Organizational and structural reform in aged care organizations: empowerment towards a change process

Aims The aims were first to explore strategies for both structural and organizational reform by the process of action research, and second to use collective self-inquiry by all study participants as a way of examining problems and deciding on actions to bring about change. Rationale It was hoped that this process would empower the staff, aged residents and family members to own and therefore be meaningfully involved in improving practice and care standards. Background/introduction Three aged care centres expressed a desire to enhance the quality of care provided in order to meet the criteria for accreditation. They wanted to participate in a process that would assist them in critically examining their resource allocation, service delivery patterns and outcomes for residents. Research methods Original data were collected in three different aged care facilities over a three-year period from 1996 to 1998 in order to seek answers to the usefulness of action research in the change process. The methodology included participant observation, interviews and focus group discussions with all participants. Results/findings Organizational change occurred across the three centres with subsequent changes in the outcomes for both residents and staff. The themes which emerged from the data analysis process and which enhanced the participatory process included the need for flattened organizational structures and management's willingness to fully support the process and to be more transparent. The factors that inhibited the process included the organizational culture and tokenistic support by management. Discussion/conclusion Participatory action research was found to be a successful process for identifying and acting on the enhancers and inhibitors to structural and organizational reform.     

The integration of comprehensive psychiatric/mental health care into the primary health system: diagnosis and treatment

This research study was funded by the Health Systems Trust in Cape Town through the University of Natal in Durban. OBJECTIVES. The objectives of this study were to teach primary health care nurses to diagnose and treat common psychiatric conditions, to refer those patients whom they cannot handle, and to evaluate the implementation of these functions in their primary health care practice. METHODS. Twenty nurses from six clinics in one province of South Africa were trained, and implementation was studied. History taking, diagnosis, pharmacological treatment and referral were studied through record reviews. Record reviews were done by two independent psychiatrists, who achieved an inter-rater reliability of 0.68. RESULTS. Record reviews showed that at the end of the project nurses could take substantially complete psychiatric histories in 89% cases, five axis diagnoses were correct in 63% of cases, and when STAT medication was prescribed it was appropriate in 92% of cases. Appropriate long-term medication was prescribed in 60% of cases. ETHICAL ISSUES. Permission was obtained from the provincial office, the Municipal Offices and participating clinics. Informed consent was obtained by the registered nurses from all participating clients. LIMITATIONS. The sample for the clinics was not representative of all clinics in the Eastern Cape but a representation of rural-urban settings sampled from 20 clinics in a region. The sample of consumers was convenient and may not represent the client population in each clinic. For this reason the findings may not be a true reflection of the entire region, and generalization of the findings should be made at the utmost discretion of the reader.     

Perceptions of nurses towards oral health in palliative care: A qualitative study

BackgroundOral health problems among people receiving palliative care are common and can significantly affect quality of life. Nurses are at the frontline of palliative care in Australia. However, how optimal oral health care is addressed in clinical practice by palliative nurses is not known.AimTo explore the perceptions of nurses working in Australian palliative care settings to determine the acceptability, challenges and recommendations that need to be considered to develop and implement an oral health care model in palliative care settings.MethodsTwo focus groups were conducted with community (n = 8) and inpatient nurses (n = 10) working in urban palliative care settings.FindingsFour main themes were developed through consensus: 1) Oral health is important in the palliative care setting; 2) Additional training could enhance what nurses already do; 3) Barriers to receiving oral care: a structural issue; 4) Exploring alternative pathways to dental services.DiscussionNurses recognised the importance of oral health in palliative care; however, the paucity of set protocols based on existing guidelines meant that oral care was often unstructured. Systemic factors reduced the number of available options for people receiving palliative care to access professional dental treatment. Although alternative solutions, including teledentistry services, were explored, there were some constraints.ConclusionA palliative care oral health model of care would need to integrate existing formal guidelines into a comprehensive framework specific for palliative care nurses and develop palliative care oral health training for them taking into consideration existing barriers for people to receive professional dental treatment.     

Staff attitudes towards aggression in health care: a review of the literature

The aim of this literature review was to explore the attitudes of health care workers towards inpatient aggression and to analyse the extent to which attitudes, as defined from a theoretical point of view, were addressed in the selected studies. Databases from 1980 up to the present were searched, and a content analysis was done on the items of the selected studies. The concepts 'cognition' and 'attitude' from the framework of 'The Theory of Reasoned Action' served as categories. The self-report questionnaire was the most common instrument used and three instruments specifically designed to measure attitudes were found. These instruments lacked profound validity testing. From a total of 74 items, two thirds focussed on cognitions and only a quarter really addressed attitudes towards aggression. Research was particularly concerned with the cognitions that nurses had about aggression, and attitudes were studied only to a limited extent. Researchers used different instruments, which makes it difficult to compare results across settings.     

Patient and provider perspectives on reducing risk of harm in primary health care: a qualitative questionnaire study in Sweden

Abstract

Objective: To explore how patients, that had experienced harm in primary care, and how primary providers and practice managers understood reasons for harm and possibilities to reduce risk of harm.

Design: Inductive qualitative analysis of structured questionnaires with free text answers.

Setting: Primary health care in Sweden.

Patients/subjects: Patients (n?=?22) who had experienced preventable harm in primary health care, and primary care providers and practice managers, including 15 physicians, 20 nurses and 24 practice managers.

Main outcome measures: Categories and overarching themes from the qualitative analysis.

Results: The three categories identified as important for safety were continuity of care, communication and competence. With flaws in these, risks were thought to be greater and if these were strengthened the risks could be reduced. The overarching theme for the patient was the experience of being neglected, like not having been properly examined. The overarching theme for primary care providers and practice managers was lack of continuity of care.

Conclusion: Primary care providers, practice managers and patients understood the risks and how to reduce the risks of patient safety problems as related to three main categories: continuity of care, communication and competence. Future work towards a safer primary health care could therefore benefit from focusing on these areas.

• Key points

• Current awareness:

• ??Patients and primary care providers are rather untapped sources of knowledge regarding patient safety in primary health care.

• Main statements:

• ??Patients understood the risk of harm as stemming from that they were not properly examined.

• ??Primary care providers understood the risk of harm to a great extent as stemming from poor continuity of care.

• ??Patients, primary care providers and practice managers believed continuity, communication and competence play an important role in reducing risks.

     

Views of xerostomia among health care professionals: a qualitative study

Aim. To explore and describe views of xerostomia among health care professionals. Background. Xerostomia (dry mouth) is caused by changes in quality and quantity of saliva due to poor health, certain drugs and radiation therapy. It is a common symptom, particularly among older people and has devastating consequences with regard to oral health and general well‐being. Methods. Data were obtained and categorised by interviewing 16 health care professionals. Qualitative content analysis was chosen as the method of analysis. Design. Qualitative. Results. The latent content was formulated into a theme: xerostomia is a well‐known problem, yet there is inadequate management of patients with xerostomia. The findings identified three categories expressing the manifest content: awareness of xerostomia, indifferent attitude and insufficient support. Conclusions. Although xerostomia was recognised as commonly occurring, it was considered to be an underestimated and an ignored problem. Proper attention to conditions of xerostomia and subsequent patient management were viewed as fragmentary and inadequate. Additional qualitative studies among patients with xerostomia would be desirable to gain further understanding of the problems with xerostomia, its professional recognition and management. Relevance to clinical practice. A holistic view, positive professional attitudes and enhanced knowledge of xerostomia seem essential to augment collaboration among health care professionals and to improve compassion for and support of patients with xerostomia.     

Governing citizens and health professionals at a distance: A critical discourse analysis of policies of intersectorial collaboration in Danish health‐care

It is widely recognised that the delivery of services across health‐care sectors faces multiple challenges related to incoherence in patient pathways. There are multiple reasons for this incoherence, which are often dealt with through national legislation and policy‐making. This paper discusses policies as powerful actors and explores how effects of a concrete policy are adapted for intersectorial collaboration in Danish health‐care. The paper is based on a critical discourse analysis of a central policy document in Danish health‐care known as the ‘Health Agreements’. Using Fairclough's three‐dimensional model for discourse analysis, we explored the document to clarify the construction of actors participating in intersectorial collaboration. The analysis revealed the Health Agreement as a ‘negotiated text’, appearing as an overriding document legitimising one possible discourse regarding the premises of intersectorial collaboration. The premises of intersectorial collaboration are maintained through a specific presentation of actors leaving little room for discussion, where professionals are constructed as actors who are expected to develop ways of collaborating according to the Triple Aim approach in order to promote productivity and efficiency. Furthermore, this presentation constructs citizens and patients as active, participating individuals who consciously prioritise and act with the purpose of controlling their life situation.     

Trends in the perceived complexity of primary health care: a secondary analysis

Rationale If the complexity of the patient's medical problems increases or the complexity of the interactions between the doctor and the patient, the staff or the health care system increase, then complexity of patient care will increase. This study examined trends in patient complexity, and identified doctor, practice and improvement strategy characteristics associated with perceived complexity. Methods This secondary analysis used data from three Community Tracking Surveys with 22 134 primary care doctors completing surveys about themselves, their practice setting, practice improvement strategies and complexity of care in three consecutive 2‐year time periods (1996–1997, 1998–1999, 2000–2001). Data were analysed using hierarchical logistic regression. Results The proportion of primary care doctors who perceived that complexity of care had increased over the past 2 years rose from 31.5% to 35.9%. Perceived complexity of patient care was consistently related to being in solo practice and the belief that they could not frequently obtain high‐quality services and referrals for patients. As availability of services increased, complexity decreased whereas as use of practice improvement strategies increased, complexity also increased. Conclusions Understanding that we cannot determine whether respondents understood care as ‘complicated’ or ‘complex’, potential consequences of this increase in complexity include an increase in medical errors and referral rates along with decreased quality of patient care and career satisfaction.     

Getting it right: Educating professionals to work together in improving health and health care

Dedication

This paper is based on a lecture given by LAH as the 2nd John Horder lecture at Imperial College, London on 11 April 2006. Dr. Horder has been influential in improving patient outcomes in multiple ways, including his contributions to professional education. He was instrumental in the development of the Royal College of General Practitioners, serving as president from 1979–1982 and acting as a key leader in establishing post-graduate training for general practitioners in the United Kingdom. Dr Horder went on to found the Centre for the Advancement of Interprofessional Education, in part because of what he observed about the power of interprofessional collaboration in his own primary care practice. It was an honor to give a lecture in tribute to Dr John Horder. It was an opportunity to reflect on what we know about educating health professionals in training about the improvement of health care, including work I've helped to lead in the United States (where I now serve as the Senior Associate Dean for Education at the University of Missouri-Columbia School of Medicine). This paper also is dedicated to Dr. Horder.     

Asthma nurse practice improves outcomes and reduces costs in primary health care

OBJECTIVE: The aim of this study was to elucidate the care of patients with asthma in primary health care from medical, patient self-management, health, quality of life, and health economic perspectives. METHODS: Asthma nurse practice (ANP), an alternative asthma self-management strategy, was compared with traditional asthma care in primary health care in southern Sweden regarding medical history, lifestyle, self-management, symptoms caused by asthma, effects on sick leave, state of health, quality of life and health care costs. The first part of the investigation comprised a retrospective study of a randomly selected sample of patient records of asthmatics (n=152). The second part, lasting 3 months, was prospective and included consecutive patients visits (n=347). RESULTS: The ANP approach showed better results in most of the evaluated outcomes such as asthma quality documentation and self-management and the number of asthma symptoms was significantly lower. From a health economic perspective the results were encouraging with respect to ANP. CONCLUSION: This alternative asthma strategy, ANP, improved asthma care in primary health care and resulted in economic advantages in the health care sector. However the result may only be generalized to other practices working with asthma nurses in the same way.     

Psychosocial support as a counselling in improving health-related quality of life in patients with recent multiple sclerosis in Finland

Aim.  The aim of the study was to describe and explain psychosocial support provided by nursing personnel as experienced by people with multiple sclerosis.
Background.  The goal of providing psychosocial support is to understand and improve patients' health, self-care, initiative, commitment to care, resources, deal with emotions, social interaction and circumstances.
Design and methods.  Informants were individuals ( n  = 204) diagnosed using multiple sclerosis between the years 2003–2005 in Finland. Data were collected in 2005 by a posted questionnaire. The data were analysed with cross-tabulations, correlation coefficients, mean tests, a factor analysis and multiple regression analysis.
Results.  People with multiple sclerosis need psychosocial support from nursing personnel to promote health and self-care, strengthen emotional and mental resources and maintain social relationships. The support was to include information on multiple sclerosis and related treatment options, as well as discussion, listening to the patient and supporting them in the new situation in life caused by the illness.
Conclusion.  The psychosocial support received by the patients was sufficient and corresponded to their needs. Nursing personnel have the skills to improve the health-related quality of life of people with multiple sclerosis.
Relevance to clinical practice.  The results of this research may be applied in practical nursing, such as in planning of program of neuropsychosocial rehabilitation, in developing of home care and institutional care and in planning of content of nursing education.     

The team survey: a tool for health care team development

AIMS: The aim of this study was to validate a psychometric tool, the team survey, in a health care setting with a range of teams from a Large National Health Service (NHS) Trust. BACKGROUND: The team survey was developed by Millward and Ramsay (1998) to measure the team dimensions identified in the cognitive-motivational model of team effectiveness (Millward & Purvis 1998). The team dimensions are team potency, team identification, Shared Mental Models and team meta-cognitions. DESIGN AND METHODS: The psychometric properties of the tool as a reliable and valid predictor of team effectiveness was assessed by way of a survey of 10 teams (comprising 124 members in all) located on different premises, within a large NHS Trust. Team size ranged between 5 and 19 members, with average team size being 10 members. Two independent ratings of 'effectiveness' were made for each team. Factor and multiple regression analyses were employed to identify the most powerful predictors of health care team effectiveness from a cognitive and motivational perspective. RESULTS: The results suggest that the team survey is psychometrically robust within a health care setting. CONCLUSIONS: It is concluded that the tool has a potentially key role in informing and evaluating team development initiatives in support of the work of practice development nurses and nursing team leaders.     

Nursing attitudes towards acute mental health care: development of a measurement tool

AIM: This paper reports the development, piloting and validation of a tool to measure attitudes for use with nursing staff working in acute mental health care units. BACKGROUND: The quality of care provided for service users in acute mental health care has come under both scrutiny and severe criticism. The attitudes of staff working in these environments have been cited as a contributory factor in poor care. No measure of attitudes specific to acute mental health has been reported. METHODS: A 64-question measure was constructed and distributed to a sample of qualified and unqualified nurses drawn from seven mental health care units in the North of England. Exploratory factor analysis and a number of other statistical tests were performed to validate the questionnaire. RESULTS: Preliminary analysis reduced the original 64 questions to 37. Five components were retained, accounting for 42% of the variance, and the five rotated factors were identified. The resultant 'Attitudes Towards Acute Mental Health Scale' (ATAMHS) achieved good internal reliability, with a Cronbach's alpha of 0.72. CONCLUSION: The construction and validation of the ATAMHS measure will enable improved understanding of the attitudes of nursing staff working in acute mental health care settings to occur. This measure is available for use in a clinical area of nursing in which attitude change is of fundamental importance for future development of care.