Promoting Patient and Family Partnerships in Ambulatory Care Improvement: A Narrative Review and Focus Group Findings

Introduction

Ambulatory practices that actively partner with patients and families in quality improvement (QI) report benefits such as better patient/family interactions with physicians and staff, and patient empowerment. However, creating effective patient/family partnerships for ambulatory care improvement is not yet routine. The objective of this paper is to provide practices with concrete evidence about meaningfully involving patients and families in QI activities.

Methods

Review of literature published from 2000–2015 and a focus group conducted in 2014 with practice advisors.

Results

Thirty articles discussed 26 studies or examples of patient/family partnerships in ambulatory care QI. Patient and family partnership mechanisms included QI committees and advisory councils. Facilitators included process transparency, mechanisms for acting on patient/family input, and compensation. Challenges for practices included uncertainty about how best to involve patients and families in QI. Several studies found that patient/family partnership was a catalyst for improvement and reported that partnerships resulted in process improvements. Focus group results were concordant.

Conclusion

This paper describes emergent mechanisms and processes that ambulatory care practices use to partner with patients and families in QI including outcomes, facilitators, and challenges.

Funding

Gordon and Betty Moore Foundation.

     

Angioedema in the emergency department: a practical guide to differential diagnosis and management

Background

Angioedema is a common presentation in the emergency department (ED). Airway angioedema can be fatal; therefore, prompt diagnosis and correct treatment are vital.

Objective of the review

Based on the findings of two expert panels attended by international experts in angioedema and emergency medicine, this review aims to provide practical guidance on the diagnosis, differentiation, and management of histamine- and bradykinin-mediated angioedema in the ED.

Review

The most common pathophysiology underlying angioedema is mediated by histamine; however, ED staff must be alert for the less common bradykinin-mediated forms of angioedema. Crucially, bradykinin-mediated angioedema does not respond to the same treatment as histamine-mediated angioedema. Bradykinin-mediated angioedema can result from many causes, including hereditary defects in C1 esterase inhibitor (C1-INH), side effects of angiotensin-converting enzyme inhibitors (ACEis), or acquired deficiency in C1-INH. The increased use of ACEis in recent decades has resulted in more frequent encounters with ACEi-induced angioedema in the ED; however, surveys have shown that many ED staff may not know how to recognize or manage bradykinin-mediated angioedema, and hospitals may not have specific medications or protocols in place.

Conclusion

ED physicians must be aware of the different pathophysiologic pathways that lead to angioedema in order to efficiently and effectively manage these potentially fatal conditions.

     

Patients’ and healthcare professionals’ experiences and perceptions of physiotherapy services in the emergency department: a qualitative systematic review

Background

Worldwide, emergency department (ED) attendances and admissions to acute care have increased significantly. Many EDs are adding physiotherapists to their team thereby allowing doctors to see more cases that are ‘urgent’. This is a move away from the ‘traditional’ physiotherapy service whereby the ED team refers patients to an outpatient physiotherapy service sometimes resulting in significant delays. Internationally, there is no agreed consensus on the role or value of ED-based physiotherapists.

Aim

The objective of this review was to retrieve, critically appraise and synthesise the evidence from studies relating to patients’ and healthcare professionals’ experiences and/or perceptions of physiotherapy services in the ED.

Method

This is a systematic review (SR) synthesising qualitative studies, which have considered patients’ (population 1) and healthcare professionals’ (population 2) experiences and/or perceptions (outcomes) of ED physiotherapy services (exposure). A comprehensive systematic search, limited to English language articles, was undertaken on seven electronic medical databases (Medline, EMBASE, CINAHL, AMED, BNI, PubMed and PEDro) for the period January 2006 to October 2016. Grey literature was identified using Google Scholar, reference lists and website searching. The Critical Appraisal Skills Programme (CASP) qualitative checklist was used to appraise all included studies. All studies were data extracted and quality appraised by two reviewers to enhance rigour and reduce bias.

Results

A total of 2163 studies were screened, 10 received full-text review and 7 studies were included in the final review. Six of the studies originated in Australia and one from the USA. The themes that emerged were as follows:

• Patients and healthcare professionals view ED-based physiotherapists as having (1) expert clinical skills and (2) an educational role.
• There is role confusion and lack of integration of the ED-based physiotherapist within the ED team.

Conclusion

This review adds an in-depth human perspective to the current ED physiotherapy literature, which provides insight into how ED healthcare services and physiotherapy services specifically should be developed and delivered in the future. The knowledge from this review has implications for future education programmes, as well as development of both new care pathways and physiotherapy clinical roles.Research into ED-based physiotherapy services is predominantly quantitative. Despite the newness of the ED physiotherapy role, this review reveals that the provision of physiotherapists within EDs contributes value to both patients and staff. However, the dominance of Australian research means it is uncertain how it translates to the UK or elsewhere. There needs to be further UK-based research.

     

Design and implementation of a medical student hazardous materials response team: the Medical Student HazMat Team

Background

To design and implement a replicable disaster training curriculum for the first on-call medical student hazardous materials response team.

Methods

Twenty-eight first-year medical students participated in a simulated citywide bioterrorism disaster drill. Students were notified of the Code Orange via email, a pager system, and group SMS text message. Twenty-five students participated in the drill, while the three remaining student leaders worked with the ED staff and HazMat Branch Director to ensure that all protocols were followed properly. Five groups of five students took turns donning HazMat gear, decontaminating three mannequins (an infant, a child, and an unconscious adult), and then safely removing the gear.

Results

All modes of communication were received within 5 min, and all the students arrived at the ED within 20 min. The decontamination was determined to be sufficient by the team leader, Emergency Department staff, and HazMat Branch Director and was completed approximately 10 min after the entrance to the decontamination chamber.

Conclusions

Current US medical school curricula lack emergency preparedness training in response to potential terrorist attacks and hazardous material exposures. Our program, while still in its early workings, not only allows students to develop critical knowledge and practical skills but also provides a unique opportunity to leverage much-needed manpower and resources during emergency situations.

     

Chapter 6. Protection of patients and staff during a pandemic

Purpose

To provide recommendations and standard operating procedures (SOPs) for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on protection of patients and staff.

Methods

Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including protection of patients and staff.

Results

Key recommendations include: (1) prepare infection control and occupational health policies for clinical risks relating to potential disease transmission; (2) decrease clinical risks and provide adequate facilities through advanced planning to maximise capacity by increasing essential equipment, drugs, supplies and encouraging staff availability; (3) create robust systems to maintain staff confidence and safety by minimising non-clinical risks and maintaining or escalating essential services; (4) prepare formal reassurance plans for legal protection; (5) provide assistance to staff working outside their normal domains.

Conclusions

Judicious planning and adoption of protocols for protection of patients and staff are necessary to optimise outcomes during a pandemic.

     

Influence of social characteristics on use of paediatric emergency care in Sweden - a questionnaire based study

Background

Parental social characteristics influence the use of emergency departments (ED) in the USA, but less is known about paediatric ED care-seeking in countries with national health insurance. This prospective study was designed to evaluate associations between parental care-seeking and social characteristics, with emphasis on impact of non-native origin, at a paediatric ED in Sweden, a European country providing paediatric healthcare free of charge.

Methods

Parents attending a paediatric ED at a large urban university hospital filled out a questionnaire on social characteristics and reasons for care-seeking. Information on patient characteristics and initial management was obtained from ED registers and patient records. Paediatric ED physicians assessed the medical appropriateness of each patient visit triaged for ED care.

Results

In total, 962 patient visits were included. Telephone healthline service before the paediatric ED visit was less often used by non-native parents (63/345 vs. 249/544, p?<?0.001). Low-aquity visits, triaged away from the ED, were more common among non-native parents (80/368 vs. 67/555, OR?=?1.66; p?=?0.018), and among those reporting lower abilities in the Swedish language (23/82 vs. 120/837, OR?=?2.66; p?=?0.003). Children of non-native parents were more often assessed by physicians not to require ED care (122/335 vs. 261/512, OR?=?0.70; p?=?0.028).

Conclusions

This study confirms more direct and less urgent use of paediatric ED care by parents of non-native origin or with limited abilities in the Swedish language, proposing that parental social characteristics influence paediatric ED care-seeking, also in a country with healthcare free of charge, and that specific needs of these groups should be better met by prehospital medical services.

     

Dealing with professional misconduct by colleagues in home care: a nationwide survey among nursing staff

Background

Professional misconduct in healthcare, a (generally) lasting situation in which patients are at risk or actually harmed, can jeopardise the health and well-being of patients and the quality of teamwork. Two types of professional misconduct can be distinguished: misconduct associated with incompetence and that associated with impairment. This study aimed to (1) quantify home-care nursing staff’s experiences with actual or possible professional misconduct; (2) provide insight into the difficulty home-care nursing staff experience in reporting suspicions of professional misconduct within the organisation and whether this is related to the individual characteristics of nursing staff; and (3) show which aspects of professional practice home-care nursing staff consider important in preventing professional misconduct.

Methods

A questionnaire survey was held among registered nurses and certified nursing assistants employed in Dutch home-care organisations in 2014. The 259 respondents (60 % response rate; mean age of 51; 95 % female) were members of the Dutch Nursing Staff Panel, a nationwide group of nursing staff members in various healthcare settings.

Results

Forty-two percent of the nursing staff in home care noticed or suspected professional misconduct by another healthcare worker during the previous year, predominantly a nursing colleague. Twenty to 52 % of the nursing staff experience difficulty in reporting suspicions of different forms of incompetence or impairment. This is related to educational level (in the case of incompetence), and managerial tasks (both in the case of incompetence and of impairment). Nursing staff consider a positive team climate (75 %), discussing incidents (67 %) and good communication between healthcare workers (57 %) most important in preventing professional misconduct among nursing staff.

Conclusions

Suspicions of professional misconduct by colleagues occur quite frequently among nursing staff. However, many nursing staff members experience difficulty in reporting suspicions of professional misconduct, especially in the case of suspected impairment. Home-care employers and professional associations should eliminate the barriers that nursing staff may encounter when they attempt to raise an issue. Furthermore, advocating a positive team climate within nursing teams, encouraging nursing staff to discuss incidents and facilitating this, and promoting good communication between healthcare workers may be appropriate strategies that help reduce professional misconduct by nursing staff.

     

Technology assessment and cost-effectiveness in orthopedics: how to measure outcomes and deliver value in a constantly changing healthcare environment

Purpose of review

The purpose of this study is to review the basic concepts of healthcare value, patient outcome measurement, and cost-effectiveness analyses as they relate to the introduction of new surgical techniques and technologies in the field of orthopedic surgery.

Recent findings

An increased focus on financial stewardship in healthcare has resulted in a plethora of cost-effectiveness and patient outcome research. Recent research has made great progress in identifying orthopedic technologies that provide exceptional value and those that do not meet adequate standards for widespread adoption.

Summary

As the pace of technological innovation advances in lockstep with an increased focus on value, orthopedic surgeons will need to have a working knowledge of value-based healthcare decision-making. Value-based healthcare and cost-effectiveness analyses can aid orthopedic surgeons in making ethical and fiscally responsible treatment choices for their patients.

     

Perceptions of Oncologists,Healthcare Policy Makers,Patients and the General Population on the Value of Pharmaceutical Treatments in Oncology

Introduction

The purpose of this study was to explore the main factors explaining the relative weight of the different attributes that determine the value of oncologic treatments from the different perspectives of healthcare policy makers (HCPM), oncologists, patients and the general population in Spain.

Methods

Structured interviews were conducted to assess: (1) the importance of the attributes on treatment choice when comparing a new cancer drug with a standard cancer treatment; (2) the importance of survival, quality of life (QoL), costs and innovation in cancer; and (3) the most worrying side effects related to cancer drugs.

Results

A total of 188 individuals participated in the study. For all participants, when choosing treatments, the best rated characteristics were greater efficacy, greater safety, treatment adaptation to patients’ individual requirements and the rapid reincorporation of patients to their daily activities. There were important differences among participants in their opinion about survival, QoL and cost. In general, oncologists, patients, and the general population gave greater value to gains in QoL than healthcare policy makers. Compared to other participants healthcare policy makers gave greater importance to the economic impact related to oncology treatments.

Conclusions

Gains in QoL, survival, safety, cost and innovation are perceived differently by different groups of stakeholders. It is recommended to consider the perspective of different stakeholders in the assessment of a new cancer drugs to obtain more informed decisions when deciding on the most appropriate treatment to use.

Funding

Eli Lilly & Co, Madrid (Spain).

     

Patienten mit chronischen Schmerzsyndromen

Background

The study was performed to reveal the effect of an individualized personal outpatient therapy program, based on a multidisciplinary assessment, on pain and health-related quality of life in patients with chronic pain.

Methods

Fifty patients were prospectively evaluated before and 3 months after establishment of an individualized outpatient therapy program. Health-related quality of life, pain and pain-related disability, depression and motivation to adopt self-management of chronic pain were assessed. Therapy adherence was tested with a structured interview.

Results

Only marginal improvements were observed in terms of pain and health-related quality of life. Therapy adherence varied between the different therapies.

Conclusions

An individualized personal outpatient therapy program has only marginal effects on pain and health-related quality of life in patients with chronic pain.

     

The stigma of schizophrenia from patients' and relatives' view: A pilot study in an Italian rehabilitation residential care unit

Objective

To identify the constituent elements of the stigma from the perspective of those having first-hand experiences of it.

Methods

Subjective experiences of stigma were explored in six focus groups: three with people suffering from schizophrenia and three with patients' relatives. Focus group sessions were tape-recorded, transcribed and analyzed by means of an inductive method, forming categories from the texts, as a basis for coding. Analysis aimed at establishing a typology of stigmatization experiences from the spoken words of the focus group participants.

Results

Four dimensions of stigma were identified: access to social roles; internalization of stigma; quality of mental health services, public image of mental illness.

Conclusion

The most frequently found topics concerned experiences of marginalization and discrimination that people with schizophrenia experience in their daily life. These results mirror the findings of similar studies obtained in other cultural contexts.

     

Olanzapine vs haloperidol: treating delirium in a critical care setting

Objective

To compare the safety and estimate the response profile of olanzapine, a second-generation antipsychotic, to haloperidol in the treatment of delirium in the critical care setting.

Design

Prospective randomized trial

Setting

Tertiary care university affiliated critical care unit.

Patients

All admissions to a medical and surgical intensive care unit with a diagnosis of delirium.

Interventions

Patients were randomized to receive either enteral olanzapine or haloperidol.

Measurements

Patient’s delirium severity and benzodiazepine use were monitored over 5 days after the diagnosis of delirium.

Main results

Delirium Index decreased over time in both groups, as did the administered dose of benzodiazepines. Clinical improvement was similar in both treatment arms. No side effects were noted in the olanzapine group, whereas the use of haloperidol was associated with extrapyramidal side effects.

Conclusions

Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom haloperidol is contraindicated.

     

Psychiatric patients turnaround times in the emergency department

Background

To analyze the turnaround times of psychiatric patients within the Emergency Department (ED) from registration to discharge or hospitalization in a University Hospital in 2002.

Methods

Data from a one-year period of psychiatric admissions to the emergency service at a University Hospital were monitored and analyzed focused on turnaround times within the ED. Information on patients variables such as age, sex, diagnosis, consultations and diagnostic procedures were extracted from the patients' charts.

Results

From 34.058 patients seen in the ED in 2002, 2632 patients were examined by psychiatrists on duty. Mean turnaround time in the ED was 123 (SD 97) minutes (median 95). Patients to be hospitalized on a psychiatric ward stayed shorter within the ED, patients who later were admitted to another faculty, were treated longer in the ED. Patients with cognitive or substance related disorders stayed longer in the ED than patients with other psychiatric diagnoses. The number of diagnostic procedures and consultations increased the treatment time significantly.

Conclusion

As the number of patients within the examined ED increases every year, the relevant variables responsible for longer or complicated treatments were assessed in order to appropriately change routine procedures without loss of medical standards. Using this basic data, comparisons with the following years and other hospitals will help to define where the benchmark of turnaround times for psychiatric emergency services might be.

     

Attitude of patients,healthcare professionals,and noninjured lay persons towards online video instructions on mild traumatic brain injury: a cross-sectional study

Background

The objective of this study was to determine the attitude of patients, healthcare professionals, and noninjured lay persons towards adding a video with discharge instructions to patient care for patients with mild traumatic brain injury (MTBI). A survey was conducted at the emergency department (ED). Participants consisted of MTBI patients (n = 50), healthcare professionals (n = 50), and noninjured lay persons (n = 50). The participants viewed a video with discharge instructions on MTBI and filled out a questionnaire that measured their attitude towards the use of a video as part of discharge instructions.

Findings

Nearly all healthcare professionals (94%) and 70% of the noninjured lay persons considered the video to be a valuable addition to oral discharge instructions. For 84% of patients, verbal information from the doctor is of importance. And, 50% of patients would like to receive additional video discharge instructions.

Conclusions

The majority of noninjured lay persons and healthcare professionals and half of the MTBI patients consider a video with discharge instructions to be a valuable addition to patient care. Video discharge instructions are a relative low-cost measure that could enhance patient care at the ED, provided that this does not compromise the personal contact between patient and healthcare professional.

     

Knowledge about systemic inflammatory response syndrome and sepsis: a survey among Dutch emergency department nurses

Background

Sepsis has a high mortality. Early recognition and timely treatment are essential for patient survival. The aim of this study is to examine the factors that influence the knowledge and recognition of systemic inflammatory response syndrome (SIRS) criteria and sepsis by emergency department (ED) nurses.

Methods

A prospective, multi-center study including 216 ED nurses from 11 hospitals and academic medical centers in The Netherlands was conducted in 2013. A validated questionnaire was used to evaluate ED nurses’ knowledge about SIRS and sepsis. Questions about demographic characteristics were also included, to investigate factors that may contribute to the knowledge about SIRS and sepsis.

Results

The mean total score was 15.9 points, with a maximum possible score of 29 points. ED nurses employed at hospitals with a level 3 intensive care unit (ICU) scored significantly higher than their colleagues employed at hospitals with a level 1 or 2 ICU. Recently completed education in sepsis was associated with a higher score. The employees in low ICU level hospitals who reported recent education did not score significantly lower than their ICU level 3 colleagues. ED nurses over the age of 50 scored significantly lower than their younger colleagues.

Conclusions

The knowledge of ED nurses concerning SIRS and sepsis rises proportionally with the level of ICU in hospitals. Recent education in sepsis raises knowledge level as well. We recommend that when there is a low exposure rate to SIRS and sepsis, more emphasis should be placed on regular education.

     

Bomb blast injuries: an exploration of patient characteristics and outcome using Pakistan National Emergency Departments Surveillance (Pak-NEDS) data

Background

Bomb blast injuries result in premature deaths and burdening of healthcare systems. The objective of this study was to explore the characteristics and outcome of patients presenting to the emergency departments in Pakistan with bomb blast injuries.

Methods

Active surveillance was conducted in seven major emergency departments of Pakistan from November 2010-March 2011. All the sites are tertiary care urban centers. All the patients who presented to the hospital's emergency department (ED) following a bomb blast injury as per self-report or the ambulance personnel were included in the study. Frequency of demographics, injury pattern, and outcomes were calculated.

Results

A total of 103 patients with bomb blast injuries presented to the selected emergency departments. The median age of patients was 30 years. Around three-fourth of the patients were males (n = 74, 74.7%). Most of the bomb blast patients were seen in Peshawar (n = 41, 39.8%) and Karachi city (n = 31, 30.1%) and the most common mode of arrival was non-ambulance transport (n = 71, 76.3%). Upper limb injuries (n = 12, 40%) were common in the under 18 age group and lower limb injuries (n = 31, 39.2%) in the 18 years and above group. There were a total of 8 (7.7%) deaths reported out of these 103 patients.

Conclusion

Bomb blast injuries in Pakistan generally affect young males. Non-ambulance transport is the most common way to access emergency departments (ED). Overall ED mortality is high and capturing data during a disaster in an emergency department is challenging.

     

More age-care staff report helping care recipients following a brief depression awareness raising intervention

Background

Those working with elderly care recipients require a good working knowledge of depression and appropriate help giving responses. While it is important for age-care staff to recognize depression in care recipients it is also critical that they know the appropriate course of action to assist a care recipient who may be depressed. This study aims to determine the knowledge of age-care staff of appropriate help giving responses, their confidence in knowing what kind of assistance to provide and their actual likelihood of providing help to potentially depressed care recipients and to examine if these measures improve following an intervention training program.

Methods

One hundred and two age-care staff were surveyed on their confidence in helping age-care recipients and on their knowledge of appropriate ways to provide assistance. Staff then participated in a two hour depression awareness raising intervention. The survey was repeated immediately following the training and again six months later.

Results

Staff confidence in knowing how to provide assistance increased significantly subsequent to training and remained significantly improved at the six month follow up. In addition, a significantly higher proportion of staff reported helping care recipients at the six month follow up.

Conclusions

This study highlights the potential of a brief staff training program to provide a cost effective means to improve staff self-confidence and increase the likelihood of staff providing assistance to depressed care recipients.

     

Experience in the use of the palliative care outcome scale

Goals of work

The objective of the study is to assess the Palliative Care Outcome Scale (POS) as a potential audit tool within a specialist cancer centre. It also aims to answer the following questions: does the tool identify problem areas and demonstrate changes in quality of life over time? How well do staff and patient ratings correlate?

Patients and methods

The POS questionnaire was piloted at a specialist cancer centre. Thirty consecutive patients admitted to the palliative care wards and ward staff completed questionnaires on admission and twice weekly until discharge or death. A further questionnaire assessed staff attitudes.

Results

There was a significant improvement in overall patient POS score at 1 week (days 5–9). Four “symptoms” or issues were scored as being important for our patients: pain, other symptoms, anxiety and patient’s perception of family anxiety. These all significantly improved within the first week. At the initial assessment, staff underestimated patients’ pain and overestimated problems relating to information giving and patients’ ability to share their feelings. There was no significant difference between staff and patient scores after 1 week. The other six areas covered by the tool were less important; this may reflect the patient population seen at our centre. Use of the tool identified areas for staff training and effectively demonstrated improvement in patient care.

Conclusion

The POS is an outcome measure tool designed to assess physical, psychological, practical and existential aspects of quality of life. It may be useful in identifying problems in individual patients and directing care to address these needs.

     

Once-Daily Triple Therapy in Patients with Advanced COPD: Healthcare Resource Utilization Data and Associated Costs from the FULFIL Trial

Introduction

Chronic obstructive pulmonary disease is associated with a high healthcare resource and cost burden. Healthcare resource utilization was analyzed in patients with symptomatic chronic obstructive pulmonary disease at risk of exacerbations in the FULFIL study. Patients received either once-daily, single inhaler triple therapy (fluticasone furoate/umeclidinium/vilanterol) 100 µg/62.5 µg/25 µg or twice-daily dual inhaled corticosteroid/long-acting beta agonist therapy (budesonide/formoterol) 400 µg/12 µg.

Methods

FULFIL was a phase III, randomized, double-blind, double-dummy, multicenter study. Unscheduled contacts with healthcare providers were recorded by patients in a daily electronic diary; the costs of healthcare resource utilization were calculated post hoc using UK reference costs.

Results

Over 24 weeks, slightly fewer patients who received fluticasone furoate/umeclidinium/vilanterol (169/911; 18.6%) required contacts with healthcare providers compared with budesonide/formoterol (180/899; 20.0%). Over 52 weeks in an extension population, fewer patients who received fluticasone furoate/umeclidinium/vilanterol required unscheduled contacts with healthcare providers compared with budesonide/formoterol (25.2% vs. 32.7%). Non-drug costs per treated patient per year were lower in the fluticasone furoate/umeclidinium/vilanterol group than the budesonide/formoterol group over 24 and 52 weeks (£653.80 vs. £763.32 and £749.22 vs. £988.03, respectively), with the total annualized cost over 24 weeks being slightly greater for fluticasone furoate/umeclidinium/vilanterol than budesonide/formoterol (£1,289.35 vs. £1,267.45).

Conclusions

This healthcare resource utilization evidence suggests that, in a clinical trial setting over a 24- or 52-week timeframe, non-drug costs associated with management of a single inhaler fluticasone furoate/umeclidinium/vilanterol are lower compared with twice-daily budesonide/formoterol.

Trial Registration

ClinicalTrials.gov number: NCT02345161.

Funding

GSK

     

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.