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Dixon CA, Roos V, Katjene M, Hoffman J. Effective Relationships Between Younger Caregivers and Older Care Recipients Across a Continuum of Formal Residential Care Settings: A Scoping Review and a Critical Analysis. Public Health Rev 2024; 45:1606562. [PMID: 38601905 PMCID: PMC11004294 DOI: 10.3389/phrs.2024.1606562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 03/05/2024] [Indexed: 04/12/2024] Open
Abstract
Objective: This article aims to conduct a scoping review of what constitutes effective relational interactions between caregivers (CGs) and older persons (OPs) across formal residential care settings. Methods: A scoping review of publications between January 2000 and December 2021 yielded 10,929 articles, and after removing duplicates and applying exclusion criteria, 36 articles were analysed. Results: Articles were scrutinised for interactions involving both CGs and OPs, using a thematic framework analysis to identify effective relational constructs. Four themes emerged: 1) Diverse perspectives on the same context: for OPs it is home, and for CGs, workplace. 2) CGs move for a one-up position and OPs submit to a one-down, or as friends. 3) Relational qualities have been mostly associated with CGs, confirming care as a unidirectional action 4). Relationships between CGs and OPs result either in effective or ineffective care outcomes. Conclusion: The dual meanings attached to the same context limit the authentic interactions between CGs and OPs. We propose a relational caregiving approach by considering the interactions of both CGs and OPs, changing the relational definition, and demonstrating effective relational qualities.
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Affiliation(s)
- Carol-Ann Dixon
- Optentia Research Unit, North West University, Vanderbijlpark, South Africa
| | - Vera Roos
- Optentia Research Unit, North West University, Vanderbijlpark, South Africa
| | - Matthews Katjene
- Optentia Research Unit, North West University, Vanderbijlpark, South Africa
| | - Jaco Hoffman
- Optentia Research Unit, North West University, Vanderbijlpark, South Africa
- Oxford Institute of Population Ageing, University of Oxford, Oxford, United Kingdom
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Dewar J, Cook C, Smythe E, Spence D. A Heideggerian analysis of good care in an acute hospital setting: Insights from healthcare workers, patients and families. Nurs Inq 2023; 30:e12561. [PMID: 37199001 DOI: 10.1111/nin.12561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
This study articulates the relational constituents of good care beyond techno-rational competence. Neoliberal healthcare means that notions of care are readily commodified and reduced to quantifiable assessments and checklists. This novel research investigated accounts of good care provided by nursing, medical, allied and auxiliary staff. The Heideggerian phenomenological study was undertaken in acute medical-surgical wards, investigating the contextual, communicative nature of care. The study involved interviews with 17 participants: 3 previous patients, 3 family members and 11 staff. Data were analysed iteratively, dwelling with stories and writing and rewriting to surface the phenomenality of good care. The data set highlighted the following essential constituents: authentic care: caring encompassing solicitude (fürsorge); impromptu care: caring beyond role category; sustained care: caring beyond specialist parameters; attuned care: caring encompassing family and culture; and insightful care: caring beyond assessment and diagnosis. The findings are clinically significant because they indicate the importance of nurse leaders and educators harnessing the potential capacity of all healthcare workers to participate in good care. Healthcare workers reported that participating in or witnessing good care was uplifting and added meaning to their work, contributing to a sense of shared humanity.
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Affiliation(s)
- Jan Dewar
- School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology North Campus, Auckland, New Zealand
| | - Catherine Cook
- School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology North Campus, Auckland, New Zealand
| | - Elizabeth Smythe
- School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology North Campus, Auckland, New Zealand
| | - Deborah Spence
- School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology North Campus, Auckland, New Zealand
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Toles M, Leeman J, McKay MH, Covington J, Hanson LC. Adapting the Connect-Home transitional care intervention for the unique needs of people with dementia and their caregivers: A feasibility study. Geriatr Nurs 2022; 48:197-202. [PMID: 36274509 PMCID: PMC9749405 DOI: 10.1016/j.gerinurse.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 12/14/2022]
Abstract
AIMS After leaving skilled nursing facilities (SNF), 20% of people with dementia (PWD) are re-hospitalized within 30 days. We assessed fidelity, acceptability, preliminary outcomes, and mechanisms of the Connect-Home ADRD transitional care intervention. DESIGN A feasibility study of Connect-Home ADRD. METHODS The Connect-Home intervention was adapted for dementia-specific needs. PWD and caregiver dyads in 2 SNFs received transitional care. Data sources included interviews with PWD and caregivers and a review of health records. RESULTS 19 of 34 eligible dyads (56%) were enrolled. The intervention was feasible (components delivered for >84% of dyads) and acceptable (dyads rated it very helpful and not difficult to use). Connect-Home ADRD adaptations included in-home support to manage symptoms of dementia and unplanned events, such as transition to hospice. IMPACT Connect-Home ADRD is feasible, acceptable, and merits future research as an intervention to reduce rapid return to acute care following SNF stays.
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Affiliation(s)
- Mark Toles
- The University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, Campus Box #7460, Chapel Hill, NC 27599-7460, United States.
| | - Jennifer Leeman
- The University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, Campus Box #7460, Chapel Hill, NC 27599-7460, United States
| | - M Heather McKay
- Partnerships for Health, Manager, 169 Boone Square St #196, Hillsborough, NC 27278, United States
| | - Jacquelyn Covington
- The University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, Campus Box #7460, Chapel Hill, NC 27599-7460, United States
| | - Laura C Hanson
- The University of North Carolina at Chapel Hill, School of Medicine, 321 S Columbia St, Chapel Hill, NC 27599, United States
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Wang J, Bian X, Wang J. Understanding person-centered dementia care from the perspectives of frontline staff: Challenges, opportunities, and implications for countries with limited long-term care resources. Geriatr Nurs 2022; 46:39-45. [DOI: 10.1016/j.gerinurse.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
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Nursing Leadership – Transforming the Work Environment in Nursing Homes. Nurs Clin North Am 2022; 57:299-314. [DOI: 10.1016/j.cnur.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Naweed A, Stahlut J, O'Keeffe V. The Essence of Care: Versatility as an Adaptive Response to Challenges in the Delivery of Quality Aged Care by Personal Care Attendants. HUMAN FACTORS 2022; 64:109-125. [PMID: 33908808 PMCID: PMC8873967 DOI: 10.1177/00187208211010962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 03/22/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The strategies adopted by personal care attendants (PCAs) to deliver quality care when faced with challenges potentially impacting clinical outcomes were assessed using phenomenological methods. BACKGROUND In Australia, recent outcry of unsatisfactory standards of care in residential facilities has instigated a national public inquiry. This study investigated how PCAs adapted to challenges in stressful and ambiguous everyday work scenarios to deliver quality care. METHOD A phenomenological approach was used to obtain insights into PCAs' experiences, perceptions, opinions, and decision processes for enacting care. Ten PCAs working in rural-based residential aged care were interviewed using a novel scenario construction task with thematic and co-occurrence network mapping applied to derive insights. RESULTS Seven themes were identified, revealing that participants formed close relationships with residents, influencing care provision but blurring personal boundaries. Key contextual factors in scenarios highlighted inadequate staffing and procedures, inadequate training, challenging residents, time poverty, and low support. Individually directed adaptive strategies were used to alleviate dissonance and maintain emotional resilience, including dynamic risk assessment involving rule breaking. CONCLUSION The findings suggest that in negotiating care delivery, PCAs strive to optimize rule-based compliance with safety, efficiency, and individualized attention to provide "good enough" care with fluidity. Implications for policy and practice are considered. APPLICATION Findings have implications for workforce development in the context of ever-increasing industry pressures. Findings identified challenging scenarios and role complexity, with decision-making occurring as a fluid and ongoing process across a flexible boundary of risk assessment influencing interactions between PCAs, registered nurses, and clients.
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Cook CM, Schouten V, Henrickson M, McDonald S, Atefi N. Sexual harassment or disinhibition? Residential care staff responses to older adults' unwanted behaviours. Int J Older People Nurs 2021; 17:e12433. [PMID: 34708549 DOI: 10.1111/opn.12433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/01/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ethical complexity of residential care is especially apparent for staff responding to residents' inappropriate sexual expression, particularly when directed towards care workers as these residents are typically frail, often cognitively impaired, and require ongoing care. OBJECTIVES To explore staff accounts of how they made meaning of and responded to residents' unwanted sexual behaviours directed towards staff. This exploration includes whether staff appeared to accept harassment as a workplace hazard to be managed, or an unacceptable workplace violation, or something else. METHODS These qualitative data are drawn from a national two-arm mixed method study in Aotearoa New Zealand undertaken in 35 residential care facilities. Semi-structured interviews were conducted with 77 staff, residents and family members. Interpretive description was used to analyse the data. RESULTS Staff had numerous ways they used to respond to behaviours: (1) minimisation, deflection and de-escalation, where staff used strategies to minimise behaviours without requiring any accountability from residents; (2) holding residents accountable, where staff to some degree addressed the behaviour directly with residents; (3) blurred boundaries and complexities in intimate long-term care, where staff noted that in a context where touch is common-place, cognitive function was diminished and relationships were long-term, boundaries were easily breached; (4) dehumanising and infantilising residents' behaviours, where staff appeared to assert control through diminishing the residents' identity as an older person. It was evident that staff had developed considerable practice wisdom focused on preserving the care relationship although few referred to policy and education guiding practice. CONCLUSIONS Staff appeared to be navigating a complex ethical terrain with thoughtfulness and skill. Care workers seemed reluctant to label resident behaviour as sexual harassment, and the term may not fit for staff where they perceive residents are frail and cognitively impaired. IMPLICATIONS FOR PRACTICE Policy, education and clinical leadership are recommended to augment practice wisdom and ensure staff and resident safety and dignity and to determine how best to intervene with residents' unwanted sexual behaviours.
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Affiliation(s)
- Catherine M Cook
- School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Vanessa Schouten
- School of Humanities, Massey University, Palmerston North, New Zealand
| | - Mark Henrickson
- School of Social Work, Massey University, Auckland, New Zealand
| | - Sandra McDonald
- School of Nursing, Manukau Institute of Technology, Manukau City, New Zealand
| | - Narges Atefi
- School of Social Work, Massey University, Auckland, New Zealand
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Chamberlain SA, Duggleby W, Teaster PB, Fast J, Estabrooks CA. Challenges in Caring for Unbefriended Residents in Long-term Care Homes: A Qualitative Study. J Gerontol B Psychol Sci Soc Sci 2020; 75:2050-2061. [PMID: 32530034 DOI: 10.1093/geronb/gbaa079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study examined challenges experienced by long-term care staff in caring for unbefriended residents who are incapacitated and alone. These residents often are estranged from or have no living family or live geographically distant from them and require a public guardian as their surrogate decision-maker. To date, research on unbefriended older adults has focused on those living in acute care and community settings. Little is known about those living in long-term care homes. METHOD We conducted semi-structured interviews with 39 long-term care staff (e.g., registered nurses, care aides, social workers) and 3 public guardians. Staff were sampled from seven long-term care homes in Alberta, Canada. We analyzed interview transcripts using content analysis and then using the theoretical framework of complex adaptive systems. RESULTS Long-term care staff experience challenges unique to unbefriended residents. Guardians' responsibilities did not fulfill unbefriended residents' needs, such as shopping for personal items or accompanying residents to appointments. Consequently, the guardians rely on long-term care staff, particularly care aides, to provide increased levels of care and support. These additional responsibilities, and organizational messages dissuading staff from providing preferential care, diminish quality of work life for staff. DISCUSSION Long-term care homes are complex adaptive systems. Within these systems, we found organizational barriers for long-term care staff providing care to unbefriended residents. These barriers may be modifiable and could improve the quality of care for unbefriended residents and quality of life of staff. Implications for practice include adjusting public guardian scope of work, improving team communication, and compensating staff for additional care.
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Affiliation(s)
| | - Wendy Duggleby
- Faculty of Nursing, University of Alberta, Edmonton, Canada
| | - Pamela B Teaster
- College of Liberal Arts and Human Sciences, Virginia Polytechnic Institute and State University, Blacksburg
| | - Janet Fast
- Department of Human Ecology, Faculty of Agricultural Life and Environmental Sciences, University of Alberta, Edmonton, Canada
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Frey R, Balmer D, Boyd M, Robinson J, Gott M. Palliative care nurse specialists' reflections on a palliative care educational intervention in long-term care: an inductive content analysis. BMC Palliat Care 2019; 18:103. [PMID: 31744507 PMCID: PMC6864945 DOI: 10.1186/s12904-019-0488-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/12/2019] [Indexed: 12/02/2022] Open
Abstract
Background Older people in long-term care facilities are at a greater risk of receiving care at the end of life that does not adequately meet their needs, yet staff in long-term care are often unprepared to provide palliative care. The objective of the study was to explore palliative care nurse specialists’ experiences regarding the benefits of and barriers to the implementation of a palliative care educational intervention, Supportive Hospice Aged Residential Exchange (SHARE) in 20 long-term care facilities. Methods Reflective logs (465), recorded over the course of the yearlong SHARE intervention by the three palliative care nurse specialists from two local hospices, who were the on-site mentors, were qualitatively analyzed by two researchers utilizing inductive content analysis. Results Categories emerging from the logs include the importance of relationships, knowledge exchange, communication, and the challenges of providing palliative care in a long-term care setting. Conclusion Evidence from the logs indicated that sustained relationships between the palliative care nurse specialists and staff (registered nurses, healthcare assistants) as well as reciprocal learning were key factors supporting the implementation of this palliative care educational intervention. Challenges remain however in relation to staffing levels, which further emphasizes the importance of palliative care nurse specialist presence as a point of stability.
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Affiliation(s)
- Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand.
| | - Deborah Balmer
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Michal Boyd
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Jackie Robinson
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
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Van Houtven CH, Hastings SN, Colón-Emeric C. A Path To High-Quality Team-Based Care For People With Serious Illness. Health Aff (Millwood) 2019; 38:934-940. [DOI: 10.1377/hlthaff.2018.05486] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Courtney H. Van Houtven
- Courtney H. Van Houtven is a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs (VA) Health Care System, and a professor in the Department of Population Health Sciences at the Duke University School of Medicine, in Durham, North Carolina
| | - S. Nicole Hastings
- S. Nicole Hastings is center director and a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and an associate professor of medicine and population health sciences and a senior fellow in the Center for the Study of Aging and Human Development at the Duke University School of Medicine
| | - Cathleen Colón-Emeric
- Cathleen Colón-Emeric is a research scientist in the Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, and in the Durham VA Geriatrics Research, Education, and Clinical Center; a professor of medicine and chief of the Division of Geriatrics in the Department of Medicine, Duke University; and a senior fellow in the Center for the Study of Aging and Human Development, Duke University School of Medicine
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11
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Owen DC, Ashcraft AS. Creating Shared Meaning: Communication Between Nurses and Physicians in Nursing Homes. Res Gerontol Nurs 2019; 12:121-132. [PMID: 30901480 DOI: 10.3928/19404921-20190315-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 02/13/2019] [Indexed: 11/20/2022]
Abstract
The current study sought to obtain pilot data from a Situation, Background, Assessment, Recommendation (SBAR) communication intervention focused on the shared meaning construct of the sensemaking model and explore shared meaning in communication between nursing home (NH) nurses and physicians. The study design was an exploratory sequential mixed method with a pre/post quasi-experiment. Grounded theory was used to collect and analyze nurse and physician interviews and medical records. The Pathway to Shared Meaning model illustrating distinct processes supported use of the sensemaking model for understanding nurse-physician communication. Quantitative changes in communication were not significant. Shared meaning and training in SBAR for communication can be used to strengthen the design and use of structured communication in NHs. TARGETS Nurses and physicians providing direct care in NHs. INTERVENTION DESCRIPTION Stories describing nurse-physician sharing of resident information using SBAR. MECHANISM OF ACTION Mutual understanding of one another's perspective enhances communication. OUTCOME Communication openness and satisfaction. [Res Gerontol Nurs. 2019; 12(3):121-132.].
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Colón-Emeric CS, Corazzini K, McConnell ES, Pan W, Toles M, Hall R, Cary MP, Batchelor-Murphy M, Yap T, Anderson AL, Burd A, Amarasekara S, Anderson RA. Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial. JAMA Intern Med 2017; 177:1634-1641. [PMID: 28973516 PMCID: PMC5710274 DOI: 10.1001/jamainternmed.2017.5073] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls. OBJECTIVE To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS). DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls. INTERVENTIONS CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program. MAIN OUTCOMES AND MEASURES Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate. RESULTS Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration. CONCLUSIONS AND RELEVANCE An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00636675.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | | | - Eleanor S McConnell
- Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina.,Duke University School of Nursing, Durham, North Carolina
| | - Wei Pan
- Duke University School of Nursing, Durham, North Carolina
| | - Mark Toles
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill
| | - Rasheeda Hall
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina.,Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | - Michael P Cary
- Duke University School of Nursing, Durham, North Carolina
| | | | - Tracey Yap
- Duke University School of Nursing, Durham, North Carolina
| | | | - Andrew Burd
- Duke University School of Nursing, Durham, North Carolina
| | | | - Ruth A Anderson
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill
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Vogelsmeier A, Anderson RA, Anbari A, Ganong L, Farag A, Niemeyer M. A qualitative study describing nursing home nurses sensemaking to detect medication order discrepancies. BMC Health Serv Res 2017; 17:531. [PMID: 28778158 PMCID: PMC5545015 DOI: 10.1186/s12913-017-2495-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022] Open
Abstract
Background Medication reconciliation is a safety practice to identify medication order discrepancies when patients’ transitions between settings. In nursing homes, registered nurses (RNs) and licensed practical nurses (LPNs), each group with different education preparation and scope of practice responsibilities, perform medication reconciliation. However, little is known about how they differ in practice when making sense of medication orders to detect discrepancies. Therefore, the purpose of this study was to describe differences in RN and LPN sensemaking when detecting discrepancies. Method We used a qualitative methodology in a study of 13 RNs and 13 LPNs working in 12 Midwestern United States nursing homes. We used both conventional content analysis and directed content analysis methods to analyze semi-structured interviews. Four resident transfer vignettes embedded with medication order discrepancies guided the interviews. Participants were asked to describe their roles with medication reconciliation and their rationale for identifying medication order discrepancies within the vignettes as well as to share their experiences of performing medication reconciliation. The analysis approach was guided by Weick’s Sensemaking theory. Results RNs provided explicit stories of identifying medication order discrepancies as well as examples of clinical reasoning to assure medication order appropriateness whereas LPNs described comparing medication lists. RNs and LPNs both acknowledged competing demands, but when performing medication reconciliation, RNs were more concerned about accuracy and safety, whereas LPNs were more concerned about time. Conclusions Nursing home nurses, particularly RNs, are in an important position to identify discrepancies that could cause resident harm. Both RNs and LPNs are valuable assets to nursing home care and keeping residents safe, yet RNs offer a unique contribution to complex processes such as medication reconciliation. Nursing home leaders must acknowledge the differences in RN and LPN contributions and make certain nurses in the most qualified role are assigned to ensure residents remain safe.
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Affiliation(s)
| | - Ruth A Anderson
- University of North Carolina at Chapel Hill, 2007 Carrington Hall, Chapel Hill, NC, 27599-7460, USA
| | - Allison Anbari
- Missouri State University, Professional Building 305, 901 S. National Ave, Springfield, MO, 65897, USA
| | - Lawrence Ganong
- University of Missouri Department of Human Development and Family Science, 405 Gentry Hall, Columbia, MO, 65211, USA
| | - Amany Farag
- University of Iowa College of Nursing, 101 College of Nursing Building, 50 Newton Road, Iowa City, IA, 52242-1121, USA
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Drach-Zahavy A, Broyer C, Dagan E. Similarity and accuracy of mental models formed during nursing handovers: A concept mapping approach. Int J Nurs Stud 2017; 74:24-33. [PMID: 28595111 DOI: 10.1016/j.ijnurstu.2017.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Shared mental models are crucial for constructing mutual understanding of the patient's condition during a clinical handover. Yet, scant research, if any, has empirically explored mental models of the parties involved in a clinical handover. OBJECTIVES This study aimed to examine the similarities among mental models of incoming and outgoing nurses, and to test their accuracy by comparing them with mental models of expert nurses. DESIGN A cross-sectional study, exploring nurses' mental models via the concept mapping technique. PARTICIPANTS 40 clinical handovers. DATA COLLECTION Data were collected via concept mapping of the incoming, outgoing, and expert nurses' mental models (total of 120 concept maps). Similarity and accuracy for concepts and associations indexes were calculated to compare the different maps. RESULTS About one fifth of the concepts emerged in both outgoing and incoming nurses' concept maps (concept similarity=23%±10.6). Concept accuracy indexes were 35%±18.8 for incoming and 62%±19.6 for outgoing nurses' maps. Although incoming nurses absorbed fewer number of concepts and associations (23% and 12%, respectively), they partially closed the gap (35% and 22%, respectively) relative to expert nurses' maps. The correlations between concept similarities, and incoming as well as outgoing nurses' concept accuracy, were significant (r=0.43, p<0.01; r=0.68 p<0.01, respectively). Finally, in 90% of the maps, outgoing nurses added information concerning the processes enacted during the shift, beyond the expert nurses' gold standard. DISCUSSION AND CONCLUSIONS Two seemingly contradicting processes in the handover were identified. "Information loss", captured by the low similarity indexes among the mental models of incoming and outgoing nurses; and "information restoration", based on accuracy measures indexes among the mental models of the incoming nurses. Based on mental model theory, we propose possible explanations for these processes and derive implications for how to improve a clinical handover.
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Affiliation(s)
- Anat Drach-Zahavy
- The Department of Nursing, Faculty of Health and Welfare Sciences, University of Haifa, Israel.
| | - Chaya Broyer
- The Department of Nursing, Faculty of Health and Welfare Sciences, University of Haifa, Israel
| | - Efrat Dagan
- The Department of Nursing, Faculty of Health and Welfare Sciences, University of Haifa, Israel
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Condit CM, Shen L, Edwards KL, Bowen DJ, Korngiebel DM, Johnson CO. Participants' Role Expectations in Genetics Research and Re-consent: Revising the Theory and Methods of Mental Models Research Relating to Roles. JOURNAL OF HEALTH COMMUNICATION 2016; 21:16-24. [PMID: 27653592 PMCID: PMC7868084 DOI: 10.1080/10810730.2016.1193914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The rise of large cohort-based health research that includes genetic components has increased the communication challenges for researchers. Controversies have been amplified over requirements for re-consent, return of results, and privacy protections, among other issues. This study extended research on the impact that the perceived role of "research participant" might have on communication expectations to illuminate research participants' preferences for re-consent. The study employed an online survey of participants in a long-standing cancer genetics registry. Results confirmed previous exploratory findings that research participants endorse multiple mental models of participant roles in research (doctor-patient, collaborator, donor, legal contract, etc.). Regression analyses indicated that high and low salience of different models of the role of research participant are related to different communication expectations. However, the pattern of relationships among roles is relevant. The results of the regression analysis also indicated that preference for mandatory re-consent and its relationship to mental models of roles are related to attitudes of trust, benefits, and informational risks. The discussion identifies implications as including the use of explicit approaches to address role relationships in communication with research participants. It also points to implications for methodological approaches in mental model research.
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Affiliation(s)
- Celeste M Condit
- a Department of Communication Studies , University of Georgia , Athens , Georgia , USA
| | - Lijiang Shen
- b Department of Communication Arts and Sciences , Pennsylvania State University , University Park , Pennsylvania , USA
| | - Karen L Edwards
- c Department of Epidemiology, School of Medicine , University of California, Irvine , Irvine , California , USA
| | - Deborah J Bowen
- d Department of Bioethics and Humanities , University of Washington , Seattle , Washington , USA
| | - Diane M Korngiebel
- e Biomedical Informatics and Medical Education , University of Washington , Seattle , Washington , USA
| | - Catherine O Johnson
- c Department of Epidemiology, School of Medicine , University of California, Irvine , Irvine , California , USA
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Williams L, Rycroft-Malone J, Burton CR, Edwards S, Fisher D, Hall B, McCormack B, Nutley SM, Seddon D, Williams R. Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions. BMJ Open 2016; 6:e011964. [PMID: 27566640 PMCID: PMC5013423 DOI: 10.1136/bmjopen-2016-011964] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES This evidence review was conducted to understand how and why workforce development interventions can improve the skills and care standards of support workers in older people's services. DESIGN Following recognised realist synthesis principles, the review was completed by (1) development of an initial programme theory; (2) retrieval, review and synthesis of evidence relating to interventions designed to develop the support workforce; (3) 'testing out' the synthesis findings to refine the programme theories, and establish their practical relevance/potential for implementation through stakeholder interviews; and (4) forming actionable recommendations. PARTICIPANTS Stakeholders who represented services, commissioners and older people were involved in workshops in an advisory capacity, and 10 participants were interviewed during the theory refinement process. RESULTS Eight context-mechanism-outcome (CMO) configurations were identified which cumulatively comprise a new programme theory about 'what works' to support workforce development in older people's services. The CMOs indicate that the design and delivery of workforce development includes how to make it real to the work of those delivering support to older people; the individual support worker's personal starting points and expectations of the role; how to tap into support workers' motivations; the use of incentivisation; joining things up around workforce development; getting the right mix of people engaged in the design and delivery of workforce development programmes/interventions; taking a planned approach to workforce development, and the ways in which components of interventions reinforce one another, increasing the potential for impacts to embed and spread across organisations. CONCLUSIONS It is important to take a tailored approach to the design and delivery of workforce development that is mindful of the needs of older people, support workers, health and social care services and the employing organisations within which workforce development operates. Workforce development interventions need to balance the technical, professional and emotional aspects of care. TRIAL REGISTRATION NUMBER CRD42013006283.
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Affiliation(s)
- L Williams
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | | | - C R Burton
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - S Edwards
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - D Fisher
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - B Hall
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | | | - S M Nutley
- University of St Andrews, St Andrews, UK
| | - D Seddon
- School of Healthcare Sciences, Bangor University, Bangor, UK
| | - R Williams
- School of Healthcare Sciences, Bangor University, Bangor, UK
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Shannon K, McKenzie-Green B. Current role challenges in New Zealand aged residential care: the potential consequences for healthcare assistant role expansion. Contemp Nurse 2016; 52:140-51. [DOI: 10.1080/10376178.2016.1221322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Caspar S, Ratner PA, Phinney A, MacKinnon K. The Influence of Organizational Systems on Information Exchange in Long-Term Care Facilities: An Institutional Ethnography. QUALITATIVE HEALTH RESEARCH 2016; 26:951-965. [PMID: 26758177 DOI: 10.1177/1049732315619893] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Person-centered care is heavily dependent on effective information exchange among health care team members. We explored the organizational systems that influence resident care attendants' (RCAs) access to care information in long-term care (LTC) settings. We conducted an institutional ethnography in three LTC facilities. Investigative methods included naturalistic observations, in-depth interviews, and textual analysis. Practical access to texts containing individualized care-related information (e.g., care plans) was dependent on job classification. Regulated health care professionals accessed these texts daily. RCAs lacked practical access to these texts and primarily received and shared information orally. Microsystems of care, based on information exchange formats, emerged. Organizational systems mandated written exchange of information and did not formally support an oral exchange. Thus, oral information exchanges were largely dependent on the quality of workplace relationships. Formal systems are needed to support structured oral information exchange within and between the microsystems of care found in LTC.
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Affiliation(s)
- Sienna Caspar
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada University of Victoria, Victoria, British Columbia, Canada
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Gray M, Shadden B, Henry J, Di Brezzo R, Ferguson A, Fort I. Meaning making in long-term care: what do certified nursing assistants think? Nurs Inq 2016; 23:244-52. [DOI: 10.1111/nin.12137] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Michelle Gray
- Office for Studies on Aging; University of Arkansas; Fayetteville AR USA
| | - Barbara Shadden
- Department of Rehabilitation, Human Resources and Communication Disorders; University of Arkansas; Fayetteville AR USA
| | - Jean Henry
- Department of Health, Human Performance, and Recreation; University of Arkansas; Fayetteville AR USA
| | - Ro Di Brezzo
- Exercise Science and Vice Provost of Faculty Development; University of Arkansas; Fayetteville AR USA
| | | | - Inza Fort
- Office for Studies on Aging; University of Arkansas; Fayetteville AR USA
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Rycroft-Malone J, Burton CR, Williams L, Edwards S, Fisher D, Hall B, McCormack B, Nutley S, Seddon D, Williams R. Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundSupport workers make up the majority of the workforce in health and social care services for older people. There is evidence to suggest that support workers are not deployed as effectively as possible, are often undervalued, and that there are gaps in understanding support worker roles across different care settings. In the context of a population that is growing older, having a skilled and knowledgeable workforce is an imperative. Workforce development includes the support required to equip those providing care to older people with the right skills, knowledge and behaviours to deliver safe and high-quality services.ObjectiveThe review answered the question ‘how can workforce development interventions improve the skills and the care standards of support workers within older people’s health and social care services?’.DesignA realist synthesis was conducted. In realist synthesis, contingent relationships are expressed as context–mechanism–outcomes (CMOs), to show how particular contexts or conditions trigger mechanisms to generate outcomes. The review was conducted in four iterative stages over 18 months: (1) development of a theoretical framework and initial programme theory; (2) retrieval, review and synthesis of evidence relating to interventions designed to develop the support workforce, guided by the programme theories; (3) ‘testing out’ the synthesis findings to refine the programme theories and establish their practical relevance/potential for implementation; and (4) forming recommendations about how to improve current workforce development interventions to ensure high standards in the care of older people.ParticipantsTwelve stakeholders were involved in workshops to inform programme theory development, and 10 managers, directors for training/development and experienced support workers were interviewed in phase 4 of the study to evaluate the findings and inform knowledge mobilisation.ResultsEight CMO configurations emerged from the review process, which provide a programme theory about ‘what works’ in developing the older person’s support workforce. The findings indicate that the design and delivery of workforce development should consider and include a number of starting points. These include personal factors about the support worker, the specific requirements of workforce development and the fit with broader organisational strategy and goals.Conclusions and recommendationsThe review has resulted in an explanatory account of how the design and delivery of workforce development interventions work to improve the skills and care standards of support workers in older people’s health and social care services. Implications for the practice of designing and delivering older person’s support workforce development interventions are directly related to the eight CMO configuration of the programme theory. Our recommendations for future research relate both to aspects of research methods and to a number of research questions to further evaluate and explicate our programme theory.LimitationsWe found that reports of studies evaluating workforce development interventions tended to lack detail about the interventions that were being evaluated. We found a lack of specificity in reports about what were the perceived and actual intended impacts from the workforce development initiatives being implemented and/or evaluated.Study registrationThis study is registered as PROSPRERO CRD42013006283.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Jo Rycroft-Malone
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Christopher R Burton
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Lynne Williams
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Stephen Edwards
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Denise Fisher
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Beth Hall
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Brendan McCormack
- Division of Nursing, School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Sandra Nutley
- School of Management, University of St Andrews, St Andrews, UK
| | - Diane Seddon
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
| | - Roger Williams
- School of Healthcare Sciences, College of Health and Behavioural Sciences, Bangor University, Bangor, UK
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Massey M, Roter DL. Assessment of immigrant certified nursing assistants' communication when responding to standardized care challenges. PATIENT EDUCATION AND COUNSELING 2016; 99:44-50. [PMID: 26337004 DOI: 10.1016/j.pec.2015.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Certified nursing assistants (CNAs) provide 80% of the hands-on care in US nursing homes; a significant portion of this work is performed by immigrants with limited English fluency. This study is designed to assess immigrant CNA's communication behavior in response to a series of virtual simulated care challenges. METHODS A convenience sample of 31 immigrant CNAs verbally responded to 9 care challenges embedded in an interactive computer platform. The responses were coded with the Roter Interaction Analysis System (RIAS), CNA instructors rated response quality and spoken English was rated. RESULTS CNA communication behaviors varied across care challenges and a broad repertoire of communication was used; 69% of response content was characterized as psychosocial. Communication elements (both instrumental and psychosocial) were significant predictors of response quality for 5 of 9 scenarios. Overall these variables explained between 13% and 36% of the adjusted variance in quality ratings. CONCLUSION Immigrant CNAs responded to common care challenges using a variety of communication strategies despite fluency deficits. PRACTICE IMPLICATIONS Virtual simulation-based observation is a feasible, acceptable and low cost method of communication assessment with implications for supervision, training and evaluation of a para-professional workforce.
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Affiliation(s)
- Meredith Massey
- National Center for Health Statistics, Hyattsville, MD, USA; Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Debra L Roter
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Allemann H, Sund-Levander M. Nurses' actions in response to nursing assistants' observations of signs and symptoms of infections among nursing home residents. Nurs Open 2015; 2:97-104. [PMID: 27642516 PMCID: PMC5006863 DOI: 10.1002/nop2.22] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 06/07/2015] [Indexed: 11/25/2022] Open
Abstract
Aims To describe what nurses do during episodes of suspected infection in elderly nursing home residents and if these actions are linked to who is initiating an episode and whether the episode is considered an infection or not. Design Prospective descriptive study. Data were collected in 2008–2010. Methods Summarized and categorized documentation by nursing assistants and nurses was used for summative content analysis. Results Nurses' actions seem to be related to who initiated the episode and if the episodes are categorized as ‘non‐infection’, ‘possible infection’ or ‘infection’. Actions could be ‘observation’, ‘screenings’, ‘engaged in waiting’, ‘follow‐ups’, ‘nurse‐prescribed actions’, ‘diagnosing’, ‘contacting the physician’, ‘carrying out an action prescribed by the physician’, ‘contacting an ambulance or arranging an emergency visit to the hospital’ and ‘prescribing screening’. As NAs often initiate episodes of suspected infection by observing changed conditions, it seems important to include the NA in the decision‐making process as these observations could detect possible early signs and symptoms of infections.
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Affiliation(s)
- Hanna Allemann
- Faculty of Health Sciences Department of Medical and Health Sciences Linköping University Linköping Sweden
| | - Märta Sund-Levander
- Faculty of Health Sciences Department of Medical and Health Sciences Linköping University Linköping Sweden
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23
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O'Keeffe VJ, Thompson KR, Tuckey MR, Blewett VL. Putting Safety in the Frame: Nurses' Sensemaking at Work. Glob Qual Nurs Res 2015; 2:2333393615592390. [PMID: 28462311 PMCID: PMC5342847 DOI: 10.1177/2333393615592390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 05/17/2015] [Accepted: 05/21/2015] [Indexed: 11/15/2022] Open
Abstract
Current patient safety policy focuses nursing on patient care goals, often overriding nurses' safety. Without understanding how nurses construct work health and safety (WHS), patient and nurse safety cannot be reconciled. Using ethnography, we examine social contexts of safety, studying 72 nurses across five Australian hospitals making decisions during patient encounters. In enacting safe practice, nurses used "frames" built from their contextual experiences to guide their behavior. Frames are produced by nurses, and they structure how nurses make sense of their work. Using thematic analysis, we identify four frames that inform nurses' decisions about WHS: (a) communicating builds knowledge, (b) experiencing situations guides decisions, (c) adapting procedures streamlines work, and (d) team working promotes safe working. Nurses' frames question current policy and practice by challenging how nurses' safety is positioned relative to patient safety. Recognizing these frames can assist the design and implementation of effective WHS management.
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24
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A qualitative study of nursing assistants' awareness of person-centred approaches to dementia care. AGEING & SOCIETY 2015. [DOI: 10.1017/s0144686x15000276] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTRecently, the number of education programmes addressing person-centred approaches to long-term residential dementia care has increased, and nursing assistants (NAs) are often the target audience. The effectiveness of employee education programmes is actively debated, and our objective is to contribute to this discussion by exploring the knowledge NAs acquire through practice. We examined approaches to person-centred care generated during a series of interviews with NAs, and compared these to the content of five frameworks for person-centred dementia care. Our results suggest that although NAs acquire significant knowledge about person-centred dementia care during the course of their work, application of person-centred care strategies varies across NAs. We propose ways of enhancing NA education in order to address gaps in knowledge. We also recommend sustained attention to organisational factors that contribute to variability in practice.
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Andersen E, Havaei F. Measuring Relational Care in Nursing Homes: Psychometric Evaluation of the Relational Care Scale. J Nurs Meas 2015; 23:82-95. [DOI: 10.1891/1061-3749.23.1.82] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background and Purpose: The Relational Care Scale (RCS) is a Canadian evaluative instrument designed to measure nursing home residents’ perceptions of care aides’ relational abilities. Care aides’ abilities to be reliable and empathetic with nursing home residents are very important determinants of quality of care, but few instruments are designed specifically for residents or focus exclusively on these determinants. Initially developed and tested in metropolitan teaching-affiliated nursing homes in Ontario, we expanded testing by reevaluating the psychometric properties of the RCS in 5 rural nursing homes in British Columbia. Method: There were 62 residents living in 5 rural nursing homes who completed 3 instruments: the RCS under investigation, the Experiences in Close Relationships-Relationship Structures (ECR-RS) questionnaire to test for convergent validity, and the Lubben Social Network Scale-6 (LSNS-6) to test for discriminant validity. Results: The reliability of the RCS was strongly supported (Cronbach’s alpha = .90, item–total correlation > .77). Consistent with previous testing, a unidimensional internal structure was extracted. A moderate to strong correlation between the RCS and the Anxiety and Avoidance subscales of the ECR-RS supported convergent validity of the instrument. Last, partial support was obtained for the discriminant validity of the RCS. Conclusions: The RCS was easy to use for both residents and researchers. Expanded testing demonstrated its recurring reliability and validity.
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Leykum LK, Lanham HJ, Provost SM, McDaniel RR, Pugh J. Improving outcomes of hospitalized patients: the Physician Relationships, Improvising, and Sensemaking intervention protocol. Implement Sci 2014; 9:171. [PMID: 25424007 PMCID: PMC4245772 DOI: 10.1186/s13012-014-0171-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 11/06/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Our goal is to improve the safety and effectiveness of inpatient care. Rather than focus on improving process of care, we focus on the social structure within physician teams. We have developed the Physician Relationships, Improvising, and Sensemaking (PRISm) intervention to improve the way physician teams round, enabling them to better relate, make sense of their patients' conditions, and improvise in uncertain clinical situations. We are currently studying the impact of PRISm on adverse events and complications in hospitalized patients. This manuscript describes the PRISm intervention. METHODS/DESIGN PRISm is a structured communication tool consisting of three components: daily briefings before rounds; use of the Situation, Task, Intent, Concern, and Calibrate (STICC) framework during rounds as part of the discussion of individual patients; and debriefings after rounds. We are implementing the PRISm intervention on eight inpatient medical and surgical physician teams in the South Texas Veterans Health Care System. We are assessing PRISm impact on the way team members relate to each other, round, and discuss patients through pre- and post-implementation observations and surveys. We are also assessing PRISm impact on complications and adverse events. Finally, we are interviewing physicians regarding their experience using the intervention. DISCUSSION Our results will allow us to begin to understand the potential impact of interventions designed to improve how providers relate to each other, improvise, and make sense of what is happening as a strategy for improving inpatient care. Our in-depth data collection will enable us to assess how relationships, improvising, and sensemaking influence patient outcomes, potentially through creating shared mental models or enhancing distributed cognition during clinical reasoning. Finally, our results will lay the groundwork for larger implementation studies to improve clinical outcomes through improving how providers, and providers, patients, and caregivers, relate.
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Affiliation(s)
- Luci K Leykum
- />South Texas Veterans Health Care System, Texas, USA
- />School of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, 373 L, San Antonio, Texas 78229 USA
- />The University of Texas at Austin, Austin, Texas USA
| | - Holly J Lanham
- />South Texas Veterans Health Care System, Texas, USA
- />School of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, 373 L, San Antonio, Texas 78229 USA
- />The University of Texas at Austin, Austin, Texas USA
| | | | | | - Jacqueline Pugh
- />South Texas Veterans Health Care System, Texas, USA
- />School of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, 373 L, San Antonio, Texas 78229 USA
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James I, Fredriksson C, Wahlström C, Kihlgren A, Blomberg K. Making Each Other's Daily Life: Nurse Assistants' Experiences and Knowledge on Developing a Meaningful Daily Life in Nursing Homes. Open Nurs J 2014; 8:34-42. [PMID: 25246997 PMCID: PMC4168648 DOI: 10.2174/1874434601408010034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/20/2014] [Accepted: 06/25/2014] [Indexed: 11/22/2022] Open
Abstract
Background: In a larger action research project, guidelines were generated for how a meaningful daily life could be developed for older persons. In this study, we focused on the nurse assistants’ (NAs) perspectives, as their knowledge is essential for a well-functioning team and quality of care. The aim was to learn from NAs’ experiences and knowledge about how to develop a meaningful daily life for older persons in nursing homes and the meaning NAs ascribe to their work. Methods: The project is based on Participatory and Appreciative Action and Reflection. Data were generated through interviews, participating observations and informal conversations with 27 NAs working in nursing homes in Sweden, and a thematic analysis was used. Result: NAs developed a meaningful daily life by sensing and finding the “right” way of being (Theme 1). They sense and read the older person in order to judge how the person was feeling (Theme 2). They adapt to the older person (Theme 3) and share their daily life (Theme 4). NAs use emotional involvement to develop a meaningful daily life for the older person and meaning in their own work (Theme 5), ultimately making each other’s daily lives meaningful. Conclusion: It was obvious that NAs based the development of a meaningful daily life on different forms of knowledge: the oreticaland practical knowledge, and practical wisdom, all of which are intertwined. These results could be used within the team to constitute a meaningful daily life for older persons in nursing homes.
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Affiliation(s)
- Inger James
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Carin Fredriksson
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Catrin Wahlström
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Annica Kihlgren
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Karin Blomberg
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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Taylor J, Sims J, Haines TP. The emergent relevance of care staff decision-making and situation awareness to mobility care in nursing homes: an ethnographic study. J Adv Nurs 2014; 70:2767-78. [PMID: 24735067 DOI: 10.1111/jan.12425] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Janice Taylor
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Notting Hill Victoria Australia
| | - Jane Sims
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Notting Hill Victoria Australia
| | - Terry P. Haines
- Allied Health Research Unit; Kingston Centre; Southern Health; Cheltenham Victoria Australia
- Southern Physiotherapy Clinical School; Monash University; Melbourne Victoria Australia
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Funk LM, Waskiewich S, Stajduhar KI. Meaning-Making and Managing Difficult Feelings: Providing Front-Line End-of-Life Care. OMEGA-JOURNAL OF DEATH AND DYING 2014; 68:23-43. [DOI: 10.2190/om.68.1.b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Managing grief and difficult emotions related to end-of-life (EOL) care is an often under-recognized part of the work of resident care aides (RCAs). In this interpretive analysis we explore the shared and socially constructed ideas that 11 RCAs in 1 Canadian city employ to make sense of death and the provision of EOL care. RCAs spoke of personal challenges involved in witnessing death and experiencing loss, as well as helplessness and frustration when they could not provide quality EOL care. RCAs invoked “consoling refrains” to manage grief, including “such is life,” “they are better off,” and “they had a full life.” To manage guilt and moral distress, RCAs reminded themselves “I did my best” and “I experience rewards.” Though these ideas help RCAs, some may need to be reframed through coaching and mentorship, to prevent unintended negative effects on care or the reproduction of ageist beliefs more broadly.
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Havig AK, Skogstad A, Veenstra M, Romøren TI. Real teams and their effect on the quality of care in nursing homes. BMC Health Serv Res 2013; 13:499. [PMID: 24289798 PMCID: PMC4220624 DOI: 10.1186/1472-6963-13-499] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 11/21/2013] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Use of teams has shown to be an important factor for organizational performance. However, research has shown that a team has to meet certain criteria and operate in a certain way to realize the potential benefits of team organizing. There are few studies that have examined how teams operate in the nursing home sector and their effect on quality of care. This study investigates the relationship between teams that meet an academic definition of the team concept and quality of care in nursing homes. METHODS A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilized to test our research question: (1) self-report questionnaires to 444 employees, (2) interviews with 40 ward managers, (3) self-report questionnaires to 40 ward managers, (4) telephone interviews with 378 relatives, and (5) 900 hours of field observations. Use of teams in nursing home wards was assessed by field observations and by interviews with ward mangers. Quality of care was assessed by data from surveys and interviews with relatives and staff and through field observations. All data were aggregated to the ward level and two-level analyses were used to assess the relationships. RESULTS The multi-level analyses showed that teams - as operationalized in the present study - were significantly positively related to two out of the three quality of care indices when controlled for ward size, days of sick leave and care level. One significant interaction effect was found between teams and days of sick leave, implying that the effect of teams decreased with higher numbers of days of sick leave. CONCLUSIONS The results suggest that teams are related to higher levels of quality of care in nursing homes. However, the study shows that there is a substantial difference between real, functional teams that meet an academic definition of the concept and quasi teams, the latter having a significantly lower effect on quality of care. Hence, nursing home leaders, directors and ward leaders should be aware of the substantial differences betweens dysfunctional - or quasi - teams and real teams, and encourage the development of real functional teams to take advantage of the potential benefits of team organizing.
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Affiliation(s)
- Anders Kvale Havig
- Norwegian Social Research (NOVA), Oslo, Norway
- Centre for Care Research, Gjøvik University College, Gjøvik, Norway
| | | | | | - Tor Inge Romøren
- Centre for Care Research, Gjøvik University College, Gjøvik, Norway
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Colon-Emeric CS, McConnell E, Pinheiro SO, Corazzini K, Porter K, Earp KM, Landerman L, Beales J, Lipscomb J, Hancock K, Anderson RA. CONNECT for better fall prevention in nursing homes: results from a pilot intervention study. J Am Geriatr Soc 2013; 61:2150-2159. [PMID: 24279686 DOI: 10.1111/jgs.12550] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS). DESIGN Cluster randomized trial. SETTING Community (n=4) and Veterans Affairs (VA) NHs (n=4). PARTICIPANTS Staff in any role with resident contact (n=497). INTERVENTION NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3 months. CONNECT used storytelling, relationship mapping, mentoring, self-monitoring, and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit and feedback. MEASUREMENTS NH staff completed surveys about interactions at baseline, 3 months (immediately after CONNECT or control period), and 6 months (immediately after FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n=651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning. RESULTS Significant improvements in staff perceptions of communication quality, participation in decision-making, safety climate, caregiving quality, and use of local interaction strategies were observed in intervention community NHs (treatment-by-time effect P=.01) but not in VA NHs, where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (falls/bed per year: baseline, 2.61; after intervention, 2.64) but decreased by 12% in intervention facilities (falls/bed per year: baseline, 2.34; after intervention, 2.06); the effect of treatment on rate of change was 0.81 (95% confidence interval=0.55-1.20). CONCLUSION CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study.
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Affiliation(s)
- Cathleen S Colon-Emeric
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina.,Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham, North Carolina
| | - Eleanor McConnell
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina.,Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
| | - Sandro O Pinheiro
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Kirsten Corazzini
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Kristie Porter
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina
| | | | - Lawrence Landerman
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
| | - Julie Beales
- Richmond Veterans Affairs Medical Center, Richmond, Virginia
| | - Jeffrey Lipscomb
- KayeM, Inc., Durham, North Carolina.,Salem Veterans Affairs Medical Center, Salem, Virginia
| | - Kathryn Hancock
- Asheville Veterans Affairs Medical Center, Asheville, North Carolina
| | - Ruth A Anderson
- Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina.,School of Nursing, Duke University, Durham, North Carolina
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Colón-Emeric CS, Pinheiro SO, Anderson RA, Porter K, McConnell E, Corazzini K, Hancock K, Lipscomb J, Beales J, Simpson KM. Connecting the learners: improving uptake of a nursing home educational program by focusing on staff interactions. THE GERONTOLOGIST 2013; 54:446-59. [PMID: 23704219 DOI: 10.1093/geront/gnt043] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE OF THE STUDY The CONNECT intervention is designed to improve staff connections, communication, and use of multiple perspectives for problem solving. This analysis compared staff descriptions of the learning climate, use of social constructivist learning processes, and outcomes in nursing facilities receiving CONNECT with facilities receiving a falls education program alone. DESIGN AND METHODS Qualitative evaluation of a randomized controlled trial was done using a focus group design. Facilities (n = 8) were randomized to a falls education program alone (control) or CONNECT followed by FALLS (intervention). A total of 77 staff participated in 16 focus groups using a structured interview protocol. Transcripts were analyzed using framework analysis, and summaries for each domain were compared between intervention and control facilities. RESULTS Notable differences in descriptions of the learning climate included greater learner empowerment, appreciation of the role of all disciplines, and seeking diverse viewpoints in the intervention group. Greater use of social constructivist learning processes was evidenced by the intervention group as they described greater identification of communication weaknesses, improvement in communication frequency and quality, and use of sense-making by seeking out multiple perspectives to better understand and act on information. Intervention group participants reported outcomes including more creative fall prevention plans, a more respectful work environment, and improved relationships with coworkers. No substantial difference between groups was identified in safety culture, shared responsibility, and self-reported knowledge about falls. IMPLICATIONS CONNECT appears to enhance the use of social constructivist learning processes among nursing home staff. The impact of CONNECT on clinical outcomes requires further study.
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Affiliation(s)
- Cathleen S Colón-Emeric
- *Address correspondence to Cathleen Colón-Emeric, MHS, Durham VA Geriatric Research Education and Clinical Center, MD 508 Fulton St., GRECC 182, Durham, NC 27705. E-mail:
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The importance of relational coordination and reciprocal learning for chronic illness care within primary care teams. Health Care Manage Rev 2013; 38:20-8. [PMID: 22310483 DOI: 10.1097/hmr.0b013e3182497262] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent research from a complexity theory perspective suggests that implementation of complex models of care, such as the Chronic Care Model (CCM), requires strong relationships and learning capacities among primary care teams. PURPOSES Our primary aim was to assess the extent to which practice member perceptions of relational coordination and reciprocal learning were associated with the presence of CCM elements in community-based primary care practices. METHODOLOGY/APPROACH We used baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM and improve risk factor control for patients with Type 2 diabetes in small primary care practices. Practice members (i.e., physicians, nonphysician providers, and staff) completed baseline assessments, which included the Relational Coordination Scale, Reciprocal Learning Scale, and the Assessment of Chronic Illness Care (ACIC) survey, along with items assessing individual and clinic characteristics. To assess the association between Relational Coordination, Reciprocal Learning, and ACIC, we used a series of hierarchical linear regression models accounting for clustering of individual practice members within clinics and controlling for individual- and practice-level characteristics and tested for mediation effects. FINDINGS A total of 283 practice members from 39 clinics completed baseline measures. Relational Coordination scores were significantly and positively associated with ACIC scores (Model 1). When Reciprocal Learning was added, Relational Coordination remained a significant yet notably attenuated predictor of ACIC (Model 2). The mediation effect was significant (z = 9.3, p < .01); 24% of the association between Relational Coordination and ACIC scores was explained by Reciprocal Learning. Of the individual- and practice-level covariates included in Model 3, only the presence of an electronic medical record was significant; Relational Coordination and Reciprocal Learning remained significant independent predictors of ACIC. PRACTICE IMPLICATIONS Efforts to implement complex models of care should incorporate strategies to strengthen relational coordination and reciprocal learning among team members.
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Anderson RA. Commentary on "Health care organizations as complex systems: new perspectives on design and management" by Reuben R. McDaniel, Dean J. Driebe, and Holly Jordan Lanham. Adv Health Care Manag 2013; 15:27-36. [PMID: 24749212 DOI: 10.1108/s1474-8231(2013)0000015008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In this commentary, I highlight a few of the assertions made by McDaniel et al. (2013) about the importance of complexity science guided management practices, and extend these ideas specifically to how we might think about reducing seemingly intractable problems in health care such as patient safety, patient falls, hospital acquired infection, and the rise of chronic illness and obesity. I suggest that such changes will require managers and providers to view health care organizations and patients as complex adaptive systems and include patients as full participants in co-producing their health care.
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McDaniel RR, Driebe DJ, Lanham HJ. Health care organizations as complex systems: new perspectives on design and management. Adv Health Care Manag 2013; 15:3-26. [PMID: 24749211 DOI: 10.1108/s1474-8231(2013)0000015007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
PURPOSE We discuss the impact of complexity science on the design and management of health care organizations over the past decade. We provide an overview of complexity science issues and their impact on thinking about health care systems, particularly with the rising importance of information systems. We also present a complexity science perspective on current issues in today's health care organizations and suggest ways that this perspective might help in approaching these issues. APPROACH We review selected research, focusing on work in which we participated, to identify specific examples of applications of complexity science. We then take a look at information systems in health care organizations from a complexity viewpoint. FINDINGS Complexity science is a fundamentally different way of understanding nature and has influenced the thinking of scholars and practitioners as they have attempted to understand health care organizations. Many scholars study health care organizations as complex adaptive systems and through this perspective develop new management strategies. Most important, perhaps, is the understanding that attention to relationships and interdependencies is critical for developing effective management strategies. RESEARCH AND PRACTICE IMPLICATIONS Increased understanding of complexity science can enhance the ability of researchers and practitioners to develop new ways of understanding and improving health care organizations. ORIGINALITY/VALUE This analysis opens new vistas for scholars and practitioners attempting to understand health care organizations as complex adaptive systems. The analysis holds value for those already familiar with this approach as well as those who may not be as familiar.
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Chung G. Understanding nursing home worker conceptualizations about good care. THE GERONTOLOGIST 2012; 53:246-54. [PMID: 22936538 DOI: 10.1093/geront/gns117] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study explored how direct care workers in nursing homes conceptualize good care and how their conceptualizations are influenced by external factors surrounding their work environment and the relational dynamics between them and residents. Study participants were drawn from a local service employees' union, and in-depth interviews were conducted. Data were analyzed using a grounded theory approach, and the results revealed that direct care workers equated good care, such as resident cleanliness, comfort, and happiness as a desirable outcome of care activities. Good care also meant affectionate, respectful, and patient attitudes of direct care workers toward residents in care delivery processes. Nursing home workers internalized the perspectives of residents and other professionals about what constitutes good care, and then drew their own conclusions about how to balance, combine, and compromise those diverse demands. It is important to communicate accurate and consistent messages about what comprises good nursing home care to nursing home workers and build a working environment where workers' conceptualizations about good care can be executed without organizational barriers.
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Affiliation(s)
- Gawon Chung
- Korean Women's Development Institute, 276 Jinheung-ro, Seoul, Korea, 122-707.
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Hunt SR, Corazzini K, Anderson RA. Top nurse-management staffing collapse and care quality in nursing homes. J Appl Gerontol 2012; 33:51-74. [PMID: 24652943 DOI: 10.1177/0733464812455096] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Director of nursing turnover is linked to staff turnover and poor quality of care in nursing homes; however the mechanisms of these relationships are unknown. Using a complexity science framework, we examined how nurse management turnover impacts system capacity to produce high quality care. This study is a longitudinal case analysis of a nursing home (n = 97 staff) with 400% director of nursing turnover during the study time period. Data included 100 interviews, observations and documents collected over 9 months and were analyzed using immersion and content analysis. Turnover events at all staff levels were nonlinear, socially mediated and contributed to dramatic care deficits. Federal mandated, quality assurance mechanisms failed to ensure resident safety. High multilevel turnover should be elevated to a sentinel event for regulators. Suggestions to magnify positive emergence in extreme conditions and to improve quality are provided.
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Anderson RA, Corazzini K, Porter K, Daily K, McDaniel RR, Colón-Emeric C. CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes. Implement Sci 2012; 7:11. [PMID: 22376375 PMCID: PMC3310735 DOI: 10.1186/1748-5908-7-11] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 02/29/2012] [Indexed: 12/02/2022] Open
Abstract
Background Quality improvement (QI) programs focused on mastery of content by individual staff members are the current standard to improve resident outcomes in nursing homes. However, complexity science suggests that learning is a social process that occurs within the context of relationships and interactions among individuals. Thus, QI programs will not result in optimal changes in staff behavior unless the context for social learning is present. Accordingly, we developed CONNECT, an intervention to foster systematic use of management practices, which we propose will enhance effectiveness of a nursing home Falls QI program by strengthening the staff-to-staff interactions necessary for clinical problem-solving about complex problems such as falls. The study aims are to compare the impact of the CONNECT intervention, plus a falls reduction QI intervention (CONNECT + FALLS), to the falls reduction QI intervention alone (FALLS), on fall-related process measures, fall rates, and staff interaction measures. Methods/design Sixteen nursing homes will be randomized to one of two study arms, CONNECT + FALLS or FALLS alone. Subjects (staff and residents) are clustered within nursing homes because the intervention addresses social processes and thus must be delivered within the social context, rather than to individuals. Nursing homes randomized to CONNECT + FALLS will receive three months of CONNECT first, followed by three months of FALLS. Nursing homes randomized to FALLS alone receive three months of FALLs QI and are offered CONNECT after data collection is completed. Complexity science measures, which reflect staff perceptions of communication, safety climate, and care quality, will be collected from staff at baseline, three months after, and six months after baseline to evaluate immediate and sustained impacts. FALLS measures including quality indicators (process measures) and fall rates will be collected for the six months prior to baseline and the six months after the end of the intervention. Analysis will use a three-level mixed model. Discussion By focusing on improving local interactions, CONNECT is expected to maximize staff's ability to implement content learned in a falls QI program and integrate it into knowledge and action. Our previous pilot work shows that CONNECT is feasible, acceptable and appropriate. Trial Registration ClinicalTrials.gov: NCT00636675
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Abstract
Sociability, interaction through which solitariness becomes togetherness or a union with others, has largely been explored without reference to the importance of bodily sources of agency. Encapsulated in the theoretical notion of embodied selfhood is the pre-reflective nature of selfhood deriving from the body's pre-reflective capacity for engaging with the world and the socio-cultural significance of the body. This paper argues for an expansion of the discourse on sociability in dementia to include embodied selfhood as a source of interactive practices. An 8-month ethnographic study of selfhood in dementia was conducted in a Canadian long-term care facility. The findings suggest that social and cultural habits, movements and other physical cues serve important communicative functions in the course of social interaction. This underscores how sociability is an embodied dimension of selfhood, which not only broadens the discourse on sociability in dementia but also offers important insights to inform person-centred dementia care.
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Affiliation(s)
- Pia C. Kontos
- Toronto Rehabilitation Institute, Canada; and University of Toronto, Canada
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Abstract
OBJECTIVES Common-sense illness beliefs are important because they influence actions that people take to prevent and treat disease. This research (1) asked younger and older adults about their illness representations of Alzheimer's disease (AD) and (2) manipulated beliefs about AD preventability to determine causal relationships in the data. METHOD In Study 1, the beliefs of younger (age 18-38; n = 82) and older (age 58-89; n = 57) adults about the causes of and ways to prevent AD were compared. In Study 2, younger adults were randomly assigned to read information stating either that AD can be prevented or not. RESULTS Compared to younger adults, older adults saw themselves as less at risk, t(137) = 3.03, p = 0.003, d = 0.52, were more likely to believe that AD is preventable, t(137) = 5.01, p < 0.001, d = 0.87 and were more likely to report engaging in behaviors to prevent AD, χ(2)(1, 139) = 19.01, p < 0.001, r = 0.37. Manipulating beliefs in Study 2 caused those told that AD was preventable to see themselves as less at risk, report more prevention behaviors, and hold those with the disease more responsible for their fate. CONCLUSION These findings highlight the association of illness representations with reports of behavior and show a disconnect between beliefs and what we currently know about AD.
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Affiliation(s)
- Lindsay N Anderson
- Department of Psychology, University of Colorado at Colorado Springs, USA.
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Toles M, Anderson RA. State of the science: Relationship-oriented management practices in nursing homes. Nurs Outlook 2011; 59:221-7. [DOI: 10.1016/j.outlook.2011.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 04/25/2011] [Accepted: 05/01/2011] [Indexed: 11/27/2022]
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Reciprocal learning and chronic care model implementation in primary care: results from a new scale of learning in primary care. BMC Health Serv Res 2011; 11:44. [PMID: 21345225 PMCID: PMC3050698 DOI: 10.1186/1472-6963-11-44] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 02/23/2011] [Indexed: 11/10/2022] Open
Abstract
Background Efforts to improve the care of patients with chronic disease in primary care settings have been mixed. Application of a complex adaptive systems framework suggests that this may be because implementation efforts often focus on education or decision support of individual providers, and not on the dynamic system as a whole. We believe that learning among clinic group members is a particularly important attribute of a primary care clinic that has not yet been well-studied in the health care literature, but may be related to the ability of primary care practices to improve the care they deliver. To better understand learning in primary care settings by developing a scale of learning in primary care clinics based on the literature related to learning across disciplines, and to examine the association between scale responses and chronic care model implementation as measured by the Assessment of Chronic Illness Care (ACIC) scale. Methods Development of a scale of learning in primary care setting and administration of the learning and ACIC scales to primary care clinic members as part of the baseline assessment in the ABC Intervention Study. All clinic clinicians and staff in forty small primary care clinics in South Texas participated in the survey. Results We developed a twenty-two item learning scale, and identified a five-item subscale measuring the construct of reciprocal learning (Cronbach alpha 0.79). Reciprocal learning was significantly associated with ACIC total and sub-scale scores, even after adjustment for clustering effects. Conclusions Reciprocal learning appears to be an important attribute of learning in primary care clinics, and its presence relates to the degree of chronic care model implementation. Interventions to improve reciprocal learning among clinic members may lead to improved care of patients with chronic disease and may be relevant to improving overall clinic performance.
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Abstract
The vast majority of care for end-stage renal disease (ESRD) patients is provided by skilled (but not formally educated) paraprofessional technicians. Using Goffman's (1959) framing of the performance of self in everyday discourse, this study examines discourse from dialysis technicians and technical aides to explore these paraprofessionals' construction and performance of professional identity and professional communication within the context of an outpatient dialysis clinic. Themes of professionalism--individualized care, vigilance, teamwork, and emotion management--are illustrated via poetic transcription of interviews with technicians. I contend that such representation offers validity equal to that of traditional research accounts while embodying alternative representational strengths.
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Affiliation(s)
- Laura L Ellingson
- Department of Communication and Women's & Gender Studies Program, Santa Clara University, CA 95053, USA.
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Making sense of health information technology implementation: A qualitative study protocol. Implement Sci 2010; 5:95. [PMID: 21114860 PMCID: PMC3001692 DOI: 10.1186/1748-5908-5-95] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 11/29/2010] [Indexed: 12/02/2022] Open
Abstract
Background Implementing new practices, such as health information technology (HIT), is often difficult due to the disruption of the highly coordinated, interdependent processes (e.g., information exchange, communication, relationships) of providing care in hospitals. Thus, HIT implementation may occur slowly as staff members observe and make sense of unexpected disruptions in care. As a critical organizational function, sensemaking, defined as the social process of searching for answers and meaning which drive action, leads to unified understanding, learning, and effective problem solving -- strategies that studies have linked to successful change. Project teamwork is a change strategy increasingly used by hospitals that facilitates sensemaking by providing a formal mechanism for team members to share ideas, construct the meaning of events, and take next actions. Methods In this longitudinal case study, we aim to examine project teams' sensemaking and action as the team prepares to implement new information technology in a tiertiary care hospital. Based on management and healthcare literature on HIT implementation and project teamwork, we chose sensemaking as an alternative to traditional models for understanding organizational change and teamwork. Our methods choices are derived from this conceptual framework. Data on project team interactions will be prospectively collected through direct observation and organizational document review. Through qualitative methods, we will identify sensemaking patterns and explore variation in sensemaking across teams. Participant demographics will be used to explore variation in sensemaking patterns. Discussion Outcomes of this research will be new knowledge about sensemaking patterns of project teams, such as: the antecedents and consequences of the ongoing, evolutionary, social process of implementing HIT; the internal and external factors that influence the project team, including team composition, team member interaction, and interaction between the project team and the larger organization; the ways in which internal and external factors influence project team processes; and the ways in which project team processes facilitate team task accomplishment. These findings will lead to new methods of implementing HIT in hospitals.
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Colón-Emeric CS, Plowman D, Bailey D, Corazzini K, Utley-Smith Q, Ammarell N, Toles M, Anderson R. Regulation and mindful resident care in nursing homes. QUALITATIVE HEALTH RESEARCH 2010; 20:1283-1294. [PMID: 20479137 PMCID: PMC2918733 DOI: 10.1177/1049732310369337] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Regulatory oversight is intended to improve the health outcomes of nursing home residents, yet evidence suggests that regulations can inhibit mindful staff behaviors that are associated with effective care. We explored the influence of regulations on mindful staff behavior as it relates to resident health outcomes, and offer a theoretical explanation of why regulations sometimes enhance mindfulness and other times inhibit it. We analyzed data from an in-depth, multiple-case study including field notes, interviews, and documents collected in eight nursing homes. We completed a conceptual/thematic description using the concept of mindfulness to reframe the observations. Shared facility mission strongly impacted staff perceptions of the purpose and utility of regulations. In facilities with a resident-centered culture, regulations increased mindful behavior, whereas in facilities with a cost-focused culture, regulations reduced mindful care practices. When managers emphasized the punitive aspects of regulation we observed a decrease in mindful practices in all facilities.
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Kontos PC, Miller KL, Mitchell GJ, Cott CA. Dementia care at the intersection of regulation and reflexivity: a critical realist perspective. J Gerontol B Psychol Sci Soc Sci 2010; 66:119-28. [PMID: 20375084 DOI: 10.1093/geronb/gbq022] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To understand point-of-care decisions, and in particular rule breaking, by personal support workers (PSWs) regarding institutionalized elders with dementia within a context of legislative and organizational care mandates. METHODS Qualitative baseline data including focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) were collected during a 2-year, multi-method trial of a 12-week interprofessional arts-informed educational intervention in two Alzheimer support units and were analyzed using a critical realist approach. RESULTS PSW care decisions were the outcome of a discordant interrelationship between PSWs' reflective deliberations, and legislative and organizational care mandates. PSWs responded to discordance through rule breaking in order to provide individualized care. Unbeknownst to PSWs, rule breaking was contingent upon supervisors' case-by-case complicity as they strove to balance fears of regulatory citations with private assessment of the soundness of PSW logic. DISCUSSION Quality care emerges at the intersection of policies governing long-term care, PSW rule breaking, and the supportive but undisclosed role supervisors play in these violations. Understanding this complexity has important implications for initiatives to improve care practices and to challenge legislation and policies that impede dementia care.
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Affiliation(s)
- Pia C Kontos
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada.
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Jordon M, Lanham HJ, Anderson RA, McDaniel RR. Implications of complex adaptive systems theory for interpreting research about health care organizations. J Eval Clin Pract 2010; 16:228-31. [PMID: 20367840 PMCID: PMC3667707 DOI: 10.1111/j.1365-2753.2009.01359.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
RATIONALE Data about health care organizations (HCOs) are not useful until they are interpreted. Such interpretations are influenced by the theoretical lenses used by the researcher. OBJECTIVE Our purpose was to suggest the usefulness of theories of complex adaptive systems (CASs) in guiding research interpretation. Specifically, we addressed two questions: (1) What are the implications for interpreting research observations in HCOs of the fact that we are observing relationships among diverse agents? (2) What are the implications for interpreting research observations in HCOs of the fact that we are observing relationships among agents that learn? METHODS We defined diversity and learning and the implications of the non-linear relationships among agents from a CAS perspective. We then identified some common analytical practices that were problematic and may lead to conceptual and methodological errors. Then we described strategies for interpreting the results of research observations. CONCLUSIONS We suggest that the task of interpreting research observations of HCOs could be improved if researchers take into account that the systems they study are CASs with non-linear relationships among diverse, learning agents. Our analysis points out how interpretation of research results might be shaped by the fact that HCOs are CASs. We described how learning is, in fact, the result of interactions among diverse agents and that learning can, by itself, reduce or increase agent diversity. We encouraged researchers to be persistent in their attempts to reason about complex systems and learn to attend not only to structures, but also to processes and functions of complex systems.
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Affiliation(s)
- Michelle Jordon
- The University of Texas at Austin, Department of Educational Psychology, College of Education
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48
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Davis BH, Pope C. Institutionalized ghosting: policy contexts and language use in erasing the person with Alzheimer's. LANGUAGE POLICY 2010; 9:29-44. [PMID: 20585465 PMCID: PMC2888108 DOI: 10.1007/s10993-009-9153-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The ordinary social engagement of human life would not usually be considered an arena for language policy. Yet clinical evidence mounts that social interaction improves our lives as we age. Since social engagement decreases cardiovascular risks (Ramsay et al. in Ann Epidemiol 18:476-483, 2008) and delays memory loss among those living in communities (Ertel et al. in Am J Public Health 98:1215-1220, 2008), practices that prohibit social interaction threaten human well-being. For persons who have Alzheimer's disease (AD), social interaction continues to play an integral part in cognitive function and delays in memory loss, according to a longitudinal study of social networks (Bennett et al. in Lancet Neurol 5:406-412, 2007). Increasingly, person-centered care that promotes social engagement for those with AD is promoted as an institutional policy to improve outcomes of dementia care (Edvardsson et al. in Int Psychogeriatr 20:764-776, 2008). Yet the training of caregivers may neither reflect person-centered care nor include attention to communication, suggesting covert policies in practice.
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Affiliation(s)
- Boyd H. Davis
- 255A Fretwell, University of North Carolina-Charlotte, 9201 University City Drive, Charlotte, NC 28212, USA,
| | - Charlene Pope
- Medical University of South Carolina, 99 Jonathan Lucas Street, MSC 160, Charleston, SC 29425, USA,
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Chung G. Nursing assistant beliefs about their roles and nursing home residents: implications for nursing home social work practice. SOCIAL WORK IN HEALTH CARE 2010; 49:718-733. [PMID: 20853211 DOI: 10.1080/00981389.2010.485085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The purpose of this study is to examine beliefs and assumptions held by nursing assistants working in nursing homes using a qualitative approach. Unchallenged notions about residents and the roles held by nursing assistants influence their way of interacting with residents, which inevitably influences quality of care in nursing homes. When nursing assistants have an opportunity to be heard and mentored by social workers, they can address and resolve the dilemma of providing informal care as a formal caregiver by discussing what is acceptable and appropriate in nursing home care.
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Affiliation(s)
- Gawon Chung
- Social Welfare, University of California, Los Angeles, California 90095-1656, USA.
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50
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Kontos PC, Miller KL, Mitchell GJ. Neglecting the importance of the decision making and care regimes of personal support workers: a critique of standardization of care planning through the RAI/MDS. THE GERONTOLOGIST 2009; 50:352-62. [PMID: 20026525 PMCID: PMC2867498 DOI: 10.1093/geront/gnp165] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The Resident Assessment Instrument-Minimum Data Set (RAI/MDS) is an interdisciplinary standardized process that informs care plan development in nursing homes. This standardized process has failed to consistently result in individualized care planning, which may suggest problems with content and planning integrity. We examined the decision making and care practices of personal support workers (PSWs) in relation to the RAI/MDS standardized process. DESIGN AND METHODS This qualitative study utilized focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) in two nursing homes in central Canada. RESULTS PSWs evidenced unique occupational contributions to assessment via proximal familiarity and biographical information as well as to individualizing care by empathetically linking their own bodily experiences and forging bonds of fictive kinship with residents. These contributions were neither captured by RAI/MDS categories nor relayed to the interdisciplinary team. Causal factors for PSW exclusion included computerized records, low status, and poor interprofessional collaboration. Intraprofessional collaboration by PSWs aimed to compensate for exclusion and to individualize care. IMPLICATIONS Exclusive institutional reliance on the RAI/MDS undermines quality care because it fails to capture residents' preferences and excludes input by PSWs. Recommendations include incorporating PSW knowledge in care planning and documentation and examining PSWs' nascent occupational identity and their role as interprofessional brokers in long-term care.
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Affiliation(s)
- Pia C Kontos
- Toronto Rehabilitation Institute, 11035-550 University Avenue, Toronto, Ontario, Canada M5G 2A2.
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