Hospital‐based home care for people with severe mental illness in Taiwan: a substantive grounded theory

Aim and objectives. The purpose of this study is to generate a substantive theory of hospital‐based home care for people with severe mental illness in Taiwan. Background. Despite the documented advantages of hospital‐based home care services, there is a lack of information and understanding regarding the practices, functions and limitations. Currently, there is no model for how those services are to be provided and what factors will affect these services. Design. The grounded theory method of Strauss and Corbin (Basics of Qualitative Research: Grounded Theory Procedures and Techniques, SAGE Publications, 1990) was used to develop a substantive theory through a paradigm model, including causal conditions, context, intervening conditions, action/interaction strategies and consequences. Methods. This study was conducted in six different hospital areas in Central Taiwan in 2007–2008. Data were collected using semi‐structured face‐to‐face interviews. Constant comparative analysis continued during the open, axial and selective coding process until data saturation occurred. Participants were selected by theoretical sampling. When theoretical saturation was achieved, 21 clients with mental illness, 19 carers and 25 professionals were interviewed. Results. A substantive theory of hospital‐based home care for people with severe mental illness in Taiwan was developed. The core category was the process of hospital‐based home care in helping people with severe mental illness, with 15 categories and 33 sub‐categories of the substantive theory. Conclusion. The substantive theory is the first to emerge from hospital‐based home care services in Taiwan. Results showed those services had several effective functions for helping people with severe mental illness and their families. Relevance to clinical practice. The recommendations based on the findings of this research can be used as a guide to improve the delivery of hospital‐based home care services to community‐dwelling people with severe mental illness and their carers.     

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.     

Measuring patient assessments of the quality of outpatient care: a systematic review

Rationale, aims and objectives The aim of the study was to answer three questions: first, what methods have been used to measure patient assessments of the quality of care? Second, how do outpatients rate their care? And third, what needs to be taken into account in measuring patient assessments of the quality of care? Methods Systematic review of the literature. Electronic searches were conducted on Medline, CINAHL and the Cochrane Database of Systematic Reviews. To be included, articles were to deal with patients’ assessments of health care in ambulatory units for somatic adult patients. They were to have been published between January 2000 and May 2005, written in English, Swedish or Finnish with an English abstract, and the research was to have been conducted in Europe. The search terms used were: ambulatory care, ambulatory care facilities, outpatient, outpatients, patient satisfaction and quality of health care. The articles were screened by two independent reviewers in three phases. Results Thirty‐five articles were included. The quality of care was measured using both quantitative and qualitative methods. Only a few studies relied on the single criterion of patient satisfaction for quality measurements. It is easy to identify common sources of dissatisfaction in different studies. Sources of satisfaction are more closely dependent on the target population, the context and research design. Conclusion Patient satisfaction is widely used as one indicator among others in assessing the quality of outpatient care. However, there is no single, universally accepted method for measuring this.     

Quality of life in the care home: a qualitative study of the perspectives of residents with multiple sclerosis

Purpose: Care home residents with multiple sclerosis (MS) are more physically dependent than the average residents. However, little is known about their quality of life (QoL). We investigated the experiences of residents with MS using qualitative research methods and developed a conceptual model of QoL. Methods: Twenty-one people with MS (age range 43–80 years) residing in a range of care homes were interviewed. The interviews were transcribed verbatim and analyzed using the constant comparative method. Results: Four core model domains identified were as follows: (i) What the care home means to the residents, (ii) Self, (iii) Environmentand (iv) Relationships. Some residents reported that care homes can relieve the burden on family, address specific environmental issues regarding safety and act as a form of social support. However, some reported isolation and difficulties adjusting to life in the care home. Having access to rehabilitation strengthened the feelings of independence within the care home. Conclusions: QoL is a broad, multidimensional construct for residents with MS. QoL measures for residents with MS should incorporate broad domains, including environmental factors. The conceptual model highlighted several areas for improving QoL of residents with MS, including more involvement of family members, encouraging independence by providing access to rehabilitation and providing support in the transition process.

Implications for Rehabilitation

• Quality of life for people with multiple sclerosis in care homes is a multidimensional construct.

• Participants in this qualitative study differed in whether they were able to have access to rehabilitation in the care home.

• For those that did have access, this appeared to enhance their feelings of maintaining some degree of independence in the care home.

• This study demonstrated that rehabilitation, such as physiotherapy, is greatly valued by care home residents with disabilities and has an impact on their quality of life.

     

Improving networks between acute care nurses and an aged care assessment team

Background. Acute care nurses have an important role in the discharge planning of older people from hospital to home. However, few nurses understand the changing aged care system or the consequences of poor referral on the lives of older people postdischarge. Aims and objectives. This paper reports the findings of a research project, which aimed to investigate the possibilities for facilitating the transition of older people from hospital to home through improving the working relationship between nurses and members of a multidisciplinary aged care assessment team (ACAT). Design and methods. The paper reports one action research cycle from a larger project. Action research was chosen because its focus on knowledge development and action leads to practical solutions to clinical problems. The research approach included interactive forums designed to facilitate effective collaboration between the nurses and ACAT in the discharge planning of older people. Data collection strategies included audiotapes of ACAT research discussions, field notes, policy documents, referral forms and an evaluation tool. Results and conclusions. The findings illustrate that ward nurses have, at best, a limited knowledge and understanding of the aged care system, its function, or how to access services. They need assistance to develop their knowledge of services available to support older people following discharge. The conduct of interactive forums, which utilize a case study approach, facilitated such knowledge development and empowered the nurses to become more involved in discharge planning. Participation in the forums also facilitated new collaborative partnerships between the nurses and ACAT, which enhanced effective discharge planning. Relevance to clinical practice. The paper outlines practical strategies to support collaboration between ward nurses and community providers and/or multi disciplinary assessment services. It provides a list of key considerations for the development of effective ward/community networks to facilitate the discharge of older people.     

Accidents in elderly care: a randomised controlled trial (part 3).

This paper reports the data on accidents from a randomised controlled trial evaluating health authority-funded nursing home and long stay care of the elderly ward care in one inner London health district. Respondents randomised to NHS nursing homes experienced a higher accident rate than respondents randomised to conventional long stay hospital wards for elderly people. Respondents in the homes also experienced an earlier decline in functional and mental ability than those in hospital. These disadvantages have to be balanced against the previously published observational data from the evaluation, which clearly indicated that quality of life in the homes was superior to that in the wards. The conclusion from this study is that earlier decline in functional and mental ability and increased accident risk in the more flexible environments of the nursing homes have to be balanced against an inferior quality of life in the large traditional hospital wards; such assessments are not easy to make on behalf of other people. This final part of the report details the authors' conclusions.     

Utilization of medical healthcare among people receiving long‐term care at home or in special accommodation

Scand J Caring Sci; 2010; 24; 404–413
Utilization of medical healthcare among people receiving long‐term care at home or in special accommodation Aim: To investigate the utilization of medical healthcare, hospital care and outpatient care, during a 1‐year period in relation to informal care, multimorbidity, functional status and health complaints and to long‐term care at home or in special accommodation among people aged 65+, with one or more hospital admissions and receiving long‐term care. Method: A total of 694 people receiving long‐term care during the year 2001 were studied. Data were collected by means of the administrative registers Patient Administrative Support in Skåne and PrivaStat and through the study Good Ageing in Skåne. Those at home and those in special accommodation were compared regarding utilization of medical healthcare, informal care, multimorbidity, functional status and health complaints. Multiple logistic regression analysis was performed using at home vs. in special accommodation as the dependent variable and also two multiple linear regression analyses using the number of hospital stays and the number of contacts with the physician in outpatient care separately as dependent variables. Findings: Those at home were significantly younger (mean age: 81 vs. 84 years) and less dependent in personal and instrumental activities of daily living (PADL/IADL) than those in special accommodation. A larger proportion of those at home was admitted to hospital three times or more (21 vs. 14%) and they had significantly more contacts with physicians in outpatient care (md: 10 vs. md: 7). Informal care was associated with care at home (OR = 0.074) and with utilization of outpatient care (B = 2.045). Dependency in PADL was associated with care in special accommodation (OR = 1.375) and with utilization of hospital care (B = ?0.060) and outpatient care (B = ?0.581). Conclusion: Medical healthcare seems more accessible to those who live at home are younger, less dependent and who have access to informal caregivers.     

Nursing staff competence, work strain, stress and satisfaction in elderly care: a comparison of home-based care and nursing homes

Abstract Aims. The aims of this study were to: (1) compare older people care nursing staff's perceptions of their competence, work strain and work satisfaction in nursing homes and home‐based care; and (2) to examine determinants of work satisfaction in both care settings. Background. The shift in older people care from hospitals to community‐based facilities and home care has had implications for nursing practice. Lack of competence development, high levels of work strain and low levels of work satisfaction among nursing staff in both care settings have been associated with high turnover. Few studies have compared staff perceptions of their competence and work in nursing homes as opposed to home‐based care. Design. A cross‐sectional questionnaire survey. Methods. Nursing staff perceptions of their competence, work strain, stress and satisfaction were measured by questionnaire in 2003 in two older people care organizations in Sweden. Comparisons of all outcome variables were made between care settings both within and between the two organizations. Multiple regression analysis was used to determine predictors of work satisfaction in home care and nursing homes respectively. Results. In general, staff in home‐based care reported significantly less sufficient knowledge compared with staff in nursing homes. However, home care staff experienced significantly less physical and emotional strain compared with staff in nursing homes. Ratings of work‐related exhaustion, mental energy and overall work satisfaction did not differ significantly between care settings. In both care settings, work‐related exhaustion was the strongest (inverse) predictor of work satisfaction. Conclusions. Future interventions should focus on counteracting work‐related exhaustion and improving competence development to improve work satisfaction among older people care nursing staff in both care settings. Relevance to clinical practice. Work‐related exhaustion and lack of competence development may have significant negative implications for work satisfaction among older people care nursing staff in both home care and nursing homes.     

Preferences and priorities for ongoing and end-of-life care: A qualitative study of older people with dementia resident in care homes

Background

The older person with dementia has a limited life expectancy and the dying trajectory can be protracted and unpredictable. For good end-of-life care, early communication, exploration of residents’ wishes, and identification of someone who can represent them, are important. In care homes the timing of these discussions, and who is involved is variable. Person-centred approaches to dementia care assume that people with dementia can actively participate in decisions about their lives. Less well understood is how this can inform end-of-life care decision making and complement information provided in advance care plans completed prior to, or at the point of admission to a care home.

Objectives

To explore how older people with dementia discuss their priorities and preferences for end-of-life care.

Methods

An exploratory, qualitative study that used guided conversations with 18 people with dementia, living in six care homes. Participants were asked about their life in the care home, their health, thoughts for the future, and wishes surrounding end of life. Data were analysed thematically.

Results

People with dementia's accounts of life in the care home, what they valued, and the impact of having dementia on how they participated in decision making, provided key insights into care preferences. Three linked themes that had relevance for thinking and talking about end of life were identified: “dementia and decision making”, “everyday relationships” and “place and purpose”. Older people with dementia's accounts of everyday experiences of care, key relationships with family and care home staff members and whether they accepted the care home as their home demonstrated what was important for them now and for the future.

Conclusion

For older people living with a diagnosis of dementia, the experience of living and dying in a care home is inextricably linked. End-of-life care planning and decision making by health care professionals, care home staff and family could be enriched by exploring and documenting the preoccupations, key relationships and wishes about everyday care of people with dementia.     

Preventive home care of frail older people: a review of recent case management studies

Preventive actions targeting community‐dwelling frail older people will be increasingly important with the growing number of very old and thereby also frail older people. This study aimed to explore and summarize the empirical literature on recent studies of case/care management interventions for community‐dwelling frail older people and especially with regard to the content of the interventions and the nurse's role and outcome of it. Very few of the interventions took either a preventive or a rehabilitative approach using psycho‐educative interventions focusing, for instance, on self‐care activities, risk prevention, health complaints management or how to preserve or strengthen social activities, community involvement and functional ability. Moreover, it was striking that very few included a family‐oriented approach also including support and education for informal caregivers. Thus it seems that the content of case/care management needs to be expanded and more influenced by a salutogenic health care perspective. Targeting frail older people seemed to benefit from a standardized two‐stage strategy for inclusion and for planning the interventions. A comprehensive geriatric assessment seemed useful as a base. Nurses, preferably trained in gerontological practice, have a key role in case/care management for frail older people. This approach calls for developing the content of case/care management so that it involves a more salutogenic, rehabilitative and family‐oriented approach. To this end it may be useful for nurses to strengthen their psychosocial skills or develop close collaboration with social workers. The outcome measures examined in this study represented one of three perspectives: the consumer's perspective, the perspective of health care consumption or the recipient's health and functional ability. Perhaps effects would be expected in all three areas and thus these should be included in evaluative studies in addition to measures for family and/or informal caregiver's strain and satisfaction.     

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.     

Daily life after moving into a care home--experiences from older people, relatives and contact persons

Aims and objectives. To describe older people's experiences of daily life at the care home after admittance with respect to their perceptions of participation in the decision to move. Furthermore, the aim was to study the experiences of their relatives and contact persons with respect to the daily life of the same residents. Background. When older persons move into a care home, the whole family often play an important part. Thus, it is interesting to study how newly admitted older people, their relatives and staff members experience daily life in a modern care home. Methods. Qualitative design. The participants comprised a purposive sample of 13 residents, recently admitted to a care home, 69–90 years old, both single living and married, both moving from their own homes and from different institutions. Interviews were carried out with the older people (n = 13), their relatives (n = 10) and contact persons (n = 11). Results. The majority of the residents reported satisfaction with care home living. The relatives were also satisfied, secure and appreciated the privacy and homely atmosphere of the flat. The disadvantage of one‐room flats was that the residents might have felt lonely. The relatives felt that the residents were bored, but few residents desired more activities, even if some of them longed for people to socialize with. For many older people, perhaps talking is the most important ‘activity’ at care homes. Concerning self‐determination, some residents did not find it satisfactory. Relevance to clinical practice. Staff members must pay attention to residents’ need to talk with people. For many older people, talking is perhaps the most important ‘activity’ at care homes. Nurses must safeguard residents’ self‐determination. When residents are in control of their lives, they may become satisfied with time.     

Forgotten resources of older home care clients: Focus group study in Finland

In this qualitative focus group study, the resources available to older home‐dwelling people, particularly incoming and existing home care clients, are described from the viewpoint of home care professionals (n = 32). The data were analyzed using inductive content analysis. There were three categories of older people requiring resources from the viewpoint of interviewers: home‐dwelling people, incoming home care clients, and existing home care clients. Based on the analysis, the resources of older home‐dwelling people were categorized in terms of support, meaningful life, everyday activities, and environment. Incoming home care client resources were support, out‐of‐home activities, in‐home activities, and environment. Existing client resources were described in terms of support, everyday activities, and environment. Home care professionals described the resources of the older home‐dwelling people in diverse ways, but those of the perspective of existing clients were reduced. The biggest difference was in everyday activities. Psychological and social resources, including meaningful life and social relationships, seemed to be forgotten. All available resources must be taken into account, especially in the everyday home care services for existing home care clients.     

Patient‐centeredness in long‐term care of older patients – a structured interview

Aim. The aim of this study was to describe assessments of older people about patient‐centeredness in the long‐term care of Estonian hospitals, and to determine correlations between patients’ assessments and their socio‐demographic characters. Background. Patient‐centeredness increases patients’ satisfaction and enhances their recovery. Still, patients’ opinions are not always taken into account. Method. A cross‐sectional study included 111 older people in long‐term care of 14 Estonian hospitals. Data were collected in 2008 by means of structured interviews. Results. What patients agreed most was that they were given enough opportunity to carry out activities they were capable of performing themselves. Two thirds of participants had not been sufficiently consulted on who would be providing their care. Half of the participants were not given sufficient opportunity to decide what kind of care was needed and how they would receive it. The more assistance patients needed in daily living activities, the less they considered the care as patient‐centred. Conclusions. From the perspective of older people, the patient‐centeredness in Estonian long‐term care is above average. Providing patient‐centred long‐term care in Estonian hospitals deserves more attention. Relevance to clinical practice. Older people should be more involved in decision‐making, especially those who need more assistance in daily living activities.     

Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice

Title. Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice. Aim. This paper is a discussion of evidence‐based core measures for developmental care in neonatal intensive care units. Background. Inconsistent definition, application and evaluation of developmental care have resulted in criticism of its scientific merit. The key concept guiding data organization in this paper is the United States of America’s Joint Commission’s concept of ‘core measures’ for evaluating and accrediting healthcare organizations. This concept is applied to five disease‐ and procedure‐independent measures based on the Universe of Developmental Care model. Data sources. Electronically accessible, peer reviewed studies on developmental care published in English were culled for data supporting the selected objective core measures between 1978 and 2008. The quality of evidence was based on a structured predetermined format that included three independent reviewers. Systematic reviews and randomized control trials were considered the strongest level of evidence. When unavailable, cohort, case control, consensus statements and qualitative methods were considered the strongest level of evidence for a particular clinical issue. Discussion. Five core measure sets for evidence‐based developmental care were evaluated: (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family‐centred care, and (5) the healing environment. These five categories reflect recurring themes that emerged from the literature review regarding developmentally supportive care and quality caring practices in neonatal populations. This practice model provides clear metrics for nursing actions having an impact on the hospital experience of infant‐family dyads. Conclusion. Standardized disease‐independent core measures for developmental care establish minimum evidence‐based practice expectations and offer an objective basis for cross‐institutional comparison of developmental care programmes.     

Discharging older people from hospital to care homes: implications for nursing

This paper summarizes a research study which explored the experiences of older people being discharged from hospital to nursing and residential homes in the North East of England. While there has been considerable research which has looked at the discharge of patients from hospital to their own homes, little literature could be found which addressed discharge to care homes. While this may reflect an assumption that this form of discharge is less problematic, it is arguable that this is only the case for staff - there is a body of literature on re-location which suggests that the move to a care home is a major life event for older people. Taking a qualitative approach, this study interviewed 20 older people and 17 of their family members after discharge from hospital to a care home. We found that few people had been offered opportunities to discuss their move with nurses, and that older people tended to adopt a stoical attitude. In focus groups, interviews and written responses from 23 members of staff in the hospital and in care homes, we found that there was a lack of clarity over whose role it was to initiate such discussions. The paper concludes with some discussion of the implications for nursing practice of changing care interfaces.     

Resident perspectives of the determinants of quality of life in residential care in Ireland

Title.  Resident perspectives of the determinants of quality of life in residential care in Ireland.
Aim.  This paper is a report of a study conducted to identify the determinants of quality of life for older people living in residential care, including exploration of mediating factors at personal and institutional levels and to construct a model of these.
Background.  The quality of life of older people living in residential care is an under-researched area. The focus in the gerontology literature has been on quality of care rather than quality of life for these people. There is emerging consensus, however, that quality of life for older people is a complex, multidimensional concept, incorporating both subjective and objective elements, whether people live at home or in residential care.
Method.  A grounded theory study was conducted in 2005–2006. A total of 101 interviews were undertaken with older people across 12 sites, representing different types of residential care in Northern Ireland. The constant comparative technique was used to analyse data.
Findings.  Four themes having an impact on the quality of life of residents were identified: ethos of care; sense of self and identity; connectedness; and activities and therapies. Mediating and facilitating and/or constraining factors for quality of life were also identified. The core category was conceptualized as 'maximizing potential'.
Conclusion.  Achieving optimal quality of life for older people in residential care will remain elusive unless all the factors which affect on it are taken into account by practitioners and policy-makers. Improving the quality of life of older people in residential care will require action in respect of all of the domains identified in this paper.