A taxonomy of needs assessment, elicited from a multiple case study of community nursing education and practice

Defining practice variation and exploring influencing factors on needs assessment in home care nursing: A Delphi study

AIM

To describe a Delphi study regarding practice variation in needs assessment by Dutch home care nurses, to define practice variation in home care nursing and explore which factors may have a role in this needs assessment.

DESIGN

A Delphi study was conducted with the participation of home care representatives.

METHOD

A Delphi questionnaire was developed, preceded by literature research and an expert meeting. The Delphi study took place between December 2020 and February 2021. The goal was to achieve a consensus level of at least 70%.

RESULTS

After three rounds, 32 experts reached a consensus about definitions regarding variation in needs assessment, warranted and unwarranted variation. In total, 59 factors were determined related to (1) the client and health, (2) the clients' context, (3) nurses and (4) the nurses' context. Thirty-four factors scored warranted of influence and 18 (of 34) were client related. Most of the factors that scored unwarranted influencing needs assessment (17 of 26) were related to the home care nurses' context.

CONCLUSION

Having a consensus about the definition of practice variation in needs assessment and possible influencing factors support the professionals to discuss and improve the unity and quality of their decision-making process in home care. This may contribute to more righteous care for clients in need of home care.

IMPACT

Since 2015, home care nurses in the Netherlands are responsible for determining the amount, type and duration of care for clients in need of home care. This so-called needs assessment legitimizes the payment by health insurers. Signals of practice variation in needs assessment are heard in home care field. Although practice variation may be justified, it can lead to over or underuse of care, which may affect clients' outcomes. If we can identify influencing factors and find patterns that contribute to practice variation, we might gain a better understanding of the process and improve home care.

PATIENT OR PUBLIC CONTRIBUTION

In this study, there was no patient or public involvement. Client representatives were included in this research as experts in the home care field, and they participated in three rounds of the Delphi study. They contributed by sharing their expert opinion on the definitions presented and the factors possibly influencing needs assessment.

Measures to improve patient needs assessments and reduce practice variation in Dutch home care organizations

AIM

Worldwide, long-term care tends to shift from institutional care towards home care. In order to deliver high-quality and adequate care, the type, amount and cost of care is determined by a patient needs assessment. However, there are indications that this patient needs assessment varies between comparable patients. In the Netherlands, some home care organizations aim to improve patient needs assessments by implementing improvement measures to reduce this practice variation. The goal of this study was to explore the type and perceived impact of those implemented improvement measures.

DESIGN

A cross-sectional explorative survey study was conducted among Dutch home care organizations between January and April 2021.

METHODS

An online questionnaire with 26 items was developed by the research team, which was distributed through Dutch nationwide home care sector organizations, the Dutch nurses' association (V&VN) and the Dutch society for home care nursing (NWG).

RESULTS

The survey was completed by 184 respondents, including home care nurses, managers and staff who are responsible for training, policy and quality of care. Intervision and peer review for home care nurses were the most common reported improvement measures that were implemented in home care organizations. The experiences of those improvement measures have been perceived as creating greater uniformity in the patient needs assessment, making home care nurses feel more supported and secure performing their patient needs assessment and that the provided care is more in line with patients' demand. Our findings give insights into type and perceived impact of improvement measures that Dutch home care organizations implemented. Further research is needed to find out whether improvement measures actually improve patient needs assessments and reduce practice variation.

To what extent do home care nurses feel free to assess the care that is needed for their patients? A nationwide survey in the Netherlands

BACKGROUND AND AIMS

Patients receiving nursing care at home require a needs assessment. There are indications that practice variation exists in needs assessments performed by Dutch home care nurses. One possible cause is that nurses are differentially influenced by others when performing needs assessments. Instruments recommending what is appropriate care have the potential to protect nurses against unwarranted influences. In the Netherlands, a framework exists including general norms about performing needs assessments. We aimed to achieve insight into whether nurses, who have heard of the framework, feel more free to assess the care that is needed for their patients, and whether other actors play a role in performing needs assessments.

METHODS

An online questionnaire was sent to members of the Dutch Nursing Staff Panel (response 47%; n = 302) in November 2019. Only nurses who perform needs assessments were included in the analyses (n = 141). χ2-tests were used to assess the relationships between the variables of having heard of the framework, feeling free to assess the care that is needed, and the influences of others.

RESULTS

We found no relationships between having heard of the framework and feeling free to assess the care that is needed for patients or reporting influence of others. However, home care nurses who state that they are not influenced by others, feel more free to assess the care that is needed for their patients. In contrast, those who state that they are influenced by informal caregivers, or health care insurers, feel less free to assess the care that is needed.

CONCLUSION

It appears that the framework for performing needs assessments does not, in its current form, protect against influences of others. Further research is recommended to examine what kind of instruments nurses need to perform unambiguous and good needs assessments and, as such, reduce unwarranted practice variation.

Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury

OBJECTIVE

To explore health disparity in on-campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries.

BACKGROUND

As a discipline, nursing espouses ideologies of inclusion, equity and valuing diversity. However, little is known about how these ideologies translate into clinical care. Pressure injury prevention is a routine aspect of nursing care; yet, there is evidence of inequity in relation to clinical care and patient assessment, as people with darker skin tones have a higher prevalence of severe pressure injuries before detection of damage occurs. Despite limited literature being available surrounding the topic of pressure injuries and skin tone diversity, it remains the responsibility of nurse educators to address contemporary issues and health disparity within the nursing curriculum.

DESIGN

A multiple method collective case study. The STROBE checklist was followed in reporting this study.

METHODS

Documentary and observational data of lectures regarding pressure injuries were collected during 2017 and 2018 from five Higher Education Institutes in England delivering approved nursing undergraduate programmes.

RESULTS

Documentary analysis confirmed all Higher Education Institutes overwhelmingly directed teaching and learning activities about pressure injury towards people with Caucasian skin tones. Observation of teaching indicated all teaching sessions only contained brief, separate and superficial information on people with pressure injuries and darker skin tones. There was no discursive language or awareness of colour or colour blindness.

CONCLUSION

Radical critique of all teaching and learning activities needs to occur, to help explore, improve and meaningfully and authentically include diversity and inclusivity in nurse education, and in particular, how people across the skin tone spectrum are included and represented in teaching and learning activities.

RELEVANCE TO CLINICAL PRACTICE

Critical examination of current teaching practice is crucial to address disparity and ensure care for people with darker skin tones is optimised. Nurse educators have a responsibility to educate for the care needs of all, as the quality of nurse education has a direct impact on care delivery and health disparity. This paper highlights the importance of addressing skin tone diversity and offers the opportunity for reflective practice, not just in formal education, but in clinical settings by preceptors and senior staff.

Correlation Between Postoperative Health-Related Quality of Life and Care Needs of Oral Cancer Patients

Oral cancer is the fifth most common form of cancer in Taiwan in terms of incidence and death rate and results in at least 2700 deaths each year.

Advancing social research relationships in postnatal support settings

Global trends in public health nursing (PHN) suggest the value of community-based social research. However, it is not always clear how social research relationships may be of benefit to PHN or how such skills can best be learned and applied. To advance this understanding, we present a qualitative analysis of the development of social research relationships in PHN. Using a background literature review as a foundation, our qualitative mixed method strategy involved a comparative case-study analysis based on the authors' participant observation in two distinct postnatal group settings. Our findings suggest that participant observation facilitates the advancement of social research relationships through practitioner-research management of role conflict. Reflexivity and reciprocity is an emergent relational process, which relies upon a de-professionalization of the traditional PHN role. Conversely, social research relationships help build PHN capacity for family health needs assessment. Thus, we contend that the application of participant observation enables the development of social research relationships, which advance the practice of PHN in postnatal support settings.

Health visiting assessment processes under scrutiny: a case study of knowledge use during family health needs assessments

BACKGROUND

Accurate assessment of family health need is a core health visiting skill, requiring considerable knowledge and expertise. To date, there has been only limited empirical examination of the types of knowledge and ways of knowing which are likely to influence health visiting practice during family health needs assessments.

OBJECTIVES

This paper will present a detailed analysis of health visiting assessment processes and will explicate some of the many elements associated with the processes of identifying and assessing family health needs.

DESIGN

An in-depth case study was undertaken to explore health visiting practice across three study sites. The focus of interest was to attempt to understand the factors that may influence a health visitor in making a professional judgement to offer a family extra support.

SETTINGS

The study was conducted in three community Trust case sites in England, UK.

METHODS AND PARTICIPANTS

The study was informed by a constructivist methodology. Data collection took place during 56 observed home visits to families receiving increased health visiting support and intervention. Following the home visits separate in-depth interviews were undertaken with the health visitors and the clients.

RESULTS/CONCLUSIONS

This paper will explicate some of the many elements associated with the processes of identifying and assessing family health needs. It endeavours to unravel some of the complexity and intricacies of these processes and provide insights into health visitors' practical 'know-how'.

Health visiting assessment--unpacking critical attributes in health visitor needs assessment practice: a case study

BACKGROUND

Assessment of family health need is a central feature of health visiting practice in which a range of skills, knowledge and judgements are used. These assessments are pivotal in uncovering need, safeguarding children and in determining levels of health intervention to be offered to children and their families by the health visiting service in the UK.

OBJECTIVES

The central focus of this paper is to outline the critical attributes of the basic principles that underpin health visiting assessment practice that emerged as part of a case study enquiry.

DESIGN

A case study design informed by a constructivist methodology was used to examine health visitors' professional judgements and use of formal guidelines in identifying health needs and prioritising families requiring extra health visiting support.

SETTINGS

The main study was conducted in three community Trust case sites in England, UK, with pilot work being undertaken in a fourth site.

METHODS AND PARTICIPANTS

Fifteen health visitors participated in the main study and data were collected during 56 observed home visits to families receiving extra health visiting support. Separate in-depth interviews were conducted with the health visitors, pre- and post-home contacts, while 53 client interviews also took place.

RESULTS/CONCLUSIONS

The analysis suggests that there are certain fundamental elements associated with the majority of health visitor assessments and these have been termed assessment principles. These characteristics are integral to, and provide the basis upon which health visitors' assessments are conducted and professional judgement is formed. They reflect the basic principles of health visiting assessment practice, which exist despite the constraints and realities of the practice context and can be differentiated from the activity centred methods of assessment processes.

Case study: a bridge across the paradigms

Case study as a teaching and research tool has an extensive history in health and social sciences. Despite its suitability for many of the research questions that face nurses, nurses have not fully embraced case study as a comprehensive approach for research. The vagaries of the real-life clinical setting can confound methodologically purist researchers. Case study provides a milieu in which nurse researchers can respond to these vagaries and move towards a paradigmatic openness. In this paper, we argue that case study offers, as yet, under-explored and under-utilised potential as a bridge across the traditional research paradigms. We argue that case study has broad research application and epistemological, ontological and methodological flexibility. When used as a research approach, case study is both the process and end product of research. It provides a delineated boundary for inquiry, and a structural process within which any methods appropriate to investigating a research area can be applied.

The guideline contradiction: health visitors' use of formal guidelines for identifying and assessing families in need

The aim of this paper is to examine health visitors' use of formal guidelines in identifying health needs and prioritizing families requiring extra health visiting support. With the increasing emphasis on targeted health visiting, a case study was used to explore the extent to which health visitors in three case sites use needs assessment guidelines in the assessment of family health need. The findings indicate how the presence of core visiting protocols hints at elements of control by managers, leading to conflicts in the relationship between professional judgements and official guidelines. Despite a management ethos of guideline formulation, several contradictions exist for which these guidelines are a focus. These include: little involvement of health visitors in guideline development, some staff not informed about the existence of formal guidelines, little evidence of guidelines contributing to improved client outcomes and their limited use by many health visitors in practice. Thus, even when guidelines exist, no accurate predictions can be made about health visitors' knowledge of or use of such guidelines in practice.

A framework for understanding clinical reasoning in community nursing

BACKGROUND

Clinical reasoning is employed to develop solutions to health needs. The impact of the clinical environment on the organization of knowledge-guiding practice has received limited attention. This gap in the clinical landscape restricts the sharing of decision-making processes.

AIMS

Focusing on the community, and specifically the patient's home as a context for nursing, this paper describes the creation of a collective conceptual map for a group of community nurses. There is a twofold aim of exploring the process of exposing and articulating the clinical framework and enhancing and sharing understanding of the clinical paradigm in this context.

DESIGN

An interpretive research approach was utilized. Hermeneutic phenomenology guided the level of meaning accessed and constructivism was used to build an educational picture.

METHODS

Multiple methods including focus groups, observation and narrative recordings were utilized to collect and analyse research data.

RESULTS

All nurses may engage with the same concepts--health, need, care and partnerships--but organized into particular frames by the guiding practice philosophy and service organization. A four-stage framework for understanding clinical reasoning in the community setting is presented. This acknowledges the multi-faceted nature of health, the lived experience of health deficits, and is located in a participation and negotiated model of care. Practice examples are presented to expose the construction of need and response which often occurs in a triadic decision-making process.

CONCLUSIONS

Environment of care has significant implications on need identification and response.

RELEVANCE TO CLINICAL PRACTICE

Mechanisms to enhance the sharing of clinical reasoning and decision-making transparency are essential to aid inter- and intra-professional communication. Presentation of a clinical reasoning framework exposes the breath of 'signals' encountered in practice and the range of knowledge employed in understanding and responding to patient need.

A literature review of the public health roles of health visitors and school nurses

This paper describes a two-stage review relating to the family-centred public health role of health visitors and the child-centred public health role of school nurses. During the first stage, literature was searched using CINAHL and Medline databases and two models were used to frame the literature analysis. The findings of this analysis were, however, disappointing. Although many policy documents advocate development of the family-centred public health role of health visitors and the child-centred public health role of school nurses, there was no overwhelming evidence of reports of these approaches in health visiting and school nursing practice. The second stage of the review comprised a content analysis of West Midlands community trusts' strategic development plans. Seventeen plans were analysed. Of these, only two were 'formal' plans, the remainder being fragmented documentation related to plans for the development of health visiting and school nursing services. It may be concluded from the analysis that NHS trusts are beginning to adopt ideas from the rhetoric of national policy documents. Additionally, public health practice initiatives form an integrated part of most of the trust strategic development plans that the researchers examined.

A structured health needs assessment tool: acceptability and effectiveness for health visiting

BACKGROUND

There is, nominally at least, a universal health visiting service in Great Britain, although the frequency of contacts may be severely restricted. Debates about whether home visiting should be universal or selective, therefore, focus on whether health visitors should use professional judgement or structured assessment tools to target attention within their caseload. Research attention has focused mainly on unstructured needs assessments and professional judgment or the development of assessment tools, so that the views of practitioners using structured instruments and their clients are not known.

METHODS

A two-phase qualitative study examined the acceptability and effectiveness of a structured health needs assessment tool (HNAT) implemented in London. Views about the tool were elicited from 30 health visitors through telephone interview, and then 21 assessments were observed and tape-recorded; 19 clients were interviewed after the event. Data were evaluated for adequate coverage of views across the target population and analysed using the framework approach.

FINDINGS

A range of views were expressed, but the HNAT caused anxiety and distress to, particularly, the most vulnerable clients. The structured format of the tool appeared to encourage the health visitors to question instead of listen. It did not help to identify all the needs and intruded into normal practice in an insensitive and unhelpful way.

LIMITATIONS

This study investigated only one form of structured HNAT. These are commonly used to prioritize undifferentiated needs of clients who have been offered an unsolicited, health promoting service. Our findings therefore do not apply to validated instruments used for screening or specific diagnostic purposes where a client has requested help with a problem.

CONCLUSIONS

Given the problems in use and potential for harm, this form of structured assessment tool appears unsuitable for routine use to determine the intensity of health visiting contacts.

Empowerment or control? An analysis of the extent to which client participation is enabled during health visitor/client interactions using a structured health needs assessment tool

The demand for explicitness in the way health visitors target their services has given rise to a plethora of different health needs assessment tools (HNATs). This paper describes an in-depth conversational analysis of the use in practice of these structured health needs assessment tools (HNATs) in two different NHS Community Trusts in England. These HNATs aimed to enable clients to participate in the assessment of their own health needs, as well as fulfilling the political requirements of justifying the expenditure of health visitor time where needs are identified. However, conversational analysis of 10 interactions showed that use of the instruments was associated with a failure to either identify needs that are relevant to the client or to enable clients to participate in the process. Use of the structured instrument simultaneously emphasises the significance of a professional lead, instead of client participation, and minimises the importance of inter-personal relationships and communication. In one site, a directly controlling style was apparent in the practice of health visitors who were, themselves, explicitly controlled by their managers. In the other site, professional expertise was emphasised, and a covert assessment style acted to disempower clients. The controlling nature of the interactions, the number of missed cues and the possibility of distress caused by the insensitivity of questioning style are all potentially harmful side effects of using structured instruments to assess needs. The problems seem to stem from the use of a pre-determined list of questions that form the basis for assuming that any family's health promotion needs can be categorised and predicted in advance. In conclusion, therefore, it is recommended that health visitors should use the open, conversational style of needs assessment that has been shown to be effective and acceptable, rather than an approach based on a structured instrument.

Health needs assessment in the health visiting service and the impact on the ethnic community

The purpose of this article is to share the experience of using a health needs assessment tool in health visiting practice in Great Britain, with clients who do not speak English. This is an important issue in developing equity of practice across the growing multi-cultural and diverse populations of the United Kingdom. The paper outlines the findings relevant to these issues drawn from a wider study that used qualitative methods to observe and interview both health visitors and clients regarding the use of the tool. It focuses on one vignette to demonstrate the practical and difficult issues when a formal system is used to assess needs in clients who do not speak English as a first language.

An empowerment approach to needs assessment in health visiting practice

This paper examines the usefulness of an integrated approach to needs assessment using an empowerment framework, within a health visitor/client interaction, in the home setting. It is intended to demonstrate the existence of a flexible approach to assessing need that is based on research about necessary processes for carrying out health visiting. The design of the tool described in this paper allows the use of professional judgement as well as fulfilling commissioning requirements to address health outcomes. Health promotion and empowerment are central to health visiting practice and should be reflected in the way needs are assessed. Many NHS trusts have introduced a system of targeting and prioritizing health visiting through a system of questioning to assess needs. This may reveal the work that health visitors do, but may also inhibit the open, listening approach required for client empowerment. Different methods of assessing need can be used that do not compromise the commissioning requirements, the health visitor's duty of care or professional accountability. The empowerment approach is key to the philosophy of health visiting. There are ways of approaching needs assessment that do not compromise the ethos of partnership-working in a health promoting way.

Development of an assessment sheet for a home care

Reliable assessment instruments are essential for a new nursing care insurance system enacted in April 2000 in Japan, to ensure the quality of home care. We developed an assessment sheet based on a minimum data set and care assessment, previously developed by the Japan Visiting Nursing Foundation. This article describes the process of testing in practice, validation and revision of the assessment sheet and problem/need areas. One hundred and twelve subjects were initially visited in 48 home care agencies. The same nurse used the assessment sheet for the same client at the initial visit and one month later. After a refinement process, the assessment items and problem/needs areas were simplified. Documentation time for the assessment was significantly shortened. These assessment instruments help development of care plans by identifying client needs, utilization of social resources and evaluation of outcomes.