Structure and process quality as predictors of satisfaction with elderly care

Adapting the Donabedian model in undergraduate nursing education: a modified Delphi study

BACKGROUND

Donabedian conceptual and multidimensional framework has been used in several studies in an educational context. In this study, we aimed to adapt the Donabedian three-component model (structure, process, and outcome) in undergraduate nursing education. This conceptual framework provides a comprehensive image of nursing education institutions and can help to evaluate institutions by measuring different aspects of their performance. A comprehensive understanding of the various elements of an educational institution helps to develop a complete, appropriate relevant set of performance indicators.

METHODS

This was a modified Delphi study. It had three rounds. The expert panel consisted of nursing faculty members and nursing Ph.D. students. In the first round, a questionnaire was designed based on interviews, focus groups, and a literature review. Experts rated their agreement with each element on a 5-point Likert scale in rounds two and three. The consensus level was set as 75%. The stability between rounds was also determined by calculating kappa coefficients. One Sample T-Test was also calculated for new items in round three.

RESULTS

All 55 items of the questionnaire were confirmed in the second round based on the consensus percentage of 75. Five new items were added to the third round based on comments in round two. Eventually, all elements except one were confirmed according to the consensus level, kappa values, means, and One-Sample T-Test in round three. The structure's key elements include staff (academic and non-academic); equipment; guidelines; resources and facilities; and students' demographics and characteristics. Process key elements include communication; education; evaluation; cooperation; and consultation. Outcome key elements include knowledge development; nursing image; alumni's outcome; students' outcome; related medical centers' performance; accreditation and evaluation results; and satisfaction.

CONCLUSIONS

Different elements of a nursing education institution at the bachelor's level were determined. The results of this study can help related bodies to develop and implement a comprehensive and systematic evaluation. These results can also be a basis for making this model useful in other nursing courses or education in other fields.

Process and Structure: Service Satisfaction and Recommendation in a Community-based Elderly Meal Service in Shanghai

Informed by Donabedian's quality-of-care framework, this study aims to examine elderly clients' service satisfaction and service recommendation for community-based meal services in Shanghai. We analyzed secondary survey data from randomly sampled elderly clients of a community-based meal service in the old Jing'an District in Shanghai (N= 690). Quality of food and caregivers' attitudes were key to respondents' service recommendation while tidiness of tableware and interactions with caregivers were positively related to their service satisfaction. Overlaps and differences between structure and process factors are discussed. We also provide tailored policy recommendations.

What should be measured? Nursing education institutions performance: a qualitative study

OBJECTIVES

In this qualitative study, we specify important domains of a nursing education institution that need to be measured to represent its performance via students' perspectives, one of the most important stakeholders in higher education.

SETTING

This study was conducted in a nursing and midwifery faculty.

PARTICIPANTS

Participants were bachelor's, master's and Ph.D. students in nursing. Convenience sampling was used. The aim and methods of the study were explained to the students, and they were invited to participate in the focus groups. Four focus groups (n=27) were held.

RESULTS

Thirteen categories emerged that were assigned to three components of the Donabedian model. The structure component contained three categories: learning fields, equipment and facilities and human resources standards. The process component contained five categories: workshops for students and staff, student familiarity with the institution's rules and plans, teaching, students evaluation and evaluation of teaching staff by students and peers. And outcome components contained five categories: results of self-evaluation by students, graduates' outcomes, students' outcomes, students surveys results and related medical centres performance.

CONCLUSIONS

Based on the needs and ideas of this important group of stakeholders, we can proceed further. Once we specify what is important to be measured, then it is appropriate to develop or choose suitable and measurable performance indicators for each of the recognised categories.

What constitutes a quality community aged care service-client perspectives: An international scoping study

Overwhelmingly, older Australians (people aged 65 years and older or 50 years and older for Aboriginal and Torres Strait Islander people) prefer to remain living in their own home rather than moving into residential care. To enable older Australians who require assistance to remain living at home, the Federal Government provides a wide range of community care services, the provision of which has increased substantially over the last 15 years. The importance of client preferences, prefaced by the introduction of consumer directed care across community aged care services, has gathered momentum in Australia following legislation in 2015. Older peoples' preferences differ in comparison to younger people with disability and those with mental health concerns. Older people focus more on the provision of services rather than the notion of independent living itself. This scoping review aimed to explore what aspects people aged 65 years and older consider to be important qualities of aged care services delivered in the community. A computerised search in MEDLINE, CINAHL, PubMed and PsychINFO and hand searches of the Cochrane database and Google Scholar were completed in May 2022. Sixty-two articles met the selection criteria and were included in the review. Data were extracted using a fit-for-purpose protocol and analysed using the Miles and Huberman Model for thematic analysis. Results identified five themes representing quality domains that describe features that are important to clients: staff knowledge, respect for clients, a person-centred approach, a collaborative partnership with clients and clear communication. When providers of community aged care services are planning to assess the quality of their services, these findings could be used to guide their evaluation. This will ensure that future services delivered accommodate the needs and preferences of clients who receive them.

Community-dwelling older adults and their informal carers call for more attention to psychosocial needs - Interview study on unmet care needs in three European countries

BACKGROUND

Unmet care needs are usually defined in terms of receiving sufficient help in instrumental activities and activities of daily living. Research on unmet needs is mostly based on quantitative data. Older persons' and informal carers' views and experiences have received less attention.

METHODS

In this paper, we rely on a definition of unmet needs which includes both unmet needs due to insufficient care and those situations where informal carers experience undue strain. Using theory-driven content analysis, we examine community-dwelling older adults' and their informal carers' experiences of unmet needs: what kind of unmet needs they have, why and in which ways these needs are left unmet and what would they want to do to improve the situation. The data consists of interviews gathered in Austria, Finland and Slovenia.

RESULTS

Results of the analysis reveal that unmet needs are largely psychosocial in nature. The predominating task-oriented care systems often do not consider these as care needs. Using methods of qualitative content analysis, we conclude that care users' unmet psychosocial needs are related to lacking a personal relationship with care workers; means to maintain or develop social contacts and pursue activities and interests; and adequate home care services or respite care. Excessive responsibilities are put on informal carers as they top up and fill in the insufficient care.

CONCLUSIONS

This study contributes to a broader understanding of unmet care needs: the relational aspects of care and the universal nature of psychosocial care needs should be addressed in care services.

Satisfaction of caregivers and older adults who use the Better at Home Program

OBJECTIVE

Evaluate the satisfaction of caregivers and older adults who use the home care service provided by the Better at Home Program (Programa Melhor em Casa) and its associated factors.

METHODS

This is a cross-sectional study with data from the national survey on the Better at Home Program, conducted by the SUS General Ombudsman. We interviewed 5,595 caregivers and 950 older adults. We combined four questions related to satisfaction to formulate the dependent variable by means of latent class analysis and used 13 questions as independent variables.

RESULTS

93.7% of the older adults and 90.2% of the caregivers were satisfied with the service. In the multiple analysis, the variables showing association with satisfaction were: also being accompanied by a family health team (older adults: OR = 4.22; p = 0.014), shorter time between referral and the first visit (older adults: OR = 10.20; p = 0.006), (caregiver: OR = 5.84; p < 0.001), taking examinations with medical requirement (older adults: OR = 5.74; p = 0.037), (caregiver: OR = 7.41; p < 0.001), consultation with specialist (caregiver: OR = 6.02; p < 0.001), visits out of the schedule when necessary (older adults: OR = 8.09; p = 0.014), (caregiver: OR = 1.81; p = 0.015) and understanding the orientations provided by the program team (caregiver: OR = 10.61; p < 0.001).

CONCLUSIONS

The majority of the older adults and caregivers showed satisfaction with the program, with a distinction in the aspects associated with this satisfaction, in which only the characteristics directly related to the program influenced the satisfaction, while the same did not occur with the socioeconomic and demographic characteristics.

How do health and allied health practitioners perceive excellence in residential aged care? An exploratory qualitative study

OBJECTIVE

To identify factors that health and allied health practitioners consider central to excellence in residential aged care facilities (RACFs) with the objective of supporting improvements in monitoring, accountability and service delivery within the sector.

METHODS

In a qualitative, exploratory designed study, interviews were undertaken with seventeen participants from 10 health and allied health disciplines (general practice, dentistry, pharmacy, psychiatry, psychology, neuropsychology, physiotherapy, speech pathology, occupational therapy and palliative care) with experience of working in Victorian RACFs. The interviews focused on how practitioners perceived excellence within RACFs. Data were analysed thematically.

RESULTS

Thematic analysis yielded five themes, which correspond with different dimensions or ways of understanding excellence, including resident well-being, residences as a true home, good practice models, effective management and skilled staff, and unmet needs. Under each of these themes, participants referred to issues closely related to the concerns of their particular professions as well as those more general in nature.

CONCLUSIONS

The diversity in issues to which participants drew attention highlights the importance of obtaining the perspectives of a broad range of practitioners providing services to RACF residents to achieving excellence in the sector. Commonalities in their responses indicate the potential for a greater level of collaboration among the health and allied health professions.

Quality of nursing care in Saudi's healthcare transformation era: A nursing perspective

BACKGROUND

The Kingdom of Saudi Arabia corporates performance improvement strategies in health sector to transform hospital operations and instituting a culture of quality through performance improvement initiatives. Quality of nursing care (QNC) is a concern for nursing professionals and administration. Donabedian's 'Quality-of-Care' framework plays a vital role in transforming nursing care and determining appropriate intervention development and implementation plans.

AIM

To explore the nurses' perception for the QNC and find their perspectives in achievements and gaps by adopting the Donabedian model.

METHODS

A cross-sectional study was conducted on a convenience sample of 639 nurses from a tertiary hospital in Saudi Arabia using Karen-personnel instrument for measuring QNC. The achievements and gaps in nursing care quality determined by redistributing Karen statements to the three dimensions of the Donabedian structure, process and outcome model.

FINDINGS

The nurses' overall perception of the QNC was positive. According to the Donabedian model, the nurses focussed on care procedures (i.e., process-oriented) and required resources (i.e., structure-oriented), although the transformation era requires nurses' performance to focus on the outcome dimension.

CONCLUSION

To activate the vital roles of nurses in accomplishing health transformation initiatives, there should be collaborative efforts among nursing managers, educators and policy-makers to sustain quality of structure, process and outcome-oriented nursing care and be more outcome-oriented.

Service process factors affecting patients' and clinicians' experiences on rapid teleconsultation implementation in out-patient neurology services during COVID-19 pandemic: a scoping review

Background

The adoption of teleconsultation for outpatient neurology services was limited until the onset of the COVID-19 pandemic which forced many outpatient neurology services to rapidly switch to virtual models. However, it remains unclear how this change has impacted patients’ and clinicians’ perceptions of service quality. The purpose of this scoping review is to identify process factors that influence patients’ and clinicians’ experiences of outpatient teleconsultation services during COVID-19.

Methods

Arksey and O’Malley scoping review framework was used to search PubMed, Scopus, CINAHL, and PsycInfo for original peer-reviewed research studies that examined the experiences of synchronous teleconsultation between a clinician and patient in a home-setting since the World Health Organization announced the COVID-19 global pandemic. The service quality model SERVQUAL was used to conduct a deductive thematic analysis to identify the key factors that impacted the patients’ and clinicians’ perception of teleconsultation services.

Results

A total of nineteen studies published between January 1, 2020, and April 17, 2021, were identified. The most common service process factors affecting the patients’ and clinicians’ experiences of teleconsultation were technical issues, addressing logistical needs, communication, ability to perform clinical activities, appropriate triage, and administrative support.

Conclusions

Our findings identified six key service process factors affecting the patients’ and clinicians’ teleconsultation experiences in outpatient neurology services. The need for improvement of triage process and standardizing administrative virtual care pathway are identified as important steps to improve patients and clinicians’ teleconsultation experiences compared to pre-COVID era. More research is needed to assess outpatient neurology teleconsultation service quality from patients’ and clinicians’ perspectives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07908-4.

Factors Associated with Quality of Care Among Dependent Older Persons in the Community

Introduction

Dependent older persons who are limited in their daily activities affect physical, mental, social ability needs help in the family and the community caregiving.

Objective

The study aimed to analyze the relationship between caregivers' characteristics and health conditions, social support, the burden of care, and the quality of respect for the dependent older persons.

Methods

The descriptive study design applies in using a Donabedian framework, including structure, process, and outcome with House's social support. The sample consists of 102 family caregivers currently caring older people with dependency in Bangkok, Thailand. Data were collected through questionnaires, semi-structured interviews, and care quality assessments through tested content validity from 3 health experts, which received a score of 0.97. Descriptive statistics and correlation coefficients were used to analyze the information and tested using Spearman's rank correlation; acceptable criteria were obtained before collecting the actual data.

Results

The results showed that they were statistically significantly related to social support and quality of care. When considering each aspect, social support was associated with the quality of physical and psychological care. Resource social support was to relate the quality of medical and financial aspects. Social support of acceptance and appreciation is associated with quality, environmental, physical, psychological, human rights, and economic elements; information social support was significantly related to information supervision quality.

Discussion

This study found that personal factors in age and comorbidity affect the burden of care in family caregivers. In addition, good social support will affect the quality of respect for the dependent older persons in psychological, medical, human rights, and financial dimensions. In particular, the appraisal support, incredible care, attentiveness, and dedication to care will result in a good quality of care in all areas except the quality of physical dimensions.

What defines quality of care for older people in aged care? A comprehensive literature review

The quality of the care provided to frail older people in aged care is a concern for all Australians and for the citizens of many other countries internationally. This paper summarizes the methods and findings from an Australian study commissioned by the Royal Commission into Aged Care Quality and Safety to identify and synthesize international literature relating to the quality of care in aged care. A comprehensive literature review was undertaken to search and identify the literature (grey and peer reviewed) relating to quality of care and/or person-centered care in aged care. The review identified nine key themes as salient to the quality of care experience, which include treating the older person with respect and dignity; acknowledging and supporting their spiritual, cultural, religious and sexual identity; the skills and training of the aged care staff providing care; relationships between the older person and the aged care staff; social relationships and the community; supporting the older person to make informed choices; supporting the older person's health and well-being; ensuring the delivery of safe care in a comfortable service environment; and the ability to make complaints and provide feedback to the aged care organization. In practice, particularly in the context of residential care, quality of care has traditionally been measured using clinical indicators of care quality. These findings highlight the central importance of person-centered care and care experience as fundamental tenets of the quality of aged care service delivery in Australia and internationally. Geriatr Gerontol Int 2021; 21: 765-778.

Implementation of clinical pharmacy services using problematization with Maguerez Arc: A quasi-experimental before-after study

RATIONALE, AIMS, AND OBJECTIVES

The growth of clinical pharmacy services (CPS) has positively impacted clinical, economic, and humanistic health outcomes. However, detailed studies on the process of implementing CPS in healthcare systems are incipient. Thus, the present study aimed to evaluate the CPS implementation in certain public health units in a metropolis in northeast Brazil.

METHODS

A quasi-experimental before-and-after study was carried out in Recife City, from July 2015 to March 2016. The study was carried out using the Methodology of Problematization with Maguerez Arc and was divided into: initial evaluation (before), planning, interventions, and preliminary evaluation (after). The participants were pharmacists, patients, health professionals, and local health managers. Descriptive statistics were used to report data. The statistical significance of the comparison between variables was evaluated using the Wilcoxon test (95% CI; P ≤ .05).

RESULTS

Initial evaluation: Identified incipient CPS, a lack of structure and work process of pharmacists. Planning: Sixteen brainstorming meetings were held with the different actors resulting in a strategic plan.

INTERVENTION

Twenty-two political-administrative meetings were held with managers and health teams and 768 hours of theoretical and practical training with mentoring for pharmacists. Preliminary evaluation: Structure indicators presented a statistically significant difference, differently from the process indicators. Pharmacists attended 842 patients and performed 1465 pharmaceutical consultations in 6 months. Regarding the outcome indicators, it was possible to identify changes in the clinical status of the most prevalent diseases among those patients who attended three pharmaceutical consultations.

CONCLUSIONS

It was possible to evaluate the CPS implementation in certain public health units in a metropolis in Brazil, through the Methodology of Problematization with Maguerez Arc. This methodology may be part of models for future implementations of CPS in health systems.

Linking supportive leadership to satisfaction with care: proposing and testing a service-profit chain inspired model in the context of elderly care

PURPOSE

As marketization has gained ground in elderly care, satisfaction with care has come to play a crucial role in designing for high-quality care. Inspired by the service-profit chain (SPC) model, the authors aimed to gain a deeper understanding of the intricate interplay between supportive leadership practices, organizational climate, job satisfaction and service quality by predicting satisfaction with care.

DESIGN/METHODOLOGY/APPROACH

A Swedish sample of frontline elderly care staff (n = 1,342) participated in a cross-sectional questionnaire study. Mediation analyses were conducted to test the proposed model.

FINDINGS

As predicted, engaging in supportive leadership practices was directly and positively associated with satisfaction with care. In addition, as predicted, this relationship was partially mediated by organizational climate and job satisfaction. Moreover, job satisfaction predicted satisfaction with care with service quality explaining a statistically significant part of this relationship.

PRACTICAL IMPLICATIONS

Managers in elderly care services may improve satisfaction with care in multiple ways but primarily by showing that they care about the staff and ensuring that they are satisfied with their working conditions. Employee job satisfaction seems to be particularly crucial for satisfaction with care, beyond what can be accounted for by care service quality.

ORIGINALITY/VALUE

The authors proposed a novel service-outcome model. Adding to the original SPC model, the model in this study suggested and validated previously unexplored relationships including a direct path between leadership practices and satisfaction with service and a multiple-mediator model explaining this relationship. Also, new measures of organizational climate and supportive leadership were developed for which satisfactory reliability estimates were obtained.

User and family satisfaction with nursing homes: a systematic review

BACKGROUND

Implementation of person-directed care planning is a challenge for nursing home services. User satisfaction is indispensable to implement it.

OBJECTIVE

The aim of this study was to address user and family satisfaction with nursing homes and the scales used and to identify the determinants of satisfaction with this service.

METHODS

A systematic review was conducted, and the Cochrane Library, PubMed, Scopus, Web of Science and CINAHL databases were searched between December 2019 and April 2020. Studies involving assessment of user or family satisfaction with nursing homes and users ≥65 years old or their families were included in this review. The methodological quality of the included studies was assessed by the Joanna Briggs Institute reviewer's manual.

RESULTS

Eight articles were included based on the eligibility criteria, from a total of 2378 records found in the electronic search. All studies presented a cross-sectional design, and the total sample of this review was 57 214 older people. Most of the studies included showed positive overall satisfaction with nursing homes. There was no consensus about the best scale to assess satisfaction because of the huge variety of tools among studies. The most common determinants of satisfaction among studies were quality of life (mental and physical components), anxiety and social and health factors.

CONCLUSION

The findings of our review may contribute to a better view of satisfaction with nursing homes experienced by users and families and to an improvement of care in these institutions.

Exploring the determinants of synergetic development of social organizations participating in home-based elderly care service: An SEM method

The current aging service industry has problems in meeting the ever-increasing demand for the home-based elderly care service (HECS). Social organizations participating in HECS seems to be a promising way to address these problems but also raises new challenges, like uncoordinated cooperation among stakeholders, which could lead to low management efficiency and low service quality. However, Synergetic development can be promising to enhance the participation of social organizations and to improve social welfare. This study introduces a conceptual model to explore relationships between five determinants and synergetic development of social organizations participating in HECS. A structural equation model (SEM) based on questionnaire survey is used as a test methodology. The results indicated that stakeholder engagement plays a critical role in synergetic development in HECS, resource allocation can only be improved by institutional climate, and supervision capacity cannot facilitate information sharing. This study provides effective strategies and directions for the improvement of home-based elderly care services.

Understanding client satisfaction in elderly care: new insights from social resource theory

Social resource theory suggests that social interaction can be conceived as resource transaction or exchange with behaviours falling within six fundamental resource categories (i.e. love, status, information, money, goods, and services) organised along two underlying dimensions: particularism-universalism and concreteness-abstractness. With the purpose of extending knowledge about quality of care, this study adopts a novel approach in that it describes and categorises care behaviours using social resource theory instead of using single instances of care behaviour. The categorisation is further used to predict client satisfaction in care services targeting older people. Daily interactions between care staff and older persons were observed in two different residential care facilities using a structured non-participant observation design. The data were analysed using principal component analysis, correlation, and regression analysis. The results confirmed the hypothesis that satisfaction with care services is predicted by resource transactions that are high on the underlying dimensions of particularism and abstractness. Thus, the resource categories of love and status (resource categories high on particularism and abstractness) were shown to be strong predictors of client satisfaction. The use of social resource theory is a novel and appropriate approach to examine person-centred care and satisfaction with care. Also, in addition to addressing potential problems in previous self-report studies on care staff behaviour, the observational technique was highly practical to this service area where dealing with clients not always able to provide feedback directly.

Sports Medicine Staffing Patterns and Incidence of Injury in Collegiate Men's Ice Hockey

CONTEXT

The relative availability of clinicians as well as the types and training of health care providers have been associated with morbidity and mortality in non-athletic health care settings. Whether staffing variations are associated with injury incidence in collegiate athletes is unknown.

OBJECTIVE

To evaluate whether the institutional ratio of athletes to athletic trainers (patient load) or the ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers or both is associated with the incidence of injuries sustained by male ice hockey athletes at the school.

DESIGN

Descriptive epidemiology study.

SETTING

National Collegiate Athletic Association (NCAA) men's ice hockey teams.

PATIENTS OR OTHER PARTICIPANTS

Collegiate men's ice hockey athletes.

MAIN OUTCOME MEASURE(S)

The NCAA Injury Surveillance Program collected data from collegiate men's ice hockey athletes. Staffing patterns were obtained through telephone interviews. Injury counts, injury rates per 1000 athlete-exposures, and injury rate ratios with 95% confidence intervals were calculated and compared between the following groups: (1) schools with high (versus low) patient load and (2) schools with high (versus low) ratio of staff to nonstaff (graduate assistant and certified intern) athletic trainers.

RESULTS

Both the patient load and relative number of staff athletic trainers were associated with variations in the incidences and types of diagnosed injuries in male ice hockey players. Specifically, fewer injuries were diagnosed by clinicians at institutions with high patient loads. The rates of injury overall and non-time-loss injuries were lower in the high patient-load group. Time-loss injury rates, severe injury rates, concussion rates, and overall rates of injury during competition were greater in the group with a higher proportion of staff athletic trainers, whereas non-time-loss injury rates were lower.

CONCLUSIONS

In this study of collegiate men's ice hockey players, athlete health outcomes were directly related to the number and types of clinicians available. Future researchers should evaluate whether this finding extends beyond men's ice hockey.

An integrated MUSA to measure health care service quality from a patient's perspective in a resource-constrained setting

PURPOSE

Although assessing the quality of health services offered in a least developed country such as Yemen is very important, it is not yet given attention. As a result, Yemeni patients started to look for higher quality of health services abroad. Thus, Yemeni health private providers need to know how to link their patients' satisfaction to the quality of the services offered to end up with more satisfied patients and higher health service quality offered.

METHODOLOGY

Data were collected form 5310 patients in 249 private clinics. The patients evaluated their satisfaction on the quality of service on the basis of nine criteria that comprised 31 subcriteria. We used multicriteria satisfaction analysis (MUSA) to analyze the data.

FINDINGS AND CONCLUSION

The data analysis results showed low level of satisfaction on the health care quality services offered by the private clinics in Yemen. The majority of the criteria and subcriteria showed low level of satisfaction, high demand, and high mandate for improvement.

Small is beautiful? Explaining resident satisfaction in Swedish nursing home care

BACKGROUND

Resident satisfaction is an important aspect of nursing home quality. Despite this, few studies have systematically investigated what aspects of nursing home care are most strongly associated with satisfaction. In Sweden, a large number of processual and structural measures are collected to describe the quality of nursing home care, though the impact of these measures on outcomes including resident satisfaction is poorly understood.

METHODS

A cross-sectional analysis of data collected in two nationally representative surveys of Swedish eldercare quality using multi-level models to account for geographic differences.

RESULTS

Of the factors examined, nursing home size was found to be the most important predictor of resident satisfaction, followed by the amount of exercise and activities offered by the nursing home. Measures of individualized care processes, ownership status, staffing ratios, and staff education levels were also weakly associated with resident satisfaction. Contrary to previous research, we found no clear differences between processual and structural variables in terms of their association with resident satisfaction.

CONCLUSIONS

The results suggest that of the investigated aspects of nursing home care, the size of the nursing home and the amount activities offered to residents were the strongest predictors of satisfaction. Investigation of the mechanisms behind the higher levels of satisfaction found at smaller nursing homes may be a fruitful avenue for further research.

Quality Clinical Care in Nursing Facilities

Despite improvements in selected nursing facility (NF) quality measures such as reduction in antipsychotic use; local, state, and national initiatives; and regulatory incentives, the quality of clinical care delivered in this setting remains inconsistent. Herein, recommendations for overcoming barriers to achieving consistent, high-quality clinical outcomes in long-term (LTC) and post-acute care are provided to address inadequate workforce, suboptimal culture and interprofessional teamwork, insufficiently evidence-based processes of care, and poor adoption and fidelity of technology and integrated clinical decision support. With high staff attrition rates in NFs, mechanisms to measure and close knowledge gaps as well as opportunities for practice simulations should be available to educate and ensure adoption of clinical quality standards on clinician hiring and on an ongoing basis. Multipronged, integrated approaches are needed to further the quest for sustainment of high clinical quality in NF care. In addition to setting a tone for attainment of clinical quality, leadership should champion adoption of practice standards, quality initiatives, and evidence-based guidelines. Maintaining an optimal ratio of hours per resident per day of nurses and nurse aides can improve quality outcomes and staff satisfaction. Clinicians must consistently and effectively apply care processes that include recognition, problem definition, diagnosis, goal identification, intervention, and monitoring resident progress. In order to do so they must have rapid, easy access to necessary tools, including evidence-based standards, algorithms, care plans, during the care delivery process. Embedding such tools into workflow of electronic health records has the potential to improve quality outcomes. On a national and international level, quality standards should be developed by interprofessional LTC experts committed to applying the highest levels of clinical evidence to improve the care of older persons. The standards should be realistic and practical, and basic principles of implementation science must be used to achieve the desired outcomes.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Modified Delphi Consensus on Developing Home Care Service Quality Indicator for Stroke Survivor in Yogyakarta, Indonesia

BACKGROUND

Assessing the quality of health services provided at home (home care) is a challenge. The formulation of indicators requires open-minded people, who able to formulate several purposes objectively, and play an active role in decision making.

AIM

To test the face validity of the home care quality indicator in stroke patients with the modified Delphi method.

METHODS

Eighty-one indicators generated from previous studies were assessed using 3 processes to get the final results: 1) conducted modified Delphi in two rounds, namely rating or scoring by experts (using median scores); 2) reviewing qualitative suggestions from experts during the Delphi process (using comments from both Delphi rounds); 3) sorting out and correcting the grammar of the appropriate indicator (based on the median score > 7, and no disagreement).

RESULTS

Eighty-seven experts were involved in the first round Delphi and 34 experts in the second round. The experts were home care team selected from health care institutions in Yogyakarta with various professional backgrounds. Delphi process resulted in 67 indicators from 81 indicators which were divided into 10 domains: 1) Personal (2 indicators), 2) Documents (13 indicators), 3) Professionalism development (3 indicators), 4) Supporting facilities (8 indicators), 5) Administrative activities (4 indicators), 6) Health workers interaction with patients and families (15 indicators), 7) Physical conditions (2 indicators), 8) Self-actualization (1 indicator), 9) Psychological condition (5 indicators), 10) Family independent and coping (14 indicators). Selected indicators got to score more than 7 and no disagreement at all.

CONCLUSION

Sixty-seven indicators of the quality of home care, which were generated from modified Delphi consensus, were face validated. Further research could be conducted particularly on the trial process of these indicators at the actual home dwelling service setting.

The Impact of Leadership and Psychosocial Work Environment on Recipient Satisfaction in Nursing Homes and Home Care

This study examines the association between nursing assistants’ assessment of leadership, their psychosocial work environment, and satisfaction among older people receiving care in nursing homes and home care. Cross-sectional surveys were conducted with nursing assistants (n = 1,132) and people receiving care (n = 1,535) in 45 nursing homes and 21 home care units. Direct leadership was associated with the psychosocial work environment in nursing homes and home care. Furthermore, better leadership was related to higher satisfaction among nursing assistants and older people in nursing homes. Thus, indirect leadership had no effect on recipients’ satisfaction in either nursing homes or home care. The path analysis showed an indirect effect between leadership factors and recipient satisfaction. The findings suggest that the psychosocial work environment of nursing assistants and recipient satisfaction in nursing homes can be increased by improving leadership.

[Critical discussion on the current quality debate on long-term care-a plea for a systemic and empirical insight into the development and measurement of quality in long-term care]

Against the background of the quality debates on long-term care and recurrent reform measures in politics on this topic, a critical discussion on the current state of quality development, testing and reporting in Germany is presented. In Germany, the linear model of Donabedian's structural, process and outcome quality is still used as a basis for quality issues in nursing care; however, international research suggests that multiple and mutually interacting factors influence nursing quality and that a more systematic and systemic perspective for the further development of nursing quality (especially of features, criteria and indicators of nursing quality) appears more appropriate. This article intends to open the perspective of the development, measurement and reporting of quality in nursing and to make a critical contribution for a systemic theory development as a relevant basis for future developments of quality evaluation programs and quality reporting systems in long-term care.

The Association Between Psychosocial Work Environment and Satisfaction With Old Age Care Among Care Recipients

This study examines the association between nursing assistants' perceptions of their psychosocial work environment and satisfaction among older people receiving care in nursing homes and home care. Cross-sectional surveys were conducted among people receiving care (N = 1,535) and nursing assistants (N = 1,132) in 45 nursing homes and 21 home care units within municipal old-age care. Better psychosocial work environment was related to higher satisfaction in old-age care among the recipients. Significant and stronger associations were more common in nursing homes than in home care. Perception of mastery and positive challenges at work were associated with higher recipient satisfaction both in home care and in nursing homes: social climate, perception of group work, perception of mastery, and positive challenges at work only in nursing homes. Findings suggest that recipient satisfaction may be increased by improving the psychosocial work environment for nursing assistants, both in nursing homes and in home care.

A mixed methods study of the experience of older adults with multimorbidity in a Care Coordination Program

Introduction

Care Coordination Programs are designed to streamline services for older adults with multimorbidity. The Triple Aim, a conceptual model for the design and evaluation of healthcare models, stipulates that a balance of three aims—reducing costs, improving population health, and improving patient experience—are needed for high-quality, value-based care. Research is beginning to show that coordinating care across the continuum of care reduces costs and improves the health of the multimorbid older adult population. Yet little is known about older adults’ experience of care and their overall assessment of interactions with healthcare providers across the length of time of these interactions in a Care Coordination Program.

Methods

To gain a deeper understanding of older adults’ experience with a Care Coordination Program, this concurrent mixed methods research study analyzed 201 older adults’ assessment of their chronic illness care using the Patient Assessment of Chronic Illness Care (PACIC+). A subset of 30 older adults also participated in a telephone interview to collect qualitative data.

Results

The experience of older adults with multimorbidity in a Care Coordination Program was related to two factors: (1) professional actions and (2) professional attitudes. Actions that improved patients’ experience of care were communication, coordination, and addressing fundamental problems. Professional attitudes that improved their experience of care included being compassionate, knowledgeable and professional, mutually respectful, and positive and encouraging.

Discussion

To improve patient experience, Care Coordination Programs must design and measure their efforts related to the actions and the attitudes of their care team, especially primary care physicians and care coordinators.

Evaluation de la culture de sécurité en Etablissement d'Hébergement pour Personnes Agées Dépendantes (EHPAD): adaptation française du questionnaire Nursing Home Survey on Patient Safety Culture

The objective was to translate into French the American questionnaire "Nursing Home Survey on Patient Safety Culture" and to test the feasibility of its use in a sample of nursing homes. The questionnaire was translated by a multidisciplinary group of six experts and tested on a sample of people working in nursing homes. The questionnaire was then administered in five nursing homes. A first version of the French NHSPSC is proposed in this article. Despite similarities between items and ceiling effect for one item, the choices made were conservative to allow international comparisons. The administration of the questionnaire in five nursing homes confirmed the feasibility of the approach, with a participation of more than 50 per cent. This work made a French version of the NHSPSC available and confirmed that it is a feasible method for evaluating safety culture in nursing homes.

Consistency of priorities for quality improvement for nursing homes in Italy and Canada: A comparison of optimization models of resident satisfaction

The paper seeks to identify aspects of care that may be easily modified to yield a desired level of improvement in residents' overall satisfaction with nursing homes, comparing data across Canada and Italy. Using a structured questionnaire, 681 and 1116 nursing home residents were surveyed in Ontario in 2009 and in Tuscany in 2012, respectively. Fourteen items were common to the surveys, including willingness to recommend (WTR), which was used as the dependent variable and measure of global satisfaction. The other analogous items were entered as covariates in ordinal logistic regression models predicting residents' WTR in each jurisdiction separately. Regression coefficients were then incorporated into a constrained nonlinear optimization problem selecting the most efficient combination of predictors necessary to increase WTR by as much as 15%. Staff-related aspects of care were selected first in the optimization models of each jurisdiction. In Ontario, to improve WTR the primary focus should be on staff relationships with residents, while in Tuscany it was the technical skill and knowledge of staff that was selected first by the optimization model. Different optimization solutions might mean that the strategies required to improve global satisfaction in one jurisdiction could be different than those for the other jurisdictions. The optimization model employed provides a novel solution for prioritizing areas of focus for quality improvement for nursing homes.

Variations in user-oriented elderly care: a multilevel approach

Purpose

National Board of Health and Welfare claims that the quality of elderly care services differ considerably between municipalities in Sweden. This study aims to analyze to what extent these variations can be accounted for by the older person’s municipality affiliation (i.e. receiving elderly care in a certain municipality).

Design/methodology/approach

Addressing this issue, national survey data from 78,538 older respondents receiving elderly care services in Sweden were analyzed using multilevel modeling (MLM).

Findings

The results showed that municipality affiliation only marginally explained the variance in satisfaction with care, i.e. its variations were larger within than between municipalities. Instead, user-oriented care accounted for the variation in satisfaction with care. Specifically, the way the care workers behave toward the older person proved to be much more crucial for satisfaction with care than municipality affiliation. Moreover, random effects analyses revealed that the effects of user-oriented care on satisfaction with care varied across municipalities. Care setting (i.e. home care or nursing home) only marginally accounted for its variance.

Practical implications

Developing care quality should start and primarily be discussed at the interpersonal care level, and not, as is customary, at the municipality level.

Originality/value

The present research is the first in its kind to quantitatively investigate the sources of variation in perceived quality of Swedish elderly care using MLM.

Understanding eldercare users' views on quality of care and strategies for dealing with problems in Swedish home help services

The aim of the present study was to gain a deeper understanding of eldercare users' strategies for dealing with problems in the quality of care and care satisfaction in relation to home help services. Based on earlier research and evaluations, it was assumed that users would express satisfaction and gratitude, and also be unwilling to complain. The specific research questions were: (i) What, if any, quality of care problems do the users mention? (ii) How do the users explain the reasons for these problems? and (iii) What strategies do the users employ to deal with these problems? A total of 35 interviews were conducted in November 2013 with 15 men and 20 women (66-92 years). The data were analysed using thematic and qualitative content analysis. The results showed that almost all users expressed overall satisfaction with their care. However, all but one also mentioned problems. The users stated very clearly and explicitly the reasons for these problems, and in most cases, they referred to the work conditions, work organisation and lack of other resources in the eldercare organisation. Two strategies were commonly used to deal with these problems: trivialisation and adaptation. A third strategy was expressed dissatisfaction, where the problem led to actions or plans to take action. One interpretation of the findings is that what is actually measured in official quality assessments and follow-ups may be care users' understanding of the work conditions and work organisation of eldercare. The understanding attitude may prevent care users from complaining because it lowers their expectations.

Quality Indicators of Nutritional Care Practice in Elderly Care

OBJECTIVES

The aim is to explore the effects of antecedent, structural and process quality indicators of nutritional care practice on meal satisfaction and screened nutritional status among older adults in residential care homes.

DESIGN

Data for this Swedish cross-sectional study regarding older adults living in residential care homes were collected by i) a national questionnaire, ii) records from the quality registry Senior Alert, iii) data from an Open Comparison survey of elderly care in 2013/2014. The data represented 1154 individuals in 117 of 290 Swedish municipalities.

MEASUREMENTS

Meal satisfaction (%) and adequate nutritional status, screened by the Mini Nutritional Assessment Short Form (MNA-SF), were the two outcome variables assessed through their association with population density of municipalities and residents' age, together with 12 quality indicators pertaining to structure and process domains in the Donabedian model of care.

RESULTS

Meal satisfaction was associated with rural and urban municipalities, with the structure quality indicators: local food policies, private meal providers, on-site cooking, availability of clinical/community dietitians, food service dietitians, and with the process quality indicators: meal choice, satisfaction surveys, and 'meal councils'. Adequate nutritional status was positively associated with availability of clinical/community dietitians, and energy and nutrient calculated menus, and negatively associated with chilled food production systems.

CONCLUSION

Municipality characteristics and structure quality indicators had the strongest associations with meal satisfaction, and quality indicators with local characteristics emerge as important for meal satisfaction. Nutritional competence appears vital for residents to be well-nourished.

Cost and Satisfaction Trends in Swedish Elderly Home Care

There is a widespread belief among the public and policy makers that quality of care in terms of user satisfaction can be improved with increased spending. However, recent research indicates that structural resources (e.g., budget per elderly) in elderly home care do not predict quality of care in terms of older persons’ satisfaction with care. In the present study, we analyzed the longitudinal trends in costs and perceived quality of care across 3 years using nationwide data in Swedish elderly home care. The results showed that although costs have been steadily increasing, perceived quality of interpersonal treatment in care has remained at the same level. An important implication is that future research and policy efforts to improve quality should more directly target the mechanisms generating satisfaction.

Advancing the Big Five of user-oriented care and accounting for its variations

Purpose

– Care process quality (i.e. how care is enacted by a care worker toward a client at the interpersonal level) is a strong predictor of satisfaction in a wide range of health care services. The purpose of this paper is to describe the basic elements of care process quality as user-oriented care. Specifically, the questions of how and why quality in user-oriented care varies were investigated in the context of elderly care.

Design/methodology/approach

– Two municipalities were selected for in-depth field studies. First, in each municipality, the authors interviewed and observed care workers’ interactions with the older persons in both home care and nursing homes during two weeks (Study 1). Second, in an attempt to gain a deeper understanding of why process quality in terms of user-oriented care varies, the authors conducted interviews with care workers and care unit managers (Study 2).

Findings

– A new taxonomy for categorizing process quality variation, the Big Five of user-oriented care (task-focus, person-focus, affect, cooperation, and time-use), is proposed. In addition, the perceived reasons for process quality variation are reported in our own developed Quality Agents Model, suggesting that variations in care process evaluations may be explained from different perspectives at multiple levels (i.e., older person, care worker-, unit-, department-, and municipality level).

Originality/value

– The proposed taxonomy and model are useful for describing user-oriented care quality and the reasons for its variations. These findings are of relevance for future quality developments of elderly care services, but also may be adapted to applications in any other enterprise employing a user-oriented approach.