Achieving change in health care practice

This study evaluated a practice development programme consisting of nine projects together known as STEP (South Thames Evidence-Based Practice Project). The aim of STEP was to establish and assess evidence-based practice in nursing and other health care practice areas. Objectives of the independent evaluation were to identify and assess outcomes from the process of change and investigate the association between these intermediate outcomes and patient outcomes. Outcomes were measured before and after the changes were introduced. Data collection methods included interviews with the change agents and other stakeholders, and a questionnaire to staff in each centre. Patient outcome data were collected from each centre. The findings revealed 'dissemination' of information to staff and 'adherence' by staff to new practice guidelines to be important intermediate outcomes in the process of change. The need emerged for a supportive organizational culture and commitment, recognition of the importance of change and a credible change agent. There was some evidence of linearity in the process of change in that a logical route appeared from dissemination of information to staff through adherence to the change guidelines to improvement in patient outcome in six of the nine centres. Linearity was less apparent in the other three centres, where the process of change seemed more dynamic and chaotic. These three centres were affected more than the others by organizational barriers to change. Our conclusions support the view that the linear model of change can work in settings with high levels of certainty but complexity theory is more likely to underpin the process of change in organizations characterized by uncertainty.     

Dying in a rural residential aged care facility: an action research and reflection project to improve end-of-life care to residents with a non-malignant disease

This article describes a qualitative research project that explored issues around end-of-life care provided to residents dying from non-malignant diseases in two, rural Australian, residential aged care facilities. Reflective processes and action research were combined to work in collaboration with 14 aged nurses, associated staff and relatives of dying residents. Reflection featured in the research and included group reflection on practice stories, critical reflection during thematic analysis and reflection on action research cycles. Themes and subthemes emerged, indicating that aspects of end-of-life care needed further improvement. Major thematic concerns were prioritized for action and included the need for better pain management practices which will be discussed. Identifying these clinical issues was an important step in creating, implementing and evaluating actions. Participants reported varying degrees of success in attempting to improve end-of-life care.     

Providing care to the elderly with depression: the views of aged care staff

The purpose of this paper was to scope the views of care staff working in an aged care setting in an effort to understand the issues these staff face in the delivery of care to the elderly with depression. Seventeen care staff working in metropolitan, regional and rural areas of Queensland participated in one-on-one interviews in order to elicit their views on the identification of depression in the elderly and the care processes staff employed to manage depression. Interview notes were taken, reviewed, transcribed and analysed using content analysis. Discussion with participants revealed five themes regarding the management of depression in both community and residential aged care settings. These included: the extent to which depression is an issue for clients and residents; staff understanding of depression and the ability to recognize when a client or resident is depressed; discussing depression with general practitioner's and other healthcare professionals; processes and procedures for treating and addressing depression; and education and training on depression for staff. The findings revealed that care staff need greater education and training about depression and targeted strategies for its identification and management.     

Beyond the 'tick and flick': facilitating best practice falls prevention through an action research approach

Aims and objectives. To examine residential aged care facility staff views on using falls risk assessment tools and the implications for developing falls prevention practices in the context of an action research project. Background. Falls risk assessments play an important role in care planning by identifying and monitoring aged care facility residents most at risk of falls. Yet while such assessments are recommended in falls prevention best practice guidelines, there is little published research that examines staff procedures and views related to conducting falls risk assessments. Design. Falls risk assessments were undertaken in the context of an action research project. Method. Twelve staff members from two residential aged care facilities (RACFs) in Tasmania formed a single Falls Action Research Group, which met 22 times over a year, providing the study’s qualitative data. During this time, key group members assessed 178 residents using a new falls risk assessment tool (FROP‐Resi). Results. According to group members, facilities evolved from a ‘tick‐and‐flick’ approach to falls risk assessment to a more individualised, face‐to‐face assessment process. Group members perceived the process to be more meaningful and enjoyable for staff involved in the assessment process resulting in higher quality of assessments and leading to improved levels of falls awareness among staff, residents and family caregivers. Conclusions. An action research process is useful for facilitating a new approach to falls risk assessments, engaging aged care facility staff with falls prevention and prompting improvements in falls prevention practices. Relevance to clinical practice. RACFs need to provide opportunities for staff to meet regularly to discuss practice, identify issues and take action. By doing so, staff can engage meaningfully with best practice activities such as optimising falls risk assessment processes.     

Influencing factors that support and build aged care research capacity: Staff perspectives

BackgroundStrategic collaborative networks between care staff and researchers can be a powerful means of improving the provision of safe and quality care. Aged care staff hold vital information on research practicality and ease of implementation in the clinical setting. Aged care staff are best positioned to advise on a study’s feasibility in the clinical environment and for the particular residents in their care, regardless of the fact that they are often not involved in the research process.AimTo explore aged care staff attitudes towards research particularly the influencing factors that promote and sustain care staff participation in research in the residential aged care facility (RACF) setting.MethodsQualitative semi-structured interviews were conducted at two aged care facility sites in Sydney with 10 aged care staff before and after their participation in a randomised controlled trial on their ward. The interviews explored aged care staff perceptions of the importance of research, staff compliance and factors that influence research conducted in the RACF setting.FindingsAged care staff reported on the importance of conducting research in RACFs. The barriers to staff participation included insufficient time (50%), lack of belief in intervention effect (30%), deficits in research knowledge (40%) or support (30%). Research perceived as practical (40%) that could be conducted unobtrusively (60%), provided tailored education (70%) with effective communication (50%) between researcher and aged care staff, was more favourable for staff participation.DiscussionAged care staff recognised that findings from research when implemented was important for improving quality care provision but it was challenging to conduct research in the RACF setting. Implementing strategies that support aged care staff research time away from clinical tasks, access to research education and foster communication between academic and staff can improve care staff participation in research.ConclusionFocused strategies fostered by collaborative partnerships between aged care staff, academic researcher and industry management can promote and sustain the research capacity of staff caring for older people in RACFs.     

Resident and family member perceptions of cultural diversity in aged care homes

Similar to many developed nations, older people living in residential aged care homes in Australia and the staff who care for them have become increasingly multicultural. This cultural diversity adds challenges for residents in adapting to the care home. This study explores: (i) residents' and family members' perceptions about staff and cultural diversity, and (ii) culturally and linguistically diverse residents' and family members' experiences. An interpretive study design employing a thematic analysis was applied. Twenty‐three residents and seven family members participated in interviews. Four themes were identified from interpreting residents and family members' perceptions of the impact of cultural diversity on their adaptation to aged care homes: (i) perceiving diversity as an attraction; (ii) adapting to cross‐cultural communication; (iii) adjusting to diet in the residential care home; and (iv) anticipating individualized psychosocial interactions. The findings have implications for identifying strategies to support staff from all cultural backgrounds in order to create a caring environment that facilitates positive relationships with residents and supports residents to adjust to the care home.     

Improving continuity of care across psychiatric and emergency services: combining patient data within a participatory action research framework

Presented with the concerns of emergency department nurses about providing appropriate and co-ordinated care for patients seeking mental health services, a Monash University School of Nursing, Victoria, Australia, research team chose a participatory action research strategy. Jointly executed with staff from the Peninsula Health Care Network, the research process brought together in a number of fora multiple disciplines involved in the care and management of psychiatric patients. The participatory action research process itself was the first step in remedial action. Through it, participants and management gained a firmer view of the issues facing Frankston Hospital Emergency Department staff in dealing with psychiatric patients, and in securing their access to suitable pathways of care. Other research outcomes included: a compilation of summary statistics showing patterns of use by psychiatric patients of Frankston Hospital's Emergency Department; beginning discussions about pathways of care for these patients; and the development of a screening tool to be used by the triage nurse for at-risk psychiatric patients presenting to the Emergency Department.     

High demand,high commitment work: What residential aged care staff actually do minute by minute: A participatory action study

This article explores staff work patterns in an Australian residential aged care facility and the implications for high-quality care. Rarely available minute by minute, time and motion, and ethnographic data demonstrate that nurses and care staff engage in high degrees of multitasking and mental switching between residents. Mental switching occurs up to 18 times per hour (every 3 min); multitasking occurs on average for 37 min/h. Labor process theory is used to examine these outcomes and to explore the concepts of high demand and high commitment as core components of work intensification. These conditions of work result in high levels of cognitive burden and stress on staff in managing the multitasking and mental switching, exacerbated by lack of knowledge about residents associated with labor force casualization. These new interpretations of data in relation to mental and manual labor can contribute to understanding, and, therefore, problem solving, in the aged care sector.     

Clinical nurses' response to an environment of health care reform and organizational restructuring

BACKGROUND: Clinical nurses at the crux of health care service delivery experienced radical organizational restructuring during the 1990s in Australia. Despite the implications organizational restructuring has for patient care delivery, clinical nurses continue to lack presence in policy decision-making processes. AIMS: The aim of this paper is to provide an explanation for clinicians' undisputed acceptance of change. This will be performed by examining the process of organizational restructuring across three analytical levels -- the macro, meso and micro; identifying the consequences of restructuring for clinical nurses' performance; and evaluating organizational restructuring using a micro-political theoretical framework. FINDINGS: Utilizing Hoyle's (1988) micro-political theory, it would appear that clinical nurses are functioning within a paradigm of maintenance. In order to provide quality patient care, effective resource use and preservation of the status quo are prioritized. CONCLUSION: Successful change outcomes are dependent on clinical nurses' performance. Whether nurses are politically inactive as a result of poor communication, as a consequence of the structural change environment or because their energy is devoted to achieving a balance between organizational imperatives and their personal commitment to patient care requires further investigation.     

What is action research and can it promote change in primary care?

Improving the quality of health care is an international priority. However, research has shown that methods of altering clinician's behaviour or implementing organizational change are often ineffective. Action research has been used successfully to facilitate change and improve service provision in industry, education and more recently in health care. In this paper, action research methodology and why it should be successful in promoting change are outlined. Recently published studies using action research in the primary health care team setting in the UK are discussed. They demonstrate that action research improves clinical care, teamwork, communication and administration. It also encourages practice teams to audit their work and identify their educational needs. The main problems encountered were the amount of time and effort required to maintain collaboration with participants, staff turnover and completing the research process in a short time scale. Action research should be a useful means of improving quality in health care and could be used more widely. In the UK, government strategy has called for individual- and team-based development plans based on individual learning needs. Action research could be a useful method of transforming these from theory to practice.     

Student nurses' experiences of the body in aged care

Little is known about how student nurses deal with 'old bodies' in the process of providing nursing care to nursing home residents. It was an issue raised by student nurse participants involved in a pilot research project designed to develop support structures for students on placement in aged care settings. During the research discussions, where students explored their experiences of working in aged care, it became apparent that the process of providing 'hands on' care to residents with 'old wrinkly bodies' was very confronting. However, in the context of the research project, students had an opportunity to share stories of their experiences of providing care to residents and critically reflect on the issues raised. Participation in these critically reflective discussions facilitated a process whereby students could challenge taken for granted understandings of older people and their bodies and develop a new appreciation of aged care. This was most evident in a significant positive shift in their attitude to working in the sector following graduation.     

University and industry partnerships: lessons from collaborative research

Collaborative research between educational institutions and health agencies is being increasingly used as a method of achieving joint outcomes and bringing together theory and practice. This paper reports on the experiences of collaboration that arose out of just such a project carried out in a residential aged care setting. The research team included university academics, two nurses in management positions in the aged care facility and a senior research assistant. In this paper, we explore some of the unexpected issues that emerged during implementation of the research project. The major challenges to successful collaboration arose not from within the collaborative research team, but from the responses of the broader staff who generally had little, if any, experience of research. Despite efforts to inform and involve staff, deep suspicions about the 'real' motives of the project proved difficult to shift. Trust and commitment are vital dimensions of successful collaborative research, yet gaining these from some staff proved elusive. Collaborative relationships between educational and practice settings need to be viewed as long-term endeavours driven by a common unifying goal to enhance client care. This has implications for costs and timelines which might be difficult to manage.     

Demonstration of the usefulness of a theoretical framework for humanising care with reference to a residential aged care service in Australia

Aims and objectives. To demonstrate the usefulness of a theoretical framework for humanising care of dementia patients. Background. The term humanisation of care has been increasingly used to describe an approach to health care that is informed by core dimensions of what it means to be human. Recent developments in dementia care highlight the importance of maintaining personhood in people with dementia. Design. A conceptual framework is proposed by which the humanisation of care can be understood and applied. Eight dimensions that articulate core features of what needs to be attended to in order for a person to feel more deeply ‘met’ as a human being are discussed. Evidence from an evaluative study of a dementia outreach service is used to illustrate the usefulness of the humanising framework. Methods. Case study examples demonstrate the value of this framework by describing how a dementia outreach service enables care staff in residential aged care facilities to change their focus in the provision of care to residents with dementia. Each of the eight dimensions of humanisation/dehumanisation is used to illustrate how the dementia outreach service team have led to the improvements in resident care. Results. Positive outcomes can be achieved by providing humanised care to residents with dementia. Conclusion. The paper highlights the potential for the humanising framework to be used in dementia care and shows how the framework can be helpfully translated into practice so that carers are supported to adopt an inclusive view of care delivery. Relevance to clinical practice. A comprehensive framework, grounded in a strong philosophical foundation, can name a breadth of criteria for humanly sensitive care and can be translated into practice in such a way as to potentially transform the provision of care to residents in residential aged care facilities.     

Evaluating a palliative care education project in nursing homes

This article reports on an evaluation of a 2-year palliative care education project for nursing home staff. The aim of the project was to provide education for all levels of nursing home staff so that the care of dying residents could be improved. In order to ascertain the outcomes of the initiative two approaches to data collection were adopted. Case studies of four participating nursing homes were undertaken, involving a period of participant observation and interviews with staff members. A postal survey of the participating nursing homes and non-participating nursing homes from the same geographical region was also carried out. The impact of the project is described, identifying how the care of residents and their relatives was affected, the differing impact on the participating staff groups and the degree to which the organizational practices of the nursing homes changed. Although the project influenced course members' practice, the provision of courses such as these was recognized to be insufficient to ensure widespread organizational changes. Questions regarding the effectiveness of education as an agent of organizational change were raised throughout the project and the evaluation.     

Nurses' experiences of practice and political reform in long-term aged care in Australia: implications for the retention of nursing personnel

AIM: The aim of the study was to explore registered nurses' experiences in long-term aged care in light of the political reform of aged care services in Australia. BACKGROUND: In Australia, the aged care industry has undergone a lengthy period of political and structural reform. Despite reviews into various aspects of these reforms, there has been little consideration of the effect these are having on the practice experiences and retention of nursing staff in long-term care. METHODS: In this critical hermeneutic study, 14 nurses from long-term care facilities in Australia were interviewed about their experiences during the reform period. RESULTS: The data revealed a sense of tension and conflict between nurses' traditional values, roles and responsibilities and those supported by the reforms. Nurses struggled to re-negotiate both their practice roles and values as the reforms were implemented and the system evolved. Nursing management support was an important aspect in mediating the effect of reforms on nursing staff. CONCLUSION: This research highlights both the tensions experienced by nurses in long-term aged care in Australia and the need to re-negotiate nursing roles, responsibilities and values within an evolving care system. This research supports a role for sensitive and proactive nursing management during periods of industry reform as a retention strategy for qualified nursing personnel.     

The Gulf War: reaction and action in institutions for the aged in Israel

In order to learn how geriatric centres were coping during the Gulf War (1991), questionnaires were distributed to 116 unit head nurses in 16 institutions in Israel. Additional information was obtained from the directors of nursing and national supervisors in a meeting 3 1/2 months after the cease-fire. Questions focused on organization of work, behaviour of staff, patients and their families, main problems, solutions and recommendations. Data showed a very high level of commitment by staff, flexibility, initiative and creativity in meeting the emotional, physical and safety needs of the aged. Stress level was highest in the 'Scud' areas and among the aged who are mentally alert. Families visited less but increased contact by telephone. Management was supportive with guidance, transport, child care facilities, etc. They also provided beds and food for spouses of the aged residents. Major problems related to safety measures (sealing rooms, moving patients during attacks), physical exhaustion and emotional stress of staff, and reorganization of care programmes. Recommendations included development of a master plan for non-conventional attacks, preparation of buildings with structural improvements, recruitment and training of volunteers, clarification of roles of staff and education for them.