services. The reason for evaluating the quality of palliative care as not high was that clinicians tried to relieve symptoms, but there were limited effects and insufficient time. Many physicians and nurses reported that they became more aware of palliative care, that the availability of palliative care specialists and knowledge about palliative care improved, and that they cooperated with other regional health care providers more easily.

Conclusion

The OPTIM study seemed to succeed in optimizing physician availability at home, improves physician information about home care, achieved maximum efforts to relieve patient distress by clinicians, and increased communication among regional health care professionals. To achieve further better outcomes, multiple interventions to the health care system to be performed on the basis of a comprehensive regional palliative care program are proposed.     

Exploring intensive care nurses’ team performance in a simulation-based emergency situation, − expert raters’ assessments versus self-assessments: an explorative study

Background

Effective teamwork has proven to be crucial for providing safe care. The performance of emergencies in general and cardiac arrest situations in particular, has been criticized for primarily focusing on the individual’s technical skills and too little on the teams’ performance of non-technical skills. The aim of the study was to explore intensive care nurses’ team performance in a simulation-based emergency situation by using expert raters’ assessments and nurses’ self-assessments in relation to different intensive care specialties.

Methods

The study used an explorative design based on laboratory high-fidelity simulation. Fifty-three registered nurses, who were allocated into 11 teams representing two intensive care specialties, participated in a videotaped simulation-based cardiac arrest setting. The expert raters used the Ottawa Crisis Resource Management Global Rating Scale and the first part of the Mayo High Performance Teamwork Scale to assess the teams’ performance. The registered nurses used the first part of the Mayo High Performance Teamwork Scale for their self-assessments, and the analyses used were Chi-square tests, Mann–Whitney U tests, Spearman’s rho and Intraclass Correlation Coefficient Type III.

Results

The expert raters assessed the teams’ performance as either advanced novice or competent, with significant differences being found between the teams from different specialties. Significant differences were found between the expert raters’ assessments and the registered nurses’ self-assessments.

Conclusions

Teams of registered nurses representing specialties with coronary patients exhibit a higher competence in non-technical skills compared to team performance regarding a simulated cardiac arrest. The use of expert raters’ assessments and registered nurses’ self-assessments are useful in raising awareness of team performance with regard to patient safety.