Interprofessional collaboration in nursing homes (interprof): A grounded theory study of nurse experiences of general practitioner visits

Current situation, strengths and problems in intra- and interprofessional collaboration in German nursing homes - A holistic multiple case study

BACKGROUND

The increasing care complexity of nursing home residents living with dementia requires new care models that strengthen professional collaboration. To contribute to the sustainable implementation of new care models, it is important that they are linked to the care reality. However, little is known about intra- and interprofessional organization and provision of care in German nursing homes. Therefore, the aim of this study was to explore the current care situation, problems and strengths regarding intra- and interprofessional collaboration in the care of residents living with dementia.

METHODS

We conducted a holistic multiple case study. The individual care units in which residents living with dementia are cared for were defined as cases. The context was built by the respective nursing homes and their regional affiliation to the federal state of North Rhine-Westphalia. We used qualitative face-to-face interviews, documents and context questionnaires for data collection. The different sources of evidence served to capture complementary perspectives and to validate the findings. First, the collected qualitative data were analyzed using deductive-inductive content analysis. Second, similarities and differences between the cases were identified to elaborate case-specific and cross-case patterns and themes. The reporting followed the EQUATOR reporting guideline for organizational case studies.

RESULTS

We included four care units comprising 21 professionals (nurses, physicians, social worker, physiotherapist, pharmacist) and 14 relatives of residents living with dementia. The analysis revealed four categories to describe current intra- and interprofessional collaboration in all cases: actors and their roles, service delivery, coordination and governance, and communication channel. Moreover, we identified three categories that relate to the strengths and problems of intra- and interprofessional collaboration in all cases: role understanding, teamwork, and communication and exchange. Although we examined similar care units, we found differences in the realization of professional collaboration and resulting problems and strengths that are connected to the organizational contexts and strategies used.

CONCLUSIONS

Even though professional collaboration follows given patterns; these patterns do differ context-specifically and are perceived as problematic and fragmentary. Therefore, the identified differences and problems in collaboration need to be addressed in future research to develop and successfully implement tailored innovative care models.

(How) Do We Theorize?: A Focused Mapping Review and Synthesis of Theoretical Nursing Research in the German-Speaking Area

There are increasing discussions on theory dynamics in nursing research. We aimed at mapping the theoretical publication output by nursing researchers from the European German-speaking area. We conducted a focused mapping review and synthesis, focusing on nursing journals articles with a theory-related aim. We identified 32 eligible publications, reflecting 2% of the nursing journal articles affiliated with researchers from our target region. Twenty-one articles involved an inductive approach. Eleven articles intended to test or revise a theory. The theoretical publication output with a theory-related aim was low. Theory-building efforts were fragmented and mostly without reference to a meta-theoretical level.

The role of qualification and quality management in the prescription of antipsychotics and potentially inappropriate medication (PIM) in nursing home residents in Germany: results of the HIOPP-3-iTBX study

BACKGROUND

Nursing home residents (NHR) show high rates of polypharmacy. The HIOPP-3-iTBX study is the first cRCT on medication optimization in nursing homes (NH) in Germany. The intervention did not result in a reduction of PIM and/or antipsychotics. This analysis looks at structure quality in the HIOPP-3-iTBX study participants.

AIMS

Evaluation of structure quality as part of a cluster-randomized controlled intervention study.

METHODS

Structure quality in multiprofessional teams from n = 44 NH (n = 44 NH directors, n = 91 family doctors (FD), and n = 52 pharmacies with n = 62 pharmacists) was assessed using self-designed questionnaires at baseline. Main aspects of the questionnaires related to the qualification of participants, quality management, the medication process and size of the facilities. All completed questionnaires were included. number of PIM/antipsychotics was drawn from the baseline medication analysis in 692 NHR. Data were analyzed by descriptive statistics and mixed model logistic regression.

RESULTS

The presence of a nurse with one of the additional qualifications pain nurse or Zertifiziertes Curriculum (Zercur) Geriatrie in the participating NH was associated with a lower risk for the prescription of PIM/antipsychotics. No association between any characteristic in the other participants at baseline was observed.

CONCLUSIONS AND DISCUSSION

The results support the known role of nursing qualification in the quality and safety of care. Further studies need to look more closely at how use is made of the additional qualifications within the multiprofessional teams. Perspectively, the results can contribute to the development of quality standards in NH in Germany.

Facilitators for developing an interprofessional learning culture in nursing homes: a scoping review

BACKGROUND

Healthcare professionals in nursing homes face complex care demands and nursing staff shortages. As a result, nursing homes are transforming into home-like personalised facilities that deliver person-centred care. These challenges and changes require an interprofessional learning culture in nursing homes, but there is little understanding of the facilitators that contribute to developing such a culture. This scoping review aims to identify those facilitators.

METHODS

A scoping review was performed in accordance with the JBI Manual for Evidence Synthesis (2020). The search was carried out in 2020-2021 in seven international databases (PubMed, Cochrane Library, CINAHL, Medline, Embase, PsycINFO and Web of Science). Two researchers independently extracted reported facilitators that contribute to an interprofessional learning culture in nursing homes. Then the researchers inductively clustered the extracted facilitators into categories.

RESULTS

In total, 5,747 studies were identified. After removing duplicates and screening titles, abstracts and full texts, 13 studies that matched the inclusion criteria were included in this scoping review. We identified 40 facilitators and clustered them into eight categories: (1) shared language, (2) shared goals, (3) clear tasks and responsibilities, (4) learning and sharing knowledge, (5) work approaches, (6) facilitating and supporting change and creativity by the frontline manager, (7) an open attitude, and (8) a safe, respectful and transparent environment.

CONCLUSION

We found facilitators that could be used to discuss the current interprofessional learning culture in nursing homes and identify where improvements are required. Further research is needed to discover how to operationalise facilitators that develop an interprofessional learning culture in nursing homes and to gain insights into what works, for whom, to what extent and in what context.

Nurses' experiences of an outreach interprofessional mental health service for nursing homes: a qualitative descriptive study

WHAT IS KNOWN ON THE SUBJECT?: Treatment and mental health care in familiar environments are beneficial for older people experiencing mental health issues. But there are not enough qualified and specialized nurses who can meet the complex needs of nursing home residents experiencing mental health issues. The University Hospital of Psychiatry Zurich, Switzerland, established an outreach interprofessional mental health service to foster the care for residents experiencing mental health issues in nursing homes. Based on existing studies, little can be said about whether nurses in nursing homes find these types of services helpful. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Nurses in nursing homes caring for residents experiencing mental health issues felt relieved by having inclusive support from the interprofessional mental health service. Nurses appreciated the mental health team and felt accompanied and more confident in their daily work. Results showed that nurses wanted to be included in the care and treatment processes and to work as partners on an equal footing with the mental health team. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Outreach interprofessional mental health services for nursing homes should take into account nurses' views and professional experience, and value and respect their role as nurses. Outreach interprofessional mental health services for nursing homes should offer further training in psychiatric nursing, include an accessible contact person in the team, and develop clear processes and responsibilities.

ABSTRACT

INTRODUCTION: Outreach interprofessional mental health services for nursing homes can increase the quality of care for residents experiencing mental health issues but research on how nurses in nursing homes experience such a service is lacking worldwide.

AIM

To describe how nurses experience the involvement of an outreach interprofessional mental health team in the care for older people experiencing mental health issues in nursing homes and to identify barriers to and facilitators of interprofessional collaboration.

METHOD

Qualitative descriptive analysis based on 13 semi-structured interviews. Framework analysis and complex adaptive systems theory were applied.

RESULTS

One core theme with two main categories: Nurses experienced relief from burden through inclusive support provided by the mental health team. Main categories were feeling accompanied and confident as a nurse and partnership-based collaboration.

DISCUSSION

Results showed for the first time that nurses felt supported by the mental health team and were encouraged to find new ways of coping with challenging situations.

IMPLICATIONS FOR PRACTICE

To empower nurses, mental health teams should take into account nurses' perceptions in the treatment process, value and respect their role as nurses, transfer knowledge in both formal and informal settings, establish a steady and reliable contact person, and define processes and responsibilities.

Boundary work in response to professionals’ contextual constraints: Micro-strategies in interprofessional collaboration

Boundary-work research has extensively explored how professionals engage in boundary work to protect or expand their professional boundaries in interprofessional collaboration (IPC). Yet professionals’ contextual constraints in everyday work, such as time pressure or legal restrictions, often result in competing interests of the professionals involved in IPC, prompting them to engage in boundary work to limit—instead of protect or expand—their boundaries. Our empirical analysis uses comprehensive qualitative data on IPC in Germany between self-employed general practitioners (GPs) and registered nurses employed in nursing homes in which GPs’ efficiency interests compete with nurses’ safeguarding interests, leading both professionals to engage in boundary-work efforts to limit their boundaries. Our findings provide a comprehensive understanding and framework of professionals’ boundary work, showing that individual GPs and nurses typically hold a portfolio of various defending and accommodating micro-strategies. Based on our first-order findings, we identify how different sources of power enable particular micro-strategies and explore how the choice of micro-strategies depends on different forms of trust in the collaborating partner. Lastly, we outline interactions of micro-strategies, illustrating how the outcomes of professionals’ bilateral boundary work depend on the sequence of these strategies.

Drug Safety for Nursing-Home Residents - Findings of a Pragmatic, Cluster-Randomized, Controlled Intervention Trial in 44 Nursing Homes

BACKGROUND

The safety of drug use by nursing-home residents can be impaired by polypharmacy, potentially inappropriate medications (PIM), and neuroleptics, as well as by a lack of adequate interprofessional coordination in the nursing home. The goal of the HIOPP-3- iTBX Trial was to improve drug safety in nursing-home residents, including a reduction of PIM and/or neuroleptic use, by means of a complex interprofessional intervention.

METHODS

This cluster-randomized, controlled trial was performed in nursing homes in Germany. Residents over age 65 were included in the trial. The intervention was carried out over six months and consisted of four elements: a drug review by trained pharmacists, educational sessions for general practitioners and nurses, a drug safety toolbox, and change management seminars for members of the three participating professions. The nursing homes in the control group continued to provide usual care. The primary endpoint was the prescription of at least one PIM and/or at least two neuroleptic drugs simultaneously. The secondary endpoints were the incidence of falls and hospitalizations, quality of life, and health-care costs. This trial is registered in the German Clinical Trials Registry (DRKS00013588).

RESULTS

44 nursing homes with 862 residents were randomized, 23 of them (with 452 residents) to the intervention group and 21 (with 410 residents) to the control group. 41% of all nursinghome residents initially took at least one PIM and/or at least two neuroleptic drugs simultaneously. Follow-up data (including, among other things, the current drug regimen) were obtained for 773 residents. The intention-to-treat analysis continued to show no difference between the intervention group and the control group with respect to the primary endpoint.

CONCLUSION

This trial of an intervention to improve drug safety in nursing homes led neither to reduced prescribing of PIM and/or neuroleptic drugs, nor to any improvement in the overall health status of the nursing-home residents.

Effects of strategies to improve general practitioner-nurse collaboration and communication in regard to hospital admissions of nursing home residents (interprof ACT): study protocol for a cluster randomised controlled trial

BACKGROUND

In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention.

METHODS

This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs' home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed.

DISCUSSION

This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426475 . Initially registered on 7 February 2018.

End-of-life care conferences in Japanese nursing homes

End-of-life (EOL) care conferences have an important role in promoting EOL care in nursing homes. However, the details of the conferences remain poorly understood. A Japanese prefecture-wide survey was conducted to investigate the factors involved in such conferences that contribute to an increase in the amount of EOL care. One hundred fifty-three nursing homes performed the conferences. The outcome was the amount of EOL care provided in nursing homes after adjusting for the facility beds in 2014. We investigated the factors of staff experience with EOL care, frequency of the conferences, years the conferences were conducted, review conferences after EOL care, and professional participants in the conferences. The multivariate analysis revealed significant associations between EOL care in nursing homes and nurses' experience with EOL care (adjusted β coefficient 2.9, 95% confidence interval (CI) 0.52 ~ 5.22, p = 0.017), more than 5 years of continuous conferences (adjusted β coefficient 3.8, 95% CI 0.46 ~ 7.05, p = 0.026), and family participation (adjusted βcoefficient ‒4.0, 95% CI ‒7.5 ~ ‒0.48, p = 0.026). In conclusion, the continuation of conferences and enrollment of the nurse with experience in EOL care may promote EOL care in nursing homes, while family enrollment in conferences may decrease EOL care in nursing homes. EOL care conferences in nursing homes should be continuously performed by staff, with an experienced nurse undertaking the task of information sharing before discussing EOL care with the patients' families.

Multidisciplinary intervention to improve medication safety in nursing home residents: protocol of a cluster randomised controlled trial (HIOPP-3-iTBX study)

Background

Medication safety is an important health issue for nursing home residents (NHR). They usually experience polypharmacy and often take potentially inappropriate medications (PIM) and antipsychotics. This, coupled with a frail health state, makes NHR particularly vulnerable to adverse drug events (ADE). The value of systematic medication reviews and interprofessional co-operation for improving medication quality in NHR has been recognized. Yet the evidence of a positive effect on NHR’ health and wellbeing is inconclusive at this stage. This study investigates the effects of pharmacists’ medication reviews linked with measures to strengthen interprofessional co-operation on NHR’ medication quality, health status and health care use.

Methods

Pragmatic cluster randomised controlled trial in nursing homes in four regions of Germany. A total of 760 NHR will be recruited. Inclusion: NHR aged 65 years and over with an estimated life expectancy of at least six months. Intervention with four elements: i) introduction of a pharmacist’s medication review combined with a communication pathway to the prescribing general practitioners (GPs) and nursing home staff, ii) facilitation of change in the interprofessional cooperation, iii) educational training and iv) a “toolbox” to facilitate implementation in daily practice. Analysis: primary outcome - proportion of residents receiving PIM and ≥ 2 antipsychotics at six months follow-up. Secondary outcomes - cognitive function, falls, quality of life, medical emergency contacts, hospital admissions, and health care costs.

Discussion

The trial assesses the effects of a structured interprofessional medication management for NHR in Germany. It follows the participatory action research approach and closely involves the three professional groups (nursing staff, GPs, pharmacists) engaged in the medication management. A handbook based on the experiences of the trial in nursing homes will be produced for a rollout into routine practice in Germany.

Trial registration

Registered in the German register of clinical studies (DRKS, study ID DRKS00013588, primary register) and in the WHO International Clinical Trials Registry Platform (secondary register), both on 25th January 2018.

Interprofessional collaboration in nursing homes (interprof): development and piloting of measures to improve interprofessional collaboration and communication: a qualitative multicentre study

BACKGROUND

Given both the increase of nursing home residents forecast and challenges of current interprofessional interactions, we developed and tested measures to improve collaboration and communication between nurses and general practitioners (GPs) in this setting. Our multicentre study has been funded by the German Federal Ministry of Education and Research (FK 01GY1124).

METHODS

The measures were developed iteratively in a continuous process, which is the focus of this article. In part 1 "exploration of the situation", interviews were conducted with GPs, nurses, nursing home residents and their relatives focusing on interprofessional interactions and medical care. They were analysed qualitatively. Based on these results, in part 2 "development of measures to improve collaboration", ideas for improvement were developed in nine focus groups with GPs and nurses. These ideas were revisited in a final expert workshop. We analysed the focus groups and expert workshop using mind mapping methods, and finally drew up the compilation of measures. In an exploratory pilot study "study part 3" four nursing homes chose the measures they wanted to adopt. These were tested for three months. Feasibility and acceptance of the measures were evaluated via guideline interviews with the stakeholders which were analysed by content analyses.

RESULTS

Six measures were generated: meetings to establish common goals, main contact person, standardised pro re nata medication, introduction of name badges, improved availability of nurse/GP and standardised scheduling/ procedure for nursing home visits. In the pilot study, the measures were implemented in four nursing homes. GPs and nurses reviewed five measures as feasible and acceptable, only the designation of a "main contact person" was not considered as an improvement.

CONCLUSIONS

Six measures to improve collaboration and communication could be compiled in a multistep qualitative process respecting the perspectives of involved stakeholders. Five of the six measures were positively assessed in an exploratory pilot study. They could easily be transferred into the daily routine of other nursing homes, as no special models have to exist in advance. Impact of the measures on patient oriented outcomes should be examined in further research.

TRIAL REGISTRATION

Not applicable.