Entangled in complexity: An ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs

AIM

The aim of this study was to visualize vulnerabilities and explore the dynamics of inter-professional collaboration and organizational adaptability in the context of care transitions for patients with complex care needs.

DESIGN

An ethnographic design using multiple convergent data collection techniques.

METHODS

Data collection involved document review, participant observations and interviews with healthcare and social care professionals (HSCPs). Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings.

RESULTS

Inconsistencies in timing and precision during care transitions pose risks for patients with complex care needs as they force healthcare systems to prioritize structural constraints over individualized care, especially during unforeseen events outside regular hours. Such systemic inflexibility can compromise patient safety, increase the workload for HSCPs and strain resources. Organizational adaptability is crucial to managing the inherent variability of patient needs. Our proposed 'safe care transition pathway' addresses these issues, providing proactive strategies such as sharing knowledge and increasing patient participation, and strengthening the capacity of professionals to meet dynamic care needs, promoting safer care transitions.

CONCLUSION

To promote patient safety in care transitions, strategies must go beyond inter-professional collaboration, incorporating adaptability and flexible resource planning. The implementation of standardized safe care transition pathways, coupled with the active participation of patients and families, is crucial. These measures aim to create a resilient, person-centred approach that may effectively manage the complexities in care transitions.

IMPLICATIONS

The recommendations of this study span the spectrum from policy-level changes aimed at strategic resource allocation and fostering inter-professional collaboration to practical measures like effective communication, information technology integration, patient participation and family involvement. Together, the recommendations offer a holistic approach to enhance care transitions and, ultimately, patient outcomes.

REPORTING METHOD

Findings are reported per the Consolidated Criteria for Reporting Qualitative research (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Measuring patients' experiences of continuity of care in a primary care context-Development and evaluation of a patient-reported experience measure

BACKGROUND

Continuity of care is viewed as a hallmark of high-quality care in the primary care context. Measures to evaluate the quality of provider performance are scarce, and it is unclear how the assessments correlate with patients' experiences of care as coherent and interconnected over time, consistent with their preferences and care needs.

AIM

To develop and evaluate a patient-reported experience measure of continuity of care in primary care for patients with complex care needs.

METHOD

The study was conducted in two stages: (1) development of the instrument based on theory and empirical studies and reviewed for content validity (16 patients with complex care needs and 8 experts) and (2) psychometric evaluation regarding factor structure, test-retest reliability, internal consistency reliability, and convergent validity. In all, 324 patients participated in the psychometric evaluation.

RESULTS

The Patient Experienced Continuity of care Questionnaire (PECQ) contains 20 items clustered in four dimensions of continuity of care measuring Information (four items), Relation (six items), Management (five items), and Knowledge (five items). Overall, the hypothesized factor structure was indicated. The PECQ also showed satisfactory convergent validity, internal consistency, and stability.

CONCLUSION/IMPLICATIONS

The PECQ is a multidimensional patient experience instrument that can provide information on various dimensions useful for driving quality improvement strategies in the primary care context for patients with complex care needs.

PATIENT OR PUBLIC CONTRIBUTION

Patients have participated in the content validation of the items.

Relational continuity may give better clinical outcomes in patients with serious mental illness - a systematic review

BACKGROUND

Continuity of care is considered important for results of treatment of serious mental illness (SMI). Yet, evidence of associations between relational continuity and different medical and social outcomes is sparse. Research approaches differ considerably regarding how to best assess continuity as well as which outcome to study. It has hitherto been difficult to evaluate the importance of relational continuity of care. The aim of this systematic review was to investigate treatment outcomes, including effects on resource use and costs associated with receiving higher relational continuity of care for patients with SMI.

METHODS

Eleven databases were searched between January 2000 and February 2021 for studies investigating associations between some measure of relational continuity and health outcomes and costs. All eligible studies were assessed for study relevance and risk of bias by at least two independent reviewers. Only studies with acceptable risk of bias were included. Due to study heterogeneity the synthesis was made narratively, without meta-analysis. The certainty of the summarized result was assessed using GRADE. Study registration number in PROSPERO: CRD42020196518.

RESULTS

We identified 8 916 unique references and included 17 studies comprising around 300 000 patients in the review. The results were described with regard to seven outcomes. The results indicated that higher relational continuity of care for patients with serious mental illness may prevent premature deaths and suicide, may lower the number of emergency department (ED) visits and may contribute to a better quality of life compared to patients receiving lower levels of relational continuity of care. The certainty of the evidence was assessed as low or very low for all outcomes. The certainty of results for the outcomes hospitalization, costs, symptoms and functioning, and adherence to drug treatment was very low with the result that no reliable conclusions could be drawn in these areas.

CONCLUSIONS

The results of this systematic review indicate that having higher relational continuity of care may have beneficial effects for patients with severe mental illness, and no results have indicated the opposite relationship. There is a need for better studies using clear and distinctive measures of exposure for relational continuity of care.

Delineating and clarifying the concept of self-care monitoring: a concept analysis

AIM

To delineate and clarify the meaning of the concept of self-care monitoring from a patient perspective.

METHODS

A systematic search was performed in the databases ASSIA, CINAHL, PsycInfo, and PubMed (January 2016-September 2021). A selection of 46 peer-reviewed articles was included in the study and analysed using Rodgers' Evolutionary Method for Concept Analysis.

RESULTS

The following four attributes were identified: Tracking symptoms, signs, and actions, Paying attention, Being confident, and Needing routines, creating a descriptive definition: "Self-care monitoring is an activity that means a person has to pay attention and be confident and needs routines for tracking symptoms, signs, and action." The antecedents of the concept were shown to be Increased knowledge, Wish for independence, and Commitment. The concepts' consequences were identified as Increased interaction, Perceived burden, and Enhanced well-being.

CONCLUSIONS

This concept analysis provides extensive understanding of self-care monitoring from a patient perspective. It was shown that the concept occurs when a person practices self-care monitoring at home either with or without devices. A descriptive definition was constructed and presented with exemplars to encourage practice of the concept in various healthcare settings and could be of relevance to people with chronic illnesses or other long-term conditions.

Exploring patient flow management through a lens of cognitive systems engineering

Hospitals work to provide quality, safety, and availability to patients with a wide variety of care needs, which makes efficient prioritisation and resource utilisation essential. Anticipation of each patients' trajectory, while monitoring available resources across the hospital, are major challenges for patient flow management. This study focuses on how hospital patient flow management is realised in situ with the help of concepts from cognitive systems engineering. Five semi-structured interviews with high level managers and shadowing observations of seven full work-shifts with management teams were conducted, to explore how patient flow is coordinated and communicated across the hospital. The data has been analysed using qualitative content analysis. The results describe patient flow management using an adapted Extended Control Model (ECOM) and reveal how authority and information might be better placed closer to clinical work for increased efficiency of patient flow.Practitioner summary: This study describes how a large tertiary paediatric hospital's patient flow management functions. The results offer a new understanding of how patient flow management is communicated and coordinated across organisational levels of the hospital and how authority and information might be better placed closer to clinical work for increased efficiency.

The challenge of risk prevention in home healthcare-An interview study with nurses in municipal care

BACKGROUND

Safety in home healthcare has garnered increased attention as more people are receiving care for complex conditions at home. The prerequisites for providing safe care at home differ from those in hospitals. Malnutrition, falls, pressure ulcers and inappropriate medication commonly follow poor risk assessments, causing unnecessary suffering and costs. Therefore, risk prevention in home healthcare needs to be prioritised and studied more closely.

AIM

To describe nurses' experiences of performing risk prevention in municipal home healthcare.

METHODS

Qualitative inductive approach, using semi-structured interviews with 10 registered nurses in a municipality in southern Sweden. Data underwent qualitative content analysis.

FINDINGS

The analysis resulted in three main categories and one overarching theme describing nurses' experiences of risk prevention in home healthcare. Getting everyone onboard comprises the categories: Managing safety while respecting the patient's self-determination, which covers patient participation, the strategic importance of respecting different views of risks and information and the fact that healthcare workers are guests in the patient's home. Finding ways to make it work touches upon the relational aspect, including next-of-kin and promoting a common understanding to prevent risks. Being squeezed between resources and requirements refers to ethical dilemmas, teamwork, leadership and organisational prerequisites.

CONCLUSION

Patient habits, living conditions and limited awareness of risks is a challenge in risk prevention in home healthcare, where patient participation plays a pivotal role. Risk prevention in home healthcare needs to be initiated at an early stage of disease and ageing and should be seen as a process where early health-promoting interventions can prevent the development and accumulation of risks over time. Long-term cross-organisational collaborations and patients' physical, mental and psychosocial conditions also need to be taken into account.

From Threatening Chaos to Temporary Order through a Complex Process of Adaptation: A Grounded Theory Study of the Escalation of Intensive Care during the COVID-19 Pandemic

To ensure high-quality care, operationalize resilience and fill the knowledge gap regarding how to improve the prerequisites for resilient performance, it is necessary to understand how adaptive capacity unfolds in practice. The main aim of this research was to explain the escalation process of intensive care during the first wave of the pandemic from a microlevel perspective, including expressions of resilient performance, intervening conditions at the micro-meso-macrolevels and short- and long-term consequences. A secondary aim was to provide recommendations regarding how to optimize the prerequisites for resilient performance in intensive care. A grounded theory methodology was used. First-person stories from different healthcare professionals (n70) in two Swedish regions were analyzed using the constant comparative method. This resulted in a novel conceptual model (including 6 main categories and 24 subcategories), and 41 recommendations. The conclusion of these findings is that the escalation of intensive care can be conceptualized as a transition from threatening chaos to temporary order through a complex process of adaptation. To prepare for the future, the components of space, stuff, staff, system and science, with associated continuity plans, must be implemented, anchored and communicated to actors at all levels of the system.

A comparative study of the 2D- and 3D-based skeleton avatar technology for assessing physical activity and functioning among healthy older adults

Background: Maintaining physical activity (PA) and functioning (mobility, balance) is essential for older adults' well-being and quality of life. However, current methods (functional tests, self-reports) and available techniques (accelerometers, sensors, advanced movement analysis systems) for assessing physical activity and functioning have shown to be less reliable, time- and resource-consuming with limited routine usage in clinical practice. There is a need to simplify the assessment of physical activity and functioning among older adults both in health care and clinical studies. This work presents a study on using Skeleton Avatar Technology (SAT) for this assessment. SAT analyzes human movement videos using artificial intelligence (AI). The study compares handy SAT based on 2D camera technology (2D SAT) with previously studied 3D SAT for assessing physical activity and functioning in older adults. Objective: To explore whether 2D SAT yields accurate results in physical activity and functioning assessment in healthy older adults, statistically compared to the accuracy of 3D SAT. Method: The mobile pose estimation model provided by Tensorflow was used to extract 2D skeletons from the video recordings of functional test movements. Deep neural networks were used to predict the outcomes of functional tests (FT), expert-based movement quality assessment (EA), accelerometer-based assessments (AC), and self-assessments of PA (SA). To compare the accuracy with 3D SAT models, statistical analysis was used to test whether the difference in the predictions between 2D and 3D models is significant or not. Results: Overall, the accuracy of 2D SAT is lower than 3D SAT in predicting FTs and EA. 2D SAT was able to predict AC with 7% Mean Absolute Error (MAE), and self-assessed PA (SA) with 16% MAE. On average MAE was 4% higher for 2D than for 3D SAT. There was no significant difference found between the 2D and the 3D model for AC and for two FTs (30 seconds chair stand test, 30sCST and Timed up and go, TUG). A significant difference was found for the 2D- and 3D-model of another FT (4-stage balance test, 4SBT). Conclusion: Altogether, the results show that handy 2D SAT might be used for assessing physical activity in older adults without a significant loss of accuracy compared to time-consuming standard tests and to bulky 3D SAT-based assessments. However, the accuracy of 2D SAT in assessing physical functioning should be improved. Taken together, this study shows promising results to use 2D SAT for assessing physical activity in healthy older adults in future clinical studies and clinical practice.

Healthcare workers' experiences of patient safety in the intensive care unit during the COVID-19 pandemic: A multicentre qualitative study

AIM

To describe healthcare workers' experiences of preconditions and patient safety risks in intensive care units during the COVID-19 pandemic.

BACKGROUND

Healthcare workers' ability to adapt to changing conditions is crucial to promote patient safety. During the COVID-19 pandemic, healthcare workers' capacity to maintain safe care was challenged and a more in-depth understanding on frontline experiences of patient safety is needed.

DESIGN

A qualitative descriptive design.

METHODS

Individual interviews were conducted with 29 healthcare workers (nurses, physicians, nurse assistants and physiotherapists) from three Swedish hospitals directly involved in intensive care of COVID-19 patients. Data were analysed with inductive content analysis. Reporting followed the COREQ checklist.

RESULTS

Three categories were identified. Hazardous changes in working conditions describes patient safety challenges associated with the extreme workload with high stress level. Imperative adaptations induced by changed preconditions for patient safety which include descriptions of safety risks following adaptations related to temporary intensive care facilities, handling shortage of medical equipment and deviations from routines. Safety risks triggered by reorganisation of care describe how the diluted skill-mix and team disruptions exposed patients to safety risks, and that safety performance mostly relied on individual healthcare worker's responsibility.

CONCLUSIONS

The study suggests that healthcare workers experienced an increase in patient safety risks during the COVID-19 pandemic mainly because the extremely high workload, imperative adaptations, and reorganisation of care regarding skill-mix and teamwork. Patient safety performance relied on the individuals' adaptability and responsibility rather than on system-based safety.

RELEVANCE TO CLINICAL PRACTICE

This study provides insights on how healthcare workers' experiences can be used as a source of information for recognition of patient safety risks. To improve detection of safety risks during future crises, guidelines on how to approach safety from a system perspective must include healthcare workers' perceptions on safety risks.

PATIENT AND PUBLIC CONTRIBUTION

None in the conceptualisation or design of the study.

Effects of Web-Based and Mobile Self-Care Support in Addition to Standard Care in Patients After Radical Prostatectomy: Randomized Controlled Trial

BACKGROUND

Prostate cancer is a common form of cancer that is often treated with radical prostatectomy, which can leave patients with urinary incontinence and sexual dysfunction. Self-care (pelvic floor muscle exercises and physical activity) is recommended to reduce the side effects. As more and more men are living in the aftermath of treatment, effective rehabilitation support is warranted. Digital self-care support has the potential to improve patient outcomes, but it has rarely been evaluated longitudinally in randomized controlled trials. Therefore, we developed and evaluated the effects of digital self-care support (electronic Patient Activation in Treatment at Home [ePATH]) on prostate-specific symptoms.

OBJECTIVE

This study aimed to investigate the effects of web-based and mobile self-care support on urinary continence, sexual function, and self-care, compared with standard care, at 1, 3, 6, and 12 months after radical prostatectomy.

METHODS

A multicenter randomized controlled trial with 2 study arms was conducted, with the longitudinal effects of additional digital self-care support (ePATH) compared with those of standard care alone. ePATH was designed based on the self-determination theory to strengthen patients' activation in self-care through nurse-assisted individualized modules. Men planned for radical prostatectomy at 3 county hospitals in southern Sweden were included offline and randomly assigned to the intervention or control group. The effects of ePATH were evaluated for 1 year after surgery using self-assessed questionnaires. Linear mixed models and ordinal regression analyses were performed.

RESULTS

This study included 170 men (85 in each group) from January 2018 to December 2019. The participants in the intervention and control groups did not differ in their demographic characteristics. In the intervention group, 64% (53/83) of the participants used ePATH, but the use declined over time. The linear mixed model showed no substantial differences between the groups in urinary continence (β=-5.60; P=.09; 95% CI -12.15 to -0.96) or sexual function (β=-.12; P=.97; 95% CI -7.05 to -6.81). Participants in the intervention and control groups did not differ in physical activity (odds ratio 1.16, 95% CI 0.71-1.89; P=.57) or pelvic floor muscle exercises (odds ratio 1.51, 95% CI 0.86-2.66; P=.15).

CONCLUSIONS

ePATH did not affect postoperative side effects or self-care but reflected how this support may work in typical clinical conditions. To complement standard rehabilitation, digital self-care support must be adapted to the context and individual preferences for use and effect.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN18055968; https://www.isrctn.com/ISRCTN18055968.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11625.

Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

BACKGROUND

Hospital discharge is a complex process encompassing multiple interactions and requiring coordination. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aims of this study were to 1) map coordination and team collaboration across healthcare and social care organisations, 2) describe interdependencies and system variability in the discharge process for older people with complex care needs, and 3) evaluate the alignment between discharge planning and the needs in the home.

METHODS

Data were collected through participant observations, interviews, and document review in a region of southern Sweden. The Functional Resonance Analysis Method (FRAM) was used to model the discharge process and visualise and analyse coordination of care across healthcare and social care organisations.

RESULTS

Hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals' performance is constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in health and social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. Flexibility and appropriate resources enable for handling variability and responding to uncertainties in care after discharge.

CONCLUSIONS

Mapping hospital discharge using the FRAM reveals couplings and interdependencies between various individuals, teams, and organisations and the most vulnerable point, when the patient arrives at home. Resilient performance in responding to unexpected events and variations during the first days after the return home requires a system allowing flexibility and facilitating successful adaptation of discharge planning.

Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: an interview study

BACKGROUND

Safety has been described as a dynamic non-event and as constantly present in professionals' work processes. Investigating management of complex everyday situations may create an opportunity to elucidate safety management. Anaesthesia has been at the frontline of enhancing patient safety - testing and implementing knowledge from other high-reliability industries, such as aviation, in the complex, adaptive system of an operating room. The aim of this study was to explore factors supporting anaesthesia nurses and anaesthesiologists in managing complex everyday situations during intraoperative anaesthesia care processes.

METHODS

Individual interviews with anaesthesia nurses (n = 9) and anaesthesiologists (n = 6) using cognitive task analysis (CTA) on case scenarios from previous prospective, structured observations. The interviews were analysed using the framework method.

RESULTS

During intraoperative anaesthesia care, management of everyday complex situations is sustained through preparedness, support for mindful practices, and monitoring and noticing complex situations and managing them. The prerequisites are created at the organization level. Managers should ensure adequate resources in the form of trained personnel, equipment and time, team and personnel sustainability and early planning of work. Management of complex situations benefits from high-quality teamwork and non-technical skills (NTS), such as communication, leadership and shared situational awareness.

CONCLUSION

Adequate resources, stability in team compositions and safe boundaries for practice with shared baselines for reoccurring tasks where all viewed as important prerequisites for managing complex everyday work. When and how NTS are used in a specific clinical context depends on having the right organizational prerequisites and a deep expertise of the relevant clinical processes. Methods like CTA can reveal the tacit competence of experienced staff, guide contextualized training in specific contexts and inform the design of safe perioperative work practices, ensuring adequate capacity for adaptation.

Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals - a qualitative study

BACKGROUND

Chronic diseases are increasing worldwide, and the complexity of disease management is putting new demands on safe healthcare. Telemonitoring technology has the potential to improve self-care management with the support of healthcare professionals for people with chronic diseases living at home. Patient safety threats related to telemonitoring and how they may affect patients' and healthcare professionals' sense of security need attention. This study aimed to explore patients' and healthcare professionals' experiences of safety and sense of security when using telemonitoring of chronic conditions at home.

METHODS

Semi-structured interviews were conducted with twenty patients and nine healthcare professionals (nurses and physicians), recruited from four primary healthcare centers and one medical department in a region in southern Sweden using telemonitoring service for chronic conditions in home healthcare.

RESULTS

The main theme was that experiences of safety and a sense of security were intertwined and relied on patients´ and healthcare professionals´ mutual engagement in telemonitoring and managing symptoms together. Telemonitoring was perceived to increase symptom awareness and promote early detection of deterioration promoting patient safety. A sense of security emerged through having someone keeping track of symptoms and comprised aspects of availability, shared responsibility, technical confidence, and empowering patients in self-management. The meeting with technology changed healthcare professionals' work processes, and patients' daily routines, creating patient safety risks if combined with low health- and digital literacy and a naïve reliance on technology. Empowering patients' self-management ability and improving shared understanding of the patient's health status and symptom management were prerequisites for safe care and the patient´s sense of security.

CONCLUSIONS

Telemonitoring chronic conditions in the homecare context can promote a sense of security when care is co-created in a mutual understanding and responsibility. Attentiveness to the patient's health literacy, symptom management, and health-related safety behavior when using eHealth technology may enlighten and mitigate latent patient safety risks. A systems approach indicates that patient safety risks related to telemonitoring are not only associated with the patient's and healthcare professionals functioning and behavior or the human-technology interaction. Mitigating patient safety risks are likely also dependent on the complex management of home health and social care service.

The Caregiver Pathway, a Model for the Systematic and Individualized Follow-up of Family Caregivers at Intensive Care Units: Development Study

BACKGROUND

Family caregivers of patients who are critically ill have a high prevalence of short- and long-term symptoms, such as fatigue, anxiety, depression, symptoms of posttraumatic stress, and complicated grief. These adverse consequences following a loved one's admission to an intensive care unit (ICU) are also known as post-intensive care syndrome-family. Approaches such as family-centered care provide recommendations for improving the care of patients and families, but models for family caregiver follow-up are often lacking.

OBJECTIVE

This study aims to develop a model for structuring and individualizing the follow-up of family caregivers of patients who are critically ill, starting from the patients' ICU admission to after their discharge or death.

METHODS

The model was developed through a participatory co-design approach using a 2-phased iterative process. First, the preparation phase included a meeting with stakeholders (n=4) for organizational anchoring and planning, a literature search, and interviews with former family caregivers (n=8). In the subsequent development phase, the model was iteratively created through workshops with stakeholders (n=10) and user testing with former family caregivers (n=4) and experienced ICU nurses (n=11).

RESULTS

The interviews revealed how being present with the patient and receiving adequate information and emotional care were highly important for family caregivers at an ICU. The literature search underlined the overwhelming and uncertain situation for the family caregivers and identified recommendations for follow-up. On the basis of these recommendations and findings from the interviews, workshops, and user testing, The Caregiver Pathway model was developed, encompassing 4 steps: within the first few days of the patient's ICU stay, the family caregivers will be offered to complete a digital assessment tool mapping their needs and challenges, followed by a conversation with an ICU nurse; when the patient leaves the ICU, a card containing information and support will be handed out to the family caregivers; shortly after the ICU stay, family caregivers will be offered a discharge conversation by phone, focusing on how they are doing and whether they have any questions or concerns; and within 3 months after the ICU stay, an individual follow-up conversation will be offered. Family caregivers will be invited to talk about memories from the ICU and reflect upon the ICU stay, and they will also be able to talk about their current situation and receive information about relevant support.

CONCLUSIONS

This study illustrates how existing evidence and stakeholder input can be combined to create a model for family caregiver follow-up at an ICU. The Caregiver Pathway can help ICU nurses improve family caregiver follow-up and aid in promoting family-centered care, potentially also being transferrable to other types of family caregiver follow-up.

Unfolding alignment - How top management work to align demand and capacity: an ethnographic study of resilience in a Swedish healthcare region

BACKGROUND

Resilient healthcare organizations maintain critical functions and high-quality care under varying conditions. While previous research has focused on the activities of frontline healthcare professionals working at the "sharp end" of care, less attention has been paid to managers at the top management level. More knowledge is needed to fully understand how the managers align demand and capacity at the "blunt end" of care. Therefore, this study aimed to explore how top managers work to align demand and capacity in a healthcare region in Sweden.

METHODS

Observations of management team meetings, interviews, and conversations were conducted with top managers responsible for healthcare in one of Sweden's 21 regions. Data collection used an ethnographic approach. Data were analyzed using qualitative reflexive thematic analysis.

RESULTS

The data showed how alignment work was done through active reflection that built on past experiences and on structures built into the organization at the same time as taking future potential outcomes and consequences into account. In addition to collaborative, preventive, supportive, and contextualizing work, which was conducted in the present, a general approach permeated the organization, which enabled connecting actions, i.e., different forms of alignment work, occurring at different points in time, and connecting different types of knowledge across organizational borders and stakeholders.

CONCLUSION

This study explored how top managers work to align demand and capacity in a healthcare region in Sweden. It was shown how four categories of work; collaborative, preventive, supportive and contextualization work, together with a general approach; focusing on opportunities, building on a stable past and taking a reflective stance, constitute alignment in practice. More; the alignment work was done in the here and now, with both the past and future in mind. The ability to take action to benefit the whole is a possibility and a responsibility for top management. In the region studied, this was done by aligning demands with capacity based on past experiences and focusing on the available opportunities to connect knowledge needed within and across organizational borders.

Exploring nursing-sensitive events in home healthcare: A national multicenter cohort study using a trigger tool

BACKGROUND

The provision of home healthcare is increasing in response to the growing aging population with the need for chronic disease management in their homes. Safety work differs from hospital care. The incidence of adverse events in home healthcare is sparsely studied but is estimated to occur in-one third of patients, and most are deemed preventable. Although nursing care is crucial for risk assessment and preventive work in the home environment, the role of registered nurses in the prevention of no-harm incidents and adverse events has not received sufficient scientific attention.

OBJECTIVES

To explore nursing-sensitive events in patients receiving home healthcare.

DESIGN, SETTING AND PARTICIPANTS

A Swedish national multicenter study based on a structured record review of 600 randomly chosen healthcare records from 10 organizations in different regions of the country.

METHODS

Ten trained teams, each including physician(s) and registered nurses, undertook a review based on the Global Trigger Tool method. The review covered a maximum of 90 days from admission to home healthcare. First, each record was screened for the presence of 38 predefined triggers. In the second step, every potential event was assessed according to preventability, types of events, severity, time of occurrence, consequences of the event, and potential contributing causes.

RESULTS

In total, 699 events were identified in the study. Of these, 495 (74.0%) were classified as nursing-sensitive (227 no-harm incidents and 268 adverse events) and affected 267 (44.5%) patients, with a mean of 1.9 events per patient. The majority (n = 367, 73.1%) were considered preventable. The most prominent types of nursing-sensitive event were falls (n = 138, 27.9%), pressure ulcers (n = 62, 12.5%), healthcare-associated infections (n = 58, 11.7%) and medication management (n = 50, 10.1%). Concerning severity, 45.9% were classified as no-harm incidents and another 36.6% resulted in temporary harm that required extra healthcare resources: 226 hospital days, 66 physician visits in outpatient care, and 99 in home healthcare. All severity types occurred from day 1, except death, which included only one patient. The most frequent contributing factors were deficiencies in nursing care, treatment & diagnosis, with the subgroups nursing care, observation, treatment & follow-up, followed by deficiencies in the organization.

CONCLUSIONS

Nursing-sensitive events in home healthcare are common, often preventable, and occur from the start of the care period. This study contributes to increased knowledge of patient safety shortcomings and points to the important role that registered nurses play in patient safety work.

Communication about medication management during patient-physician consultations in primary care: a participant observation study

OBJECTIVE

To explore communication about medication management during annual consultations in primary care.

DESIGN

passive participant observations of primary care consultations.

SETTING

Two primary care centres in southern Sweden.

PARTICIPANTS

Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis.

RESULTS

Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further.

CONCLUSION

Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.

Outcomes associated with higher relational continuity in the treatment of persons with asthma or chronic obstructive pulmonary disease: A systematic review

Background

Asthma and chronic obstructive pulmonary disease (COPD) are chronic conditions where relational continuity of care, as in regularly meeting the same health care provider, creates opportunities for monitoring and adjustment of treatment based on an individual's changing needs, potentially affecting quality of delivered care. The aim of this systematic review was to investigate the effects of relational continuity in the treatment of persons with asthma or COPD.

Methods

Eleven databases (CINAHL, Medline, PsycINFO, Scopus, Embase, Cochrane Library, Database of Systematic Review of Effects, DARE, Epistemonikos, NICE Evidence Search, KSR Evidence and AHRQ) were searched between January 1, 2000, and February 1 - 4, 2021, for controlled and observational studies about relational continuity and health outcomes for persons with asthma and/or COPD. Inclusion criteria were studies investigating an index or aspect relevant to relational continuity between a health professional/team of health professionals and patients. After screening, and assessment of study relevance and quality by at least two independent reviewers, studies with acceptable risk of bias were included and summary data was extracted from the publications. Main outcomes were mortality, morbidity (including health care utilization) and cost measures. Syntheses without metanalyses were performed due to considerable study heterogeneity. The certainty of the summarized result was assessed using GRADE (the Grading of Recommendations Assessment, Development and Evaluation). PROSPERO study registration number: CRD42020196518.

Findings

We identified 2824 unique references and included 15 studies (14 observational and 1 randomized controlled trial) in the review, from which results were derived for six outcomes. For persons with asthma or COPD we found that higher compared to lower relational continuity of care prevents premature mortality (low certainty; 2 studies, 111 545 participants), lowers risk of emergency department visits (low certainty, 5 studies, 362 305 participates) and risk of hospitalization (moderate certainty, 9 studies, 525 716 participants), and lowers health care costs (low certainty; 4 studies, 390 682 participants). Results regarding treatment adherence (1 study, 971 participants) and patient perceptions (3 studies, 2026 participants) were assessed as having very low certainty.

Interpretation

Low to moderate certainty evidence suggests that higher versus lower relational continuity of care for persons with asthma or COPD prevents premature mortality, lowers risks of unplanned health care utilization and reduces health care costs. The results may be of value when planning care for individuals and for policymakers in organizing health care and developing guidelines for treatment and follow-up routines.

Funding

None.

What is needed for continuity of care and how can we achieve it? - Perceptions among multiprofessionals on the chronic care trajectory

Background

Continuity of care (CoC) implies delivery of services in a coherent, logical and timely fashion. Continuity is conceptualized as multidimensional, encompassing three specific domains – relational, management and informational continuity – with emphasis placed on their interrelations, i.e., how they affect and are affected by each other. This study sought to investigate professionals’ perceptions of the prerequisites of CoC within and between organizations and how CoC can be realized for people with complex care needs.

Methods

This study had a qualitative design using individual, paired and focus group interviews with a purposeful sample of professionals involved in the chain of care for patients with chronic conditions across healthcare and social care services from three different geographical areas in Sweden, covering both urban and rural areas. Transcripts from interviews with 34 informants were analysed using conventional content analysis.

Results

CoC was found to be dependent on professional and cross-disciplinary cooperation at the micro, meso and macro system levels. Continuity is dependent on long-term and person-centred relationships (micro level), dynamic stability in organizational structures (meso level) and joint responsibility for cohesive care and enabling of uniform solutions for knowledge and information exchange (macro level).

Conclusions

Achieving CoC that creates coherent and long-term person-centred care requires knowledge- and information-sharing that transcends disciplinary and organizational boundaries. Collaborative accountability is needed both horizontally and vertically across micro, meso and macro system levels, rather than a focus on personal responsibility and relationships at the micro level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08023-0.

'We just have to make it work': a qualitative study on assistant nurses' experiences of patient safety performance in home care services using forum play scenarios

OBJECTIVE

Safety is essential to support independent living among the rising number of people with long-term healthcare and social care needs. Safety performance in home care leans heavily on the capacity of unlicensed staff to respond to problems and changes in the older patients' functioning and health. The aim of this study is to explore assistant nurses' adaptive responses to everyday work to ensure safe care in the home care context.

DESIGN

A qualitative approach using the drama-based learning and reflection technique forum play with subsequent group interviews. The audio-recorded interviews were transcribed and analysed with thematic analysis.

SETTING

Home care services organisations providing care to older people in their private homes in two municipalities in southern Sweden.

PARTICIPANTS

Purposeful sampling of 24 assistant nurses and three managers from municipal home care services and a local geriatric hospital clinic.

RESULTS

Home care workers' adaptive responses to provide safe home care were driven by an ambition to 'make it work in the best interests of the person' by adjusting to and accommodating care recipient needs and making autonomous decisions that expanded the room for manoeuvrability, while weighing risks of a trade-off between care standards and the benefits for the community-dwelling older people's independent living. Adaptations to ensure information transfer and knowledge acquisition across disciplines and borders required reciprocity.

CONCLUSIONS

Safety performance in home care service is dependent on the staff closest to the older people, who deal with safety risks and ethical dilemmas on a day-to-day basis and their access to information, competence, and resources that fit the demands. A proactive leadership characterised by mutual trust and adequate support for decision making is suggested. Managers and decision-makers across healthcare and social care need to consider how they can develop interprofessional collaborations and adaptive routines supporting safety from a broader perspective.

Mapping registered nurse anaesthetists' intraoperative work: tasks, multitasking, interruptions and their causes, and interactions: a prospective observational study

INTRODUCTION

Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care.

OBJECTIVE

To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process.

METHODS

Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool.

RESULTS

High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia.

CONCLUSION

The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity and adaptivity of the nature of RNAs' work should be taken into consideration in future management, development, research and education.

Design and Development of an eHealth Service for Collaborative Self-Management among Older Adults with Chronic Diseases: A Theory-Driven User-Centered Approach

The increasing prevalence of chronic conditions and multimorbidity poses great challenges to healthcare systems. As patients' engagement in self-managing their chronic conditions becomes increasingly important, eHealth interventions are a promising resource for the provision of adequate and timely support. However, there is inconclusive evidence about how to design eHealth services to meet the complex needs of patients. This study applied an evidence-based and theory-informed user-centered design approach in three phases to identify the needs of older adults and healthcare professionals in the collaborative management of multimorbidity (phase 1), develop an eHealth service to address these needs (phase 2), and test the feasibility and acceptance of the eHealth service in a clinical setting (phase 3). Twenty-two user needs were identified and a web-based application-ePATH (electronic Patient Activation in Treatment at Home)-with separate user interfaces for patients and healthcare professionals was developed. The feasibility study with two nurses and five patients led to a redesign and highlighted the importance of adequately addressing not only varying user needs but also the complex nature of healthcare organizations when implementing new services and processes in chronic care management.

Resilient performance in healthcare during the COVID-19 pandemic (ResCOV): study protocol for a multilevel grounded theory study on adaptations, working conditions, ethics and patient safety

INTRODUCTION

Since early 2020, the COVID-19 pandemic has challenged societies and revealed the built-in fragility and dependencies in complex adaptive systems, such as healthcare. The pandemic has placed healthcare providers and systems under unprecedented amounts of strain with potential consequences that have not yet been fully elucidated. This multilevel project aims to explore resilient performance with the purpose of improving the understanding of how healthcare has adapted during the pandemic's rampage, the processes involved and the consequences on working conditions, ethics and patient safety.

METHODS

An emerging explorative multilevel design based on grounded theory methodology is applied. Open and theoretical sampling is performed. Empirical data are gathered over time from written narratives and qualitative interviews with staff with different positions in healthcare organisations in two Swedish regions. The participants' first-person stories are complemented with data from the healthcare organisations' internal documents and national and international official documents.

ANALYSIS

Experiences and expressions of resilient performance at different system levels and times, existing influencing risk and success factors at the microlevels, mesolevels and macrolevels and inter-relationships and consequences in different healthcare contexts, are explored using constant comparative analysis. Finally, the data are complemented with the current literature to develop a substantive theory of resilient performance during the pandemic.

ETHICS AND DISSEMINATION

This project is ethically approved and recognises the ongoing strain on the healthcare system when gathering data. The ongoing pandemic provides unique possibilities to study system-wide adaptive capacity across different system levels and times, which can create an important basis for designing interventions focusing on preparedness to manage current and future challenges in healthcare. Feedback is provided to the settings to enable pressing improvements. The findings will also be disseminated through scientific journals and conferences.

Health care professionals' experiences of how an eHealth application can function as a value-creating resource - a qualitative interview study

Background

The number of patients with one or more chronic conditions is increasing globally. One strategy to achieve more sustainable care for these patients is by implementing use of home-based eHealth applications. Such services support patients to take on a more active role as value-creating co-producers of their own care, in collaboration with health care professionals. Health care professionals have a key role in the value creation process, but little is known about value formation within eHealth interactions, especially from their perspective. Therefore, this study aimed to provide a deeper understanding of how an eHealth application can function as a value-creating resource from the perspective of health care professionals.

Methods

Semi-structured interviews were conducted with thirteen health care professionals (nurses, physicians and first-line managers). Qualitative content analysis was used to analyze the interviews.

Results

The findings indicate that value formation processes are strongly influenced by the organizational preconditions and by the usability and functionality of technology. The experiences of the health care professionals indicated that value was conceptualized in dimensions of meaningfulness, building of relationships, building safety and feelings of trust. Although these dimensions were mainly expressed in a positive way, such as perceived improvement of medical care, accessibility and continuity, they also had a negative side that caused value destruction. This was primarily due to patient difficulties in using the application or making measurements. Subsequent efforts at value recovery resulted in value creation, but were often time-consuming for the professionals.

Conclusions

This study contributes by extending conceptualizations of value to the role of health care professionals and by highlighting technology as sometimes facilitating and sometimes hampering value formation processes. The findings indicate that the eHealth application was a value-creating resource, facilitating proactive communication and supporting patients’ engagement and control over their self-care. However, for the application to become a more valuable resource in practice and counteract inequity in care, it needs to be further developed to be adapted to the needs and preconditions of patients.

What matters in care continuity on the chronic care trajectory for patients and family carers?-A conceptual model

AIMS AND OBJECTIVES

To describe essential aspects of care continuity from the perspectives of persons with complex care needs and their family carers.

BACKGROUND

Continuity of care is an important aspect of quality, safety and efficiency. For people with multiple chronic diseases and complex care needs, care must be experienced as connected and coherent, and consistent with medical and individual needs. The more complex the need for care, the greater the need for continuity across different competencies, services and roles.

DESIGN

A constructivist grounded theory approach was applied.

METHODS

Sixteen patients with one or more chronic diseases needing both health care and social care, living in their private homes, and twelve family carers, were recruited. Semi-structured interviews were conducted and analysed with constructivist grounded theory. The COREQ checklist was followed.

RESULTS

A conceptual model of care continuity was constructed, consisting of five categories that were interconnected through the core category: time and space. Patients' and family carers' experiences of care continuity were closely related to timely personalised care delivery, where access to tailored information, regardless of who was performing a care task, was essential for mutual understanding. This required clarity in responsibilities and roles, interprofessional collaboration and achieving a trusting relationship between each link in the chain of care, over time and space. To achieve care continuity, all the identified categories were important, as they worked in synergy, not in isolation.

CONCLUSION

Care continuity for people with complex care needs and family carers is experienced as multidimensional, with several essential aspects that work in synergy, but varies over time and depends on each person's own resources and situational and contextual circumstances.

RELEVANCE TO CLINICAL PRACTICE

The findings promote understanding of patients' and family carers' experiences of care continuity and may guide the delivery of care to people with complex care needs.

Self-management challenges following hospital discharge for patients with multimorbidity: a longitudinal qualitative study of a motivational interviewing intervention

OBJECTIVES

The aim of this study was to describe challenges in self-management activities among people with multimorbidity during a 4-week post-discharge period.

DESIGN

This is a longitudinal qualitative study using data from a randomised controlled trial (RCT) of motivational interviewing (MI) sessions.

SETTING

The RCT was conducted at six wards in two hospitals-one university hospital and one general hospital in Stockholm, Sweden, during 2016-2018.

PARTICIPANTS

Sixteen participants from the intervention group, diagnosed with heart failure or chronic obstructive pulmonary disease and at least one other chronic condition, were purposively selected for this study.

INTERVENTIONS

Each participant had four or five post-discharge MI sessions with a trained social worker during a period of approximately 4 weeks. The sessions were recorded digitally and analysed using content analysis. Altogether, 70 recorded sessions were analysed.

RESULTS

Self-management after hospital discharge was a dynamic process with several shifting features that evolved gradually over time. Patients with multimorbidity experienced two major challenges with self-management in the first 4 weeks following hospital discharge: 'Managing a system-centred care' and 'Handling the burden of living with multiple illnesses at home post-discharge'.

CONCLUSIONS

Self-management for patients with multimorbidity in the first post-discharge period does not equate to a fixed set of tasks, but varies over the post-discharge period. Self-management challenges include not only the burden of the disease itself, but also that of navigating and understanding the healthcare system. Hence, self-management support post-discharge involves both aiding patients with care coordination and meeting their gradually shifting disease-related needs.

TRIAL REGISTRATION NUMBER

NCT02823795.

A First-line management team's strategies for sustaining resilience in a specialised intensive care unit-a qualitative observational study

OBJECTIVES

Acute care units manage high risk patients at the edge of scientifically established treatments and organisational constraints while aiming to balance reliability to standards with the needs of situational adaptation (resilience). First-line managers are central in coordinating clinical care. Any systemic brittleness will be evident only in retrospect through, for example, care quality measures and accident statistics. This challenges us to understand what successful managerial strategies for adaptation are and how they could be improved. The managerial work of balancing reliability and adaptation is only partially understood. This study aims to explore and describe how system resilience is enhanced by naturally occurring coordination performed in situ by a management team under variable circumstances.

DESIGN

An explorative observational study of a tertiary neonatal intensive care unit (NICU) in Sweden. One year of broad preparatory work followed by focused shadowing observations of coordination analysed through inductive-deductive content analysis from a perspective of resilience engineering.

PARTICIPANTS

A team of managers (ie, clinical coordinators, head nurses, senior medical doctors).

RESULTS

The results describe a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Managers focused on maintaining coherence in escalating problematic situations by facilitating teamwork through goalsetting, problem-solving and circumventing the technical systems' limitations.

CONCLUSIONS

Coordination supports a coherent goal setting by increased team collaboration and is supported by team members' abilities to predict the behaviour of each other. Our findings suggest that in design of future research or training for coordination, the focus of assessment and reflection on adaptive managerial responses may lie on situations where the system was 'stretched' or 'needed reorganisation' and that learning should be about whether the actions were able to achieve short-term goals while preserving the long-term goals.

Evaluation of the Skeleton Avatar Technique for Assessment of Mobility and Balance Among Older Adults

Background: Mobility and balance is essential for older adults' well-being and independence and the ability to maintain physically active. Early identification of functional impairment may enable early risk-of-fall assessments and preventive measures. There is a need to find new solutions to assess functional ability in easy, efficient, and accurate ways, which can be clinically used frequently and repetitively. Therefore, we need to understand how functional tests and expert assessments (EAs) correlate with new techniques.

Objective: To explore whether the skeleton avatar technique (SAT) can predict the results of functional tests (FTs) of mobility and balance: Timed Up and Go (TUG), the 30-s chair stand test (30sCST), the 4-stage balance test (4SBT), and EA scoring of movement quality.

Methods: Fifty-four older adults (+65 years) were recruited through pensioners' associations. The test procedure contained three standardized FTs: TUG, 30sCST, and 4SBT. The test performances were recorded using a three-dimensional SAT camera. EA scoring was performed based on the video recordings of the 30sCST. Functional ability scores were aggregated from balance and mobility scores. Probability theory-based statistical analyses were used on the data to aggregate sets of individual variables into scores, with correlation analysis used to assess the dependency between variables and between scores. Machine learning techniques were used to assess the appropriateness of easily observable variables/scores as predictors of the other variables included.

Results: The results indicate that SAT data of the fourth 4SBT stage could be used to predict the aggregated results of all stages of 4SBT (with 7.82% mean absolute error), the results of the 30sCST (11.0%), the TUG test (8.03%), and the EA of the sit-to-stand movement (8.79%). There is a moderate (significant) correlation between the 30sCST and the 4SBT (0.31, p = 0.03), but not between the EA and the 30sCST.

Conclusion: SAT can predict the results of the 4SBT, the 30sCST (moderate accuracy), and the TUG test and might add important qualitative information to the assessment of movement performance in active older adults. SAT might in the future provide the means for a simple, easy, and accessible assessment of functional ability among older adults.

"Standing on common ground" - a qualitative study of self-management support for patients with multimorbidity in primary health care

BACKGROUND

Multimorbidity, the co-existence of two or more chronic conditions in an individual, is present in most patients over 65 years. Primary health care (PHC) is uniquely positioned to provide the holistic and continual care recommended for this group of patients, including support for self-management. The aim of this study was to explore professionals', patients', and family caregivers' perspectives on how PHC professionals should support self-management in patients with multimorbidity. This study also includes experiences of using telemedicine to support self-management.

METHODS

A mixed qualitative method was used to explore regular self-management support and telemedicine as a tool to support self-management. A total of 42 participants (20 physicians, 3 registered nurses, 12 patients, and 7 family caregivers) were interviewed using focus group interviews (PHC professionals), pair interviews (patients and family caregivers), and individual interviews (registered nurses, patients, and family caregivers). The study was performed in urban areas in central Sweden and rural areas in southern Sweden between April 2018 and October 2019. Data were analyzed using content analysis.

RESULTS

The main theme that emerged was "Standing on common ground enables individualized support." To achieve such support, professionals needed to understand their own views on who bears the primary responsibility for patients' self-management, as well as patients' self-management abilities, needs, and perspectives. Personal continuity and trustful relationships facilitated this understanding. The findings also indicated that professionals should be accessible for patients with multimorbidity, function as knowledge translators (help patients understand their symptoms and how the symptoms correlated with diseases), and coordinate between levels of care. Telemedicine supported continual monitoring and facilitated patient access to PHC professionals.

CONCLUSION

Through personal continuity and patient-centered consultations, professionals could collaborate with patients to individualize self-management support. For some patients, this means that PHC professionals are in control and monitor symptoms. For others, PHC professionals play a less controlling role, empowering patients' self-management. Development and improvement of eHealth tools for patients with multimorbidity should focus on improving the ability to set mutual goals, strengthening patients' inner motivation, and including multiple caregivers to enhance information-sharing and care coordination.

Patients' experiences of using an e-Health tool for self-management support after prostate cancer surgery: a deductive interview study explained through the FITT framework

OBJECTIVE

To evaluate patients' experiences of using a web-based application, especially its usability as support for self-care activities after prostate cancer surgery.

DESIGN

A deductive content analysis was used, stemming from the Fit between Individuals, Task and Technology (FITT) framework.

SETTING

One surgical department in south of Sweden between October 2015 and April 2016 and between September 2017 and July 2018.

PARTICIPANTS

Fifteen men who had undergone radical prostatectomy for prostate cancer.

RESULTS

By organising data in accordance with the FITT model, three main categories with ten subcategories were identified. Patients gave feedback on functions that suited them and their needs, as well as potential adjustments and improvements. Patients experienced that ePATH gave them easy access to reliable information regarding their rehabilitation. Directed information about ePATH at enrolment was seen as important. ePATH was perceived to have a logical structure that was easy to follow. However, when the structure was unclear, patients became less motivated to use a function.

CONCLUSIONS

Patients experienced ePATH as satisfactorily user-friendly and useful as a complementary self-management support after prostate cancer surgery, especially when the information and tasks were tailored to their preferences and the system design features supported individual autonomy.

Identifying no-harm incidents in home healthcare: a cohort study using trigger tool methodology

BACKGROUND

Patient safety in home healthcare is largely unexplored. No-harm incidents may give valuable information about risk areas and system failures as a source for proactive patient safety work. We hypothesized that it would be feasible to retrospectively identify no-harm incidents and thus aimed to explore the cumulative incidence, preventability, types, and potential contributing causes of no-harm incidents that affected adult patients admitted to home healthcare.

METHODS

A structured retrospective record review using a trigger tool designed for home healthcare. A random sample of 600 home healthcare records from ten different organizations across Sweden was reviewed.

RESULTS

In the study, 40,735 days were reviewed. In all, 313 no-harm incidents affected 177 (29.5%) patients; of these, 198 (63.2%) no-harm incidents, in 127 (21.2%) patients, were considered preventable. The most common no-harm incident types were "fall without harm," "deficiencies in medication management," and "moderate pain." The type "deficiencies in medication management" was deemed to have a preventability rate twice as high as those of "fall without harm" and "moderate pain." The most common potential contributing cause was "deficiencies in nursing care and treatment, i.e., delayed, erroneous, omitted or incomplete treatment or care."

CONCLUSION

This study suggests that it is feasible to identify no-harm incidents and potential contributing causes such as omission of care using record review with a trigger tool adapted to the context. No-harm incidents and potential contributing causes are valuable sources of knowledge for improving patient safety, as they highlight system failures and indicate risks before an adverse event reach the patient.

Sleep and Adiposity in Children From 2 to 6 Years of Age

OBJECTIVES

To compare sleep in young children at different obesity risks, which were based on parental weight, as well as to explore the longitudinal associations of sleep characteristics with adiposity.

METHODS

In total, 107 children from an obesity prevention project were included, of which 43 had normal-weight parents (low obesity risk) and 64 had overweight and/or obese parents (high obesity risk). Sleep was measured yearly from ages 2 to 6 years by using actigraphy. Five sleep characteristics, that of late sleep, long sleep latency, short sleep duration, low sleep efficiency, and irregular sleep onset, were defined and scored across ages, with a higher score indicating more frequent exposure. The outcome variables, also measured yearly, were BMI z score and waist circumference.

RESULTS

There was no difference in sleep patterns among children at different risks. Higher short sleep duration score was associated with a greater increase in BMI z score (0.12; 95% confidence interval [CI] 0.01 to 0.25) across ages. Independently of sleep duration, higher late sleep score was associated with greater increases in BMI z score (0.16; 95% CI 0.05 to 0.27) and waist circumference (0.60 cm; 95% CI 0.23 to 0.98). Moreover, compared with children at low risk and without habitual late sleep, children at high risk and with habitual late sleep had greater increases in BMI z score (0.93; 95% CI 0.40 to 1.45) and waist circumference (3.45 cm; 95% CI 1.78 to 5.12).

CONCLUSIONS

More frequent exposures to late sleep were associated with greater increases in adiposity measures from ages 2 to 6 years, particularly in children with obese parents.

Validation of the patient activation measure in patients at discharge from hospitals and at distance from hospital care in Sweden

Background

The Patient Activation Measure (PAM) is a recognized measure of how active patients are in their care, and has been translated into several languages and cultural contexts. Patient activity, self-care, and health literacy have become increasingly important aspects of health care, and thus reliable measures of these are needed. However, a Swedish translation of PAM is currently lacking. The aim of the study was to translate and assess the validity and reliability of the Swedish PAM-13.

Methods

A self-report questionnaire was handed out to 521 patients at ten medical, geriatric, and surgical wards, and one Virtual Health Room. The Rasch model was employed, using the partial credit model, to assess the functioning of the PAM scale, item fit, targeting, unidimensionality, local independence, differential item functioning (DIF), and person-separation index. Evidence of substantive, content, structural, and external validity was examined.

Results

Of the 521 patients who were consecutively handed a questionnaire, 248 consented to participate, yielding a response rate of 47.6%. The average measure for each category advanced monotonically. The difficulty of the PAM items ranged from − 1.55 to 1.26. The infit and outfit values for the individual items were acceptable. Items 1, 2, and 4 showed disordered thresholds. The mean person location was 1.48 (SD = 1.66). The person-item map revealed that there were no item representations at the top of the scale. The evidence for unidimensionality was ambiguous and response dependency was seen in some items. DIF was found for age. The person separation index was 0.85.

Conclusion

The Swedish PAM-13 was reliable, but was not conclusively found to represent one underlying construct. It seems that the Swedish PAM-13 lacks strong evidence for substantive, content, and structural validity. Although valid and reliable measures of ability for activation in self-care among patients are highly warranted, we recommend further development of PAM-13 before application in everyday clinical care.

Nursing students' perception of the clinical learning environment and supervision in relation to two different supervision models - a comparative cross-sectional study

Background

Knowledge concerning nursing students' experiences of the clinical learning environment and how supervision is carried out is largely lacking. This study compares nursing students' perceptions of the clinical learning environment and supervision in two different supervision models: peer learning in student-dedicated units, with students working together in pairs and supervised by a "preceptor of the day" (model A), and traditional supervision, in which each student is assigned to a personal preceptor (model B).

Methods

The study was performed within the nursing programme at a university college in Sweden during students' clinical placements (semesters 3 and 4) in medical and surgical departments at three different hospitals. Data was collected using the Clinical Learning Environment, Supervision and Nurse Teacher evaluation scale, CLES+T, an instrument tested for reliability and validity, and a second instrument developed for this study to obtain deeper information regarding how students experienced the organisation and content of the supervision. Independent t-tests were used for continuous variables, Mann-Whitney U-tests for ordinal variables, and the chi-square or Fischer's exact tests for categorical variables.

Results

Overall, the students had positive experiences of the clinical learning environment and supervision in both supervision models. Students supervised in model A had more positive experiences of the cooperation and relationship between student, preceptor, and nurse teacher, and more often than students in model B felt that the ward had an explicit model for supervising students. Students in model A were more positive to having more than one preceptor and felt that this contributed to the assessment of their learning outcomes.

Conclusions

A good learning environment for students in clinical placements is dependent on an explicit structure for receiving students, a pedagogical atmosphere where staff take an interest in supervision of students and are easy to approach, and engagement among and collaboration between preceptors and nurse teachers. This study also indicates that supervision based on peer learning in student-dedicated rooms with many preceptors can be more satisfying for students than a model where each student is assigned to a single preceptor.

Development of sleep patterns in children with obese and normal-weight parents

AIM

To study the sleep development and sleep characteristics in children at different obesity risks, based on parental weight, and also to explore their weekday-weekend sleep variations and associated family factors.

METHODS

A total of 145 children participating in a longitudinal obesity prevention project were included, of which 37 had normal-weight parents (low obesity risk), and 108 had overweight/obese parents (high obesity risk). Sleep diaries at ages 1 and 2 years were used to study sleep development in children at different obesity risks. Objectively assessed sleep using an accelerometer at 2 years of age was used to analyse weekday-weekend sleep variations.

RESULTS

There was no difference in sleep development from age 1 to age 2 among children at different obesity risks, but more children in the high-risk group had prolonged sleep onset latency and low sleep efficiency. At 2 years of age, children in the high-risk group had more weekday-weekend variation in sleep offset (mean difference 18 min, 95% confidence interval (CI) 4-33 min), midpoint of sleep (mean difference 14 min, 95% CI 3-25 min) and nap onset (mean difference 42 min, 95% CI 10-74 min) than children in the low-risk group, after adjusting for other family factors. However, no difference could be detected between groups in weekday-weekend variation in sleep duration.

CONCLUSIONS

Unfavourable sleep characteristics, as well as more variation in sleep schedules, have been observed in children at high obesity risk. While the differences were relatively small, they may reflect the unfavourable sleep hygiene in families at high obesity risk.

Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study

OBJECTIVES

The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.

DESIGN

Prospective observational study using the Work Observation Method By Activity Timing tool.

SETTING

An OR department at a county hospital in Sweden.

PARTICIPANTS

OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).

RESULTS

The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.

CONCLUSIONS

The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.

TRIAL REGISTRATION NUMBER

2016/264.

Factors That Hinder and Facilitate Cancer Patients' Knowledge About Pain Management-A Qualitative Study

CONTEXT

Pain management education may improve pain control for some patients, whereas individual differences exist.

OBJECTIVES

To evaluate possible critical components, facilitators, and hindrances for improved knowledge about pain management, in not hospitalized adult oncology patients with pain from bone metastasis participating in a pain management intervention.

METHODS

This substudy is a qualitative evaluation of the PRO-SELF Pain Control Program, tested in a randomized controlled trial. During six weeks, 87 participants in the intervention group received tailored coaching encounters by a trained oncology nurse. Three encounters for each patient were audio recorded. The encounter between patient's with the largest (n = 12) and lowest (n = 8) change in knowledge about pain management from before to after the intervention was transcribed verbatim and analyzed with qualitative content analysis.

RESULTS

The critical components of the intervention were repetition of information, struggling with resistance, use of peer experiences, and keeping track of variations. Facilitators of improvement were patients' trust and preparedness to try new procedures, the patient's self-awareness and body awareness, and taking active role in own care. Difficulties in processing complex information, culturally conditioned behaviors, fear, and lack of knowledge were the most important barriers to the success of the intervention.

CONCLUSION

Education in pain management in cancer patients requires repeated information, allowing time for overcoming resistance related to dysfunctional beliefs and fear. To facilitate the patient's involvement in their pain management, tailored and person-centered education is needed.

Enhanced Patient Activation in Cancer Care Transitions: Protocol for a Randomized Controlled Trial of a Tailored Electronic Health Intervention for Men With Prostate Cancer

Background

Prostate cancer has increased in incidence worldwide and is the leading cause of cancer death in 24 countries. The most common treatment is radical prostatectomy. However, surgery is associated with postoperative complications such as urinary incontinence and sexual dysfunction, causing decreased quality of life. If survivors are encouraged to be more active in self-care management, the symptom burden may decrease and quality of life may improve. An electronic health (eHealth) intervention based on motivational behavioral theory has been developed for this purpose.

Objective

This study aimed to compare the effectiveness of standard care in combination with a tailored eHealth and mobile health self-management support system, electronic Patient Activation in Treatment at Home (ePATH), with standard care of adverse effects of prostate cancer treatment (urinary incontinence and sexual functioning) in men undergoing radical prostatectomy. The secondary aim was to test the effect on patient activation, motivation, overall well-being, and health literacy over time in and between groups.

Methods

A pragmatic multicenter, block-randomized controlled trial with 2 study arms, standard care (control) and eHealth-assisted standard care (intervention), for patients undergoing radical prostatectomy. For 80% power, a sample of 242 men will need to be recruited.

Results

Recruitment started in January 2018 and is expected to be completed by August 2019. Data collection will be completed in August 2020. The first cross-sectional results from this trial are anticipated to be published in January 2020.

Conclusions

With the increasing number of prostate cancer survivors, attention should be paid to rehabilitation, psychosocial care, and support for endurance of self-care to reduce suffering from adverse treatment effects, poor quality of life, and depression because of postoperative complications. This project may increase knowledge of how patients can be supported to feel involved in their care and returning to as normal a life as possible. The anticipated effects of ePATH could improve health outcomes for individuals and facilitate follow-up for health care professionals.

Trial Registration

International Standard Randomised Controlled Trial Number: 18055968; http://www.isrctn.com/ISRCTN18055968 (Archived by WebCite at http://www.isrctn.com/ISRCTN18055968).

International Registered Report Identifier (IRRID)

DERR1-10.2196/11625

Longing to get back on track: Patients' experiences and supportive care needs after lung cancer surgery

AIMS AND OBJECTIVES

This study aims to describe surgically treated lung cancer patients' experiences of coming home after discharge from hospital to expand the knowledge about their supportive care needs.

BACKGROUND

Existing research reports that patients suffer from a high symptom burden after lung cancer surgery. Such burden has negative impacts on their physical, emotional and social wellbeing. Few studies have explored the surgically treated patients' supportive care needs after being discharged from hospital.

DESIGN

This study used a qualitative descriptive design, following the EQUATOR guidelines (COREQ).

METHODS

The information about 14 patients' experiences was collected from semi-structured interviews. The interviews were conducted in their homes within three weeks after their discharge from hospital. The data were analysed using qualitative content analysis.

RESULTS

The main theme of the study, "Longing to get back on track with their lives", consisted of four categories: "Burdened with problems related to postoperative symptoms and treatment", "Struggling for the needed support", "A pendulum between being in need of support and being independent", and "Striving to adapt to a new way of life". The participants experienced many problems related to postoperative symptoms and treatment. Information and support from healthcare professionals were deficient. Life was characterised by striving to be independent and adapting to a new lifestyle.

CONCLUSIONS

The findings demonstrate the supportive care needs of surgically treated lung cancer patients. Nurses and other healthcare professionals could offer more individualised support during the first few weeks after the patients' discharge by including them and their caregivers in the discharge planning.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of patients' perspectives and experiences of everyday life at home after lung cancer surgery can provide hospital nurses with a better understanding of what is important for such patients beyond hospitalisation. This knowledge should be included in discharge planning.

Exploring patient safety in Swedish specialised home healthcare: an interview study with multidisciplinary teams and clinical managers

OBJECTIVE

Home healthcare is the fastest growing arena in the healthcare system but patient safety research in this context is limited. The aim was to explore how patient safety in Swedish specialised home healthcare is described and adressed from multidisciplinary teams' and clinical managers' perspectives.

DESIGN

An explorative qualitative study.

SETTING

Multidisciplinary teams and clinical managers were recruited from three specialised home healthcare organisations in Sweden.

METHODS

Nine focus group interviews with multidisciplinary teams and six individual interviews with clinical managers were conducted, in total 51 participants. The data were transcribed verbatim and analysed using qualitative content analysis.

RESULTS

Patient safety was inherent in the well-established care ideology which shaped a common mindset between members in the multidisciplinary teams and clinical managers. This patient safety culture was challenged by the emerging complexity in which priority had to be given to standardised guidelines, quality assessments and management of information in maladapted communication systems and demands for required competence and skills. The multiple guidelines and quality assessments that aimed to promote patient safety from a macro-perspective, constrained the freedom, on a meso-level and micro-level, to adapt to challenges based on the care ideology.

CONCLUSION

Patient safety in home healthcare is dependent on adaptability at the management level; the team members' ability to adapt to the varying conditions and on patients being capable of adjusting their homes and behaviours to reduce safety risks. A strong culture related to a patient's value as a person where patients' and families' active participation and preferences guide the decisions, could be both a facilitator and a barrier to patient safety, depending on which value is given highest priority.

Measuring care transitions in Sweden: validation of the care transitions measure

Objective

To translate and assess the validity and reliability of the original American Care Transitions Measure, both the 15-item and the shortened 3-item versions, in a sample of people in transition from hospital to home within Sweden.

Design

Translation of survey items, evaluation of psychometric properties.

Setting

Ten surgical and medical wards at five hospitals in Sweden.

Participants

Patients discharged from surgical and medical wards.

Main outcome measure

Psychometric properties of the Swedish versions of the 15-item (CTM-15) and the 3-item (CTM-3) Care Transition Measure.

Results

We compared the fit of nine models among a sample of 194 Swedish patients. Cronbach’s alpha was 0.946 for CTM-15 and 0.74 for CTM-3. The model indices for CTM-15 and CTM-3 were strongly indicative of inferior goodness-of-fit between the hypothesized one-factor model and the sample data. A multidimensional three-factor model revealed a better fit compared with CTM-15 and CTM-3 one factor models. The one-factor solution, representing 4 items (CTM-4), showed an acceptable fit of the data, and was far superior to the one-factor CTM-15 and CTM-3 and the three-factor multidimensional models. The Cronbach’s alpha for CTM-4 was 0.85.

Conclusions

CTM-15 with multidimensional three-factor model was a better model than both CTM-15 and CTM-3 one-factor models. CTM-4 is a valid and reliable measure of care transfer among patients in medical and surgical wards in Sweden. It seems the Swedish CTM is best represented by the short Swedish version (CTM-4) unidimensional construct.

Patients' experiences of motivation, change, and challenges in group treatment for insomnia in primary care: a focus group study

Background

The majority of patients who seek help for insomnia do so in primary health care. Nurse-led group treatment in primary care based on cognitive behavioral therapy for insomnia (CBT-I) can lead to improvements in both day- and nighttime symptoms. This study aimed to explore patients’ experiences of nurse-led group treatment for insomnia in primary health care.

Methods

Seventeen patients who had participated in the group treatment program were interviewed in five focus groups. Interview transcriptions were analyzed with qualitative content analysis.

Results

Four themes emerged that described patients’ experiences of the group treatment program. Involvement and trust open the door for change: Motivation to engage in treatment arose from patients’ own desire for change, from being together with others who shared or understood their struggles, and from feeling emotionally affirmed and trustful. Competence arising from deeper understanding: Patients obtained knowledge and made it their own, which enabled them to develop functional sleep habits and let go of sleep performance and worry. The ability to impact their insomnia increased patients’ trust in their own efficacy and helped them persist in behavioral change. Struggling with vulnerability and failure: Treatment was tough, and patients could feel challenged by external circumstances. Moreover, they could distrust their own efficacy. Tailoring treatment to individual needs: Patients experienced different life circumstances and adapted the techniques to their needs and abilities by focusing on what felt right for them.

Conclusions

Patients went through a process of motivation, change, and challenges. They experienced certain aspects of treatment as essential to changing behavior and achieving improvements. Examples included being in a group with others who shared similar experiences, gaining knowledge about sleep, keeping a sleep diary, and practicing the sleep restriction technique. The study provides insights into patients’ struggles during treatment, both those related to external circumstances and those related to feelings of vulnerability and failure. It also highlights the importance of adapting treatment to patients’ differing needs, underscoring the value of person-centered care.

Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology

OBJECTIVE

Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare.

DESIGN

A study using retrospective record review and trigger tool methodology.

SETTING AND METHODS

Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 predefined triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs.

RESULTS

The patients were aged 20-79 years, 280 men and 320 women. The review teams identified 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers.

CONCLUSIONS

AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies.

Digitalization of Patient Information Process from Hospital to Community (Home) Care Nurses: International Perspectives

For older people who transition from hospital to home, home care is an increasingly important and effective way of managing chronic illness with skilled nursing care in the home. Communication between clinicians across care settings is fundamental for continuity of care. Poor communication of patient information is acknowledged to be a root cause of sentinel events. In Scandinavia and the United States, researchers study the communication of patient information from hospital to home care. The health care systems of these two countries differ. Differences are reflected in the characteristics of patients transferred from hospital to home care, as well as the characteristics of health information systems (ICT). These differences help to elucidate key issues related to the transfer of patient information from hospital to home care.

Developing an eHealth Tool to Support Patient Empowerment at Home

In previous research we have learned that patients with chronic or complex diseases often experience difficulties when transitioning from hospital care to self-care in their home. We address these difficulties by developing an eHealth tool for patients - ePATH (electronic Patient Activation in Treatment at Home) - intended to empower each patient to manage their individual situation. We have employed a user-centered design process involving both patients and healthcare personnel to specify the content and functionality of ePATH. The system is deployed as a web application with secure login for patients. In this article, we describe the main content and functionality of the system that makes it possible for a patient to manage symptoms development in relation to treatment progression Interactive functionality, e.g., reminders and social support, is included to make the ePATH a useful and informative bridge between patients, next-of-kin and different caregivers. One lesson learned is that it is necessary to incorporate motivational components in the development of an eHealth tool to successfully overcome the "intention-behavior" gap. The self-determination theory of motivation can be used to ensure that important aspects are not missed.

Development of a trigger tool to identify adverse events and no-harm incidents that affect patients admitted to home healthcare

BACKGROUND

Adverse events (AEs) and no-harm incidents are common and of great concern in healthcare. A common method for identification of AEs is retrospective record review (RRR) using predefined triggers. This method has been used frequently in inpatient care, but AEs in home healthcare have not been explored to the same extent. The aim of this study was to develop a trigger tool (TT) for the identification of both AEs and no-harm incidents affecting adult patients admitted to home healthcare in Sweden, and to describe the methodology used for this development.

METHODS

The TT was developed and validated in a stepwise manner, in collaboration with experts with different skills, using (1) literature review and interviews, (2) a five-round modified Delphi process, and (3) two-stage RRRs. Ten trained teams from different sites in Sweden reviewed 600 randomly selected records.

RESULTS

In all, triggers were found 4031 times in 518 (86.3%) records, with a mean of 6.7 (median 4, range 1-54) triggers per record with triggers. The positive predictive values (PPVs) for AEs and no-harm incidents were 25.4% and 16.3%, respectively, resulting in a PPV of 41.7% (range 0.0%-96.1% per trigger) for the total TT when using 38 triggers. The most common triggers were unplanned contact with physician and/or registered nurse, moderate/severe pain, moderate/severe worry, anxiety, suffering, existential pain and/or psychological pain. AEs were identified in 37.7% of the patients and no-harm incidents in 29.5%.

CONCLUSION

This study shows that adapted triggers with definitions and decision support, developed to identify AEs and no-harm incidents that affect patients admitted to home healthcare, may be a valid method for safety and quality improvement work in home healthcare.