Care home services at the vanguard: a qualitative study exploring stakeholder views on the development and evaluation of novel, integrated approaches to enhancing healthcare in care homes

'I don't think they really link together, do they?' An ethnography of multi-professional involvement in advance care planning in nursing homes

BACKGROUND

Given the globally ageing population, care homes have an important role in delivering palliative and end-of-life care. Advance care planning (ACP) is promoted to improve the quality of end-of-life care in this setting. While many professionals can be involved in ACP, little is known about what influences multi-professional involvement and how multi-professional working impacts the ACP process in the UK. This study investigated multi-professional practice in relation to ACP in nursing homes.

DESIGN AND METHODS

An ethnography was undertaken in two UK nursing homes using multiple methods of data collection: observations, interviews and document review. Participants included the following: nursing home residents (n = 6), relatives (n = 4), nursing home staff (n = 19), and visiting health and social care professionals (n = 7). Analysis integrated thematic analysis, mapping of resident ACP trajectories and documentary analysis.

FINDINGS

This paper suggests that multi-professional and relatives' involvement in ACP was disjointed. Continuity and coordination were disrupted by misalignment of visiting professional and nursing home organisational structures. Findings show a 'knotworking' approach to teamwork and power imbalance between nursing home staff and visiting professionals, such as general practitioners. While residents wished their relatives to be involved in their ACP, this was not formally recognised, and limited support existed to facilitate their involvement.

CONCLUSION

The structure and organisation of multi-professional and relatives' involvement in ACP led to fragmentation of the process. This marginalised the voice of both the resident and nursing home staff, thereby limiting ACP as a tool to enhance quality of end-of-life care.

Exploring Potential Achievements and Barriers to Provide Homecare for Women with Preeclampsia: A Qualitative Study

BACKGROUND

Preeclampsia (PE) is one of the leading causes of mortality and complications during pregnancy. It seems that usual prenatal care is not enough for these patients. They require more assistance, support, and guidance from health professionals, and home care is an effective strategy in this regard. Also, Iran has no official or compiled program for home care in high-risk pregnancy. This study was designed to explore the potential achievements and barriers of home care for mothers with PE.

METHODS

In this qualitative study with conventional content analysis, twenty-eight participants (mothers with PE, maternal health policy-makers, and health care providers) were selected through purposeful sampling with maximum variation. Data were collected through semi-structured interviews until saturation was achieved. Simultaneously, data analysis was performed using MXQDA software. Finally, the main categories were extracted.

RESULTS

Seven main categories were extracted. Three main categories for the potential achievement included "family involvement in maternal care", "holistic maternal health promotion", and "improving utility of services". The other four categories emerged for barriers included: "more willingness to provide in-hospital medical care", "clients' concerns about cultural issues", "providers` unwillingness to delivery home care", and "insufficiency of infrastructures for home care".

CONCLUSION

Paying attention to home care advantages, based on the socio-cultural context of the community, making effort to remove the barriers, and organizing home care infrastructures contribute to improvement in the quality of care in women with PE.

A qualitative comparison of care home staff and palliative care specialists' experiences of providing end of life care to people living and dying with dementia in care homes in two countries: A focus group study

BACKGROUND

Palliative care for people with dementia dying in care homes is an important aspect of long-term care. Whilst there is consensus about the principles of palliative care, less is known about how care home staff negotiate and influence decisions around end of life and how organisational context shapes that process.

AIM

To explore the views and experiences of care home staff and palliative care specialists on end of life care in care homes and understand how care home settings affected palliative care provision in England and Australia.

DESIGN/PARTICIPANTS

Eight focus groups in Australia and England with care home staff and palliative care specialists (n = 49). Reflexive thematic analysis was undertaken.

FINDINGS

Australian participants reported collaboration between care home staff, visiting professions and family members though case conferences. English participants discussed resident-focussed involvement from specialists that was less formally organised. Negotiating roles and responsibilities in end of life care; the importance of relationships to overcome deficiencies in formal processes; and the legitimacy and authority of advance care planning at times of crisis were recurring themes. The organisation and embedding of end of life care in processes and practices of care homes differed; this closely linked to care home procedures in Australia but was less apparent in England.

CONCLUSION

In both countries, partnership working was recognised and valued as key to effective palliative care. Work that enables care home staff to identify challenges with visiting professionals, such as agreeing priorities for care and negotiating their shared responsibilities, may lead to context-sensitive, sustainable solutions.

GPs’ involvement to improve care quality in care homes in the UK: a realist review

Background

Organising health-care services for residents living in care homes is an important area of development in the UK and elsewhere. Medical care is provided by general practitioners in the UK, and the unique arrangement of the NHS means that general practitioners are also gatekeepers to other health services. Despite recent focus on improving health care for residents, there is a lack of knowledge about the role of general practitioners.

Objectives

First, to review reports of research and quality improvement (or similar change management) in care homes to explore how general practitioners have been involved. Second, to develop programme theories explaining the role of general practitioners in improvement initiatives and outcomes.

Design

A realist review was selected to address the complexity of integration of general practice and care homes.

Setting

Care homes for older people in the UK, including residential and nursing homes.

Participants

The focus of the literature review was the general practitioner, along with care home staff and other members of multidisciplinary teams. Alongside the literature, we interviewed general practitioners and held consultations with a Context Expert Group, including a care home representative.

Interventions

The primary search did not specify interventions, but captured the range of interventions reported. Secondary searches focused on medication review and end-of-life care because these interventions have described general practitioner involvement.

Outcomes

We sought to capture processes or indicators of good-quality care.

Data sources

Sources were academic databases [including MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Cumulative Index to Nursing and Allied Health Literature, PsycInfo® (American Psychological Association, Washington, DC, USA), Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA) and Cochrane Collaboration] and grey literature using Google Scholar (Google Inc., Mountain View, CA, USA).

Methods

Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines were followed, comprising literature scoping, interviews with general practitioners, iterative searches of academic databases and grey literature, and synthesis and development of overarching programme theories.

Results

Scoping indicated the distinctiveness of the health and care system in UK and, because quality improvement is context dependent, we decided to focus on UK studies because of potential problems in synthesising across diverse systems. Searches identified 73 articles, of which 43 were excluded. To summarise analysis, programme theory 1 was ‘negotiated working with general practitioners’ where other members of the multidisciplinary team led initiatives and general practitioners provided support with the parts of improvement where their skills as primary care doctors were specifically required. Negotiation enabled matching of the diverse ways of working of general practitioners with diverse care home organisations. We found evidence that this could result in improvements in prescribing and end-of-life care for residents. Programme theory 2 included national or regional programmes that included clearly specified roles for general practitioners. This provided clarity of expectation, but the role that general practitioners actually played in delivery was not clear.

Limitations

One reviewer screened all search results, but two reviewers conducted selection and data extraction steps.

Conclusions

If local quality improvement initiatives were flexible, then they could be used to negotiate to build a trusting relationship with general practitioners, with evidence from specific examples, and this could improve prescribing and end-of-life care for residents. Larger improvement programmes aimed to define working patterns and build suitable capacity in care homes, but there was little evidence about the extent of local general practitioner involvement.

Future work

Future work should describe the specific role, capacity and expertise of general practitioners, as well as the diversity of relationships between general practitioners and care homes.

Study registration

This study is registered as PROSPERO CRD42019137090.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 20. See the NIHR Journals Library website for further project information.

Experiences of a National Early Warning Score (NEWS) intervention in care homes during the COVID-19 pandemic: a qualitative interview study

BACKGROUND

The COVID-19 pandemic has taken a heavy toll on the care home sector, with residents accounting for up to half of all deaths in Europe. The response to acute illness in care homes plays a particularly important role in the care of residents during a pandemic. Digital recording of a National Early Warning Score (NEWS), which involves the measurement of physical observations, started in care homes in one area of England in 2016. Implementation of a NEWS intervention (including equipment, training and support) was accelerated early in the pandemic, despite limited evidence for its use in the care home setting.

OBJECTIVES

To understand how a NEWS intervention has been used in care homes in one area of North-East England during the COVID-19 pandemic, and how it has influenced resident care, from the perspective of stakeholders involved in care delivery and commissioning.

METHODS

A qualitative interview study with care home (n=10) and National Health Service (n=7) staff. Data were analysed using thematic analysis.

RESULTS

Use of the NEWS intervention in care homes in this area accelerated during the COVID-19 pandemic. Stakeholders felt that NEWS, and its associated education and support package, improved the response of care homes and healthcare professionals to deterioration in residents' health during the pandemic. Healthcare professionals valued the ability to remotely monitor resident observations, which facilitated triage and treatment decisions. Care home staff felt empowered by NEWS, providing a common clinical language to communicate concerns with external services, acting as an adjunct to staff intuition of resident deterioration.

CONCLUSIONS

The NEWS intervention formed an important part of the care home response to COVID-19 in the study area. Positive staff perceptions now need to be supplemented with data on the impact on resident health and well-being, workload, and service utilisation, during the pandemic and beyond.

Defining the concepts of a smart nursing home and its potential technology utilities that integrate medical services and are acceptable to stakeholders: a scoping review protocol

INTRODUCTION

Smart technologies, digital health and eHealth have been shown to enhance institutional elderly care. Because of the rapidly ageing societies, information technologies in geriatric healthcare are urgently needed. A lot of innovation in smart healthcare has occurred in the past decade, and its use in nursing care assessment, daily living activities and service management is yet to be defined. More fundamentally, the concepts, definitions and scopes of a smart nursing home are still vague. Thus, this scoping review aims to examine the extent, range (variety) and nature (characteristics) of evidence on the existing smart concepts and feasible healthcare technologies, types of medical services in nursing home settings and acceptability of a smart nursing home by the elderly people ≥60 years old, their caregivers, nursing home operators and government agencies.

METHODS AND ANALYSIS

This scoping review will be guided by the smart technology adoption behaviours of elder consumers theoretical model (Elderadopt) by Golant and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. First, we will conduct an internet search for nursing homes and websites and databases related to the stakeholders to retrieve the definitions, concepts and criteria of a smart nursing home (phase 1). Second, we will conduct an additional systematic electronic database search for published articles on any measures of technological feasibility and integration of medical services in nursing home settings and their acceptability by nursing home residents and caregivers (phase 2). The electronic database search will be carried out from 1999 to 30 September 2020 and limited to works published in English and Chinese languages. For phase 2, the selection of literature is further limited to residents of nursing homes aged ≥60 years old with or without medical needs but are not terminally ill or bed-bound. Qualitative data analysis will follow the Framework Methods and thematic analysis using combined inductive and deductive approaches, conducted by at least two reviewers.

ETHICS AND DISSEMINATION

This protocol is registered on osf.io (URL: https://osf.io/qtwz2/). Ethical approval is not necessary as the scoping review is not a primary study, and the information is collected from selected articles that are publicly available sources. All findings will be disseminated at conferences and published in peer-reviewed journals.

Effects of interorganisational information technology networks on patient safety: a realist synthesis

OBJECTIVE

Health services in many countries are investing in interorganisational networks, linking patients' records held in different organisations across a city or region. The aim of the systematic review was to establish how, why and in what circumstances these networks improve patient safety, fail to do so, or increase safety risks, for people living at home.

DESIGN

Realist synthesis, drawing on both quantitative and qualitative evidence, and including consultation with stakeholders in nominal groups and semistructured interviews.

ELIGIBILITY CRITERIA

The coordination of services for older people living at home, and medicine reconciliation for older patients returning home from hospital.

INFORMATION SOURCES

17 sources including Medline, Embase, CINAHL, Cochrane Library, Web of Science, ACM Digital Library, and Applied Social Sciences Index and Abstracts.

OUTCOMES

Changes in patients' clinical risks.

RESULTS

We did not find any detailed accounts of the sequences of events that policymakers and others believe will lead from the deployment of interoperable networks to improved patient safety. We were, though, able to identify a substantial number of theory fragments, and these were used to develop programme theories.There is good evidence that there are problems with the coordination of services in general, and the reconciliation of medication lists in particular, and it indicates that most problems are social and organisational in nature. There is also good evidence that doctors and other professionals find interoperable networks difficult to use. There was limited high-quality evidence about safety-related outcomes associated with the deployment of interoperable networks.

CONCLUSIONS

Empirical evidence does not currently justify claims about the beneficial effects of interoperable networks on patient safety. There appears to be a mismatch between technology-driven assumptions about the effects of networks and the sociotechnical nature of coordination problems.

PROSPERO REGISTRATION NUMBER

CRD42017073004.

The effects of interoperable information technology networks on patient safety: a realist synthesis

Background

Interoperable networks connect information technology systems of different organisations, allowing professionals in one organisation to access patient data held in another one. Health policy-makers in many countries believe that they will improve the co-ordination of services and, hence, the quality of services and patient safety. To the best of our knowledge, there have not been any previous systematic reviews of the effects of these networks on patient safety.

Objectives

The aim of the study was to establish how, why and in what circumstances interoperable information technology networks improved patient safety, failed to do so or increased safety risks. The objectives of the study were to (1) identify programme theories and prioritise theories to review; (2) search systematically for evidence to test the theories; (3) undertake quality appraisal, and use included texts to support, refine or reject programme theories; (4) synthesise the findings; and (5) disseminate the findings to a range of audiences.

Design

Realist synthesis, including consultation with stakeholders in nominal groups and semistructured interviews.

Settings and participants

Following a stakeholder prioritisation process, several domains were reviewed: older people living at home requiring co-ordinated care, at-risk children living at home and medicines reconciliation services for any patients living at home. The effects of networks on services in health economies were also investigated.

Intervention

An interoperable network that linked at least two organisations, including a maximum of one hospital, in a city or region.

Outcomes

Increase, reduction or no change in patients’ risks, such as a change in the risk of taking an inappropriate medication.

Results

We did not find any detailed accounts of the ways in which interoperable networks are intended to work and improve patient safety. Theory fragments were identified and used to develop programme and mid-range theories. There is good evidence that there are problems with the co-ordination of services in each of the domains studied. The implicit hypothesis about interoperable networks is that they help to solve co-ordination problems, but evidence across the domains showed that professionals found interoperable networks difficult to use. There is insufficient evidence about the effectiveness of interoperable networks to allow us to establish how and why they affect patient safety.

Limitations

The lack of evidence about patient-specific measures of effectiveness meant that we were not able to determine ‘what works’, nor any variations in what works, when interoperable networks are deployed and used by health and social care professionals.

Conclusions

There is a dearth of evidence about the effects of interoperable networks on patient safety. It is not clear if the networks are associated with safer treatment and care, have no effects or increase clinical risks.

Future work

Possible future research includes primary studies of the effectiveness of interoperable networks, of economies of scope and scale and, more generally, on the value of information infrastructures.

Study registration

This study is registered as PROSPERO CRD42017073004.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 40. See the NIHR Journals Library website for further project information.

Lessons learnt from the implementation of new care models in the NHS: a qualitative study of the North East Vanguards programme

OBJECTIVE

To examine lessons learnt from the implementation of five Vanguard initiatives in the North East of England.

DESIGN

Data collection comprised semistructured interviews with key informants at each site.

SETTING

The study took place across six local authority areas in the North East of England and within six clinical commissioning groups responsible for the delivery of each Vanguard's aims and objectives.

PARTICIPANTS

Sixty-six interviewees with participants from five Vanguard initiatives in the North East of England, including senior clinicians, project leads and directors, commissioners, and healthcare managers.

RESULTS

While the context for each Vanguard is separate and distinct, there also exists a set of common issues which have a regional dimension. Participants felt that the national programme helped to raise the profile of local change initiatives and also contributed to the wider understanding of regional service integration issues. At the same time our findings demonstrate that all five sites experienced, and were subject to, unrealistic pressure placed on them to deliver outcomes. Of particular concern among all sites was the sheer scale and pace of change occurring at the same time as the National Health Service was being tasked with making significant, if unrealistic, efficiency savings.

CONCLUSIONS

It is too early to conclude with any confidence that a successful outcome for the new care models programme will be forthcoming. While early indications show some encouraging signs of promise, the overall context in which the complex and ambitious changes are being implemented remains both fragile and fluid.

Hearing the voices of older adult patients: processes and findings to inform health services research

PLAIN ENGLISH SUMMARY

Whilst Patient and Public Involvement and Engagement (PPIE) are widely regarded as critical to developing clinical research, there is a perception that older adults may not be able to contribute and there is less emphasis on gaining a wide range of opinions before developing research questions or projects; for example an organisational change. This PPIE initiative used three PPIE processes including existing panels and wider networking to access older adults in the community who had used the hospital services and been discharged. Older adults expressed a range of views about their experience of discharge planning and this provided an important perspective on patients' research priorities associated with their personal independence. Efforts were taken to ensure representative views across a cross section of the population. As a result of this initial PPIE, a permanent, co-ordinated 'elders' panel has been established to ensure a representation of older adult views for research, service development and evaluation. This panel has permanent, fully supported members who provide reflection and feedback on any projects and programmes relating to older people's services in the City.

ABSTRACT

Background Clinical academic research and service improvement is planned using Patient and Public Involvement and Engagement (PPIE) but older PPIE participants are consulted less often due to the perception that they are vulnerable or hard to engage. Objectives To consult frail older adults about a recently adopted service, discharge to assess (D2A), and to prioritise services improvements and research topics associated with the design and delivery of discharge from hospital. To use successive PPIE processes to enable a permanent PPIE panel to be established. Participants Following guidance from an established hospital PPI panel 27 older adult participants were recruited. Participants from Black, Asian and Minority Ethnic (BAME) communities, affluent and non-affluent areas and varied social circumstances were included. Methods Focus groups and individual interviews were conducted in participants own homes or nearby social venues. Results Priorities for discharge included remaining independent despite often feeling lonely at home; to remain in hospital if needed; and for services to ensure effective communication with families. The main research priority identified was facilitating independence, whilst establishing a permanent PPIE panel involving older adults was viewed favourably. Conclusions Taking a structured approach to PPIE enabled varied older peoples' voices to express their priorities and concerns into early discharge from hospital, as well as enabling the development of health services research into hospital discharge planning and management. Older people as participants identified research priorities after reflecting on their experiences. Listening and reflection enabled researchers to develop a new "Community PPIE Elders Panel" to create an enduring PPIE infrastructure for frail older housebound people to engage in research design, development and dissemination.