District nurses’ perceptions of the concept of delegating administration of medication to home care aides working in the municipality: A discrepancy between legal regulations and practice

Registered nurses' challenges and suggestions for improvement of their leadership close to older adults in municipal home healthcare

BACKGROUND

Worldwide people are living longer. The need for healthcare for older adults is increasing. The trend is towards advanced home healthcare, where registered nurses are key figures. This implies challenges for municipal home healthcare, as well as for registered nurses' leadership. The aim is to explore registered nurses' perceptions of challenges and suggestions for improvements in their leadership close to older adults in municipal home healthcare.

METHODS

The present study is part of a larger web-based questionnaire survey with a cross-sectional design. The design is inductive, analysing data using qualitative content analysis and descriptive statistics. A questionnaire with open-ended and closed-ended questions was used. A total of n = 70 registered nurses leading close to older adults participated in seven municipalities in two geographic areas in Sweden.

RESULTS

The results show registered nurses' perceptions of challenges as leaders close to older adults in terms of 11 categories. The categories are motivating for care, adjusting and coordinating nursing care to the older adult, relating to next of kin, managing communication difficulties, relating to social situations in the home, managing demands, working alone, having lack of time, collaborating with physicians, and care staff having low competence. The registered nurses suggested improvements for their leadership close to older adults in terms of nine categories. The categories are adjusting the work to the older adult, clarifying registered nurses' responsibility, balancing demands and resources, setting time aside, improving staffs' competence, ensuring staff's competence development, improving the work environment, and cooperation between professions in the municipality, as well as between healthcare organizations.

CONCLUSION

The results show that registered nurses' leadership in municipal home healthcare implies a wide range of challenges. There is a need for strategies to improve the organizational preconditions to reduce challenges in registered nurses' leadership in order to promote positive patient outcomes for safe and quality care.

Controlling the Uncontrollable: Patient Safety and Medication Management From the Perspective of Registered Nurses in Municipal Home Health Care

Most adverse events in health care are related to medication management and they are almost always preventable. Increased knowledge of patient safety related to medication management in home health care is an urgent issue to provide safe care for all patients regardless of where the health care takes place. This study explored patient safety within medication management in municipal home health care. Vignettes were used as stimulus during qualitative interviews with registered nurses. Three main themes with related subthemes were identified as challenges to patient safety within medication management in home health care: (1) challenges to information transfer, (2) challenges related to delegation, and (3) challenges of advanced medical treatments in the home. The issue of transfer of information permeated our findings. Coordinating medications, delegating tasks, along with more advanced care require clear communication between care providers to be compatible with patient safety within medication management in home health care.

Recent research into healthcare professions regulation: a rapid evidence assessment

BACKGROUND AND AIMS

Over the last decade, regulators have taken significant steps towards tackling perceptions that regulatory systems are burdensome. There has been much international research activity in the regulation of health and care professionals. This article reports a review of studies on health professions regulation between January 2011 and March 2020. Its chief object was to provide robust and up-to-date evidence to assist regulators in policy development and implementation. The main objectives of this study were to: 1. Identify and retrieve research in the field of health and care professions regulation in English since 2011; 2. Evaluate the published research, exploring its utility to regulators and practitioners, and drawing out any key messages; 3. Draw conclusions concerning the scope and limitations of the research literature and identify areas for further research.

METHODS

We undertook a rapid evidence assessment (REA) of the international literature on health and care professions regulation, including reviewing ten UK regulators' websites to identify issues of concern and strategic priorities. We retrieved 3833 references, using a four-stage screening process to select the 81 most relevant.

RESULTS

Results are reported within six key themes: harm prevention and patient safety; fitness to practise; quality assurance of education and training; registration including maintenance of registers; guidelines and standards and relations with regulatory bodies.

CONCLUSIONS

Regulation of professionals in health and care is comparatively undeveloped as a field of academic study. Consequently, the published evidence is diffuse and small-scale. Most work presents relatively weak data of low relevance to regulators, mainly reporting or describing the current position. Few studies are able to show the impact of regulation or demonstrate a causal link between regulation and its effects. To inform their research and policy agendas health and social care regulators need to commission, interpret and apply the scholarly literature more effectively; academics need to engage with regulators to ensure that their research provides high-quality evidence with practical relevance to the regulators' agendas. Further study is needed to explore how effective academic collaborations between regulators and researchers may be created and sustained.

Errors linked to medication management in nursing homes: an interview study

Background

The number of errors in medication management in nursing homes is increasing, which may lead to potentially life-threatening harm. Few studies on this subject are found in the municipal nursing home setting, and causes need to be identified. The aim of this study was to explore perceptions of errors connected to medication management in nursing homes by exploring the perspective of first-line registered nurses, registered nurses, and non-licensed staff involved in the care of older persons.

Methods

A qualitative research approach was applied based on semi-structured interviews with 21 participants at their workplaces: Seven in each of the occupational categories of first-line registered nurses, registered nurses, and non-licensed staff. Subcategories were derived from transcribed interviews by content analysis and categorized according to the Man, Technology, and Organization concept of error causation, which is as a framework to identify errors.

Results

Mistakes in medication management were commonly perceived as a result of human shortcomings and deficiencies in working conditions such as the lack of safe tools to facilitate and secure medication management. The delegation of drug administration to non-licensed staff, the abandonment of routines, carelessness, a lack of knowledge, inadequate verbal communication between colleagues, and a lack of understanding of the difficulties involved in handling the drugs were all considered as risk areas for errors. Organizational hazards were related to the ability to control the delegation, the standard of education, and safety awareness among staff members. Safety issues relating to technology involved devices for handling prescription cards and when staff were not included in the development process of new technological aids. A lack of staff and the lack of time to act safely in the care of the elderly were also perceived as safety hazards, particularly with the non-licensed staff working in nursing homes.

Conclusions

The staff working in nursing homes perceive that the risks due to medication management are mainly caused by human limitations or technical deficiencies. Organizational factors, such as working conditions, can often facilitate the occurrence of malpractice. To minimize mistakes, care managers need to have a systemwide perspective on safety issues, where organizational issues are essential.

A Systematic Review of the Legal Considerations Surrounding Medicines Management

This study explores the legal considerations surrounding medicines management, providing a synthesis of existing knowledge. An integrative systematic review of the current international knowledge was performed. The search encompassed the online databases of PubMed (including Medline), Scopus, CINAHL, and Web of Science using MeSH terms and relevant keywords relating to the legal considerations of medicines management in healthcare settings. The search process led to the identification of 6051 studies published between 2010 and 2020, of which six articles were found to be appropriate for data analysis and synthesis based on inclusion criteria. Research methods were varied and included qualitative interviews, mixed-methods designs, retrospective case reports and cross-sectional interrupted time-series analysis. Their foci were on the delegation of medicines management, pharmacovigilance and reporting of adverse drug reactions (ADRs) before and after legislation by nurses, physicians and pharmacists, medico-legal litigation, use of forced medication and the prescription monitoring program. Given the heterogenicity of the studies in terms of aims and research methods, a meta-analysis could not be performed and, therefore, our review findings are presented narratively under the categories of 'healthcare providers' education and monitoring tasks', 'individual and shared responsibility', and 'patients' rights'. This review identifies legal aspects surrounding medicines management, including supervision and monitoring of the effects of medicines; healthcare providers' knowledge and attitudes; support and standardised tools for monitoring and reporting medicines' adverse side effects/ADRs; electronic health record systems; individual and shared perceptions of responsibility; recognition of nurses' roles; detection of sentinel medication errors; covert or non-voluntary administration of medication, and patient participation.

Community-based homecare nursing in Denmark: exploring factors related to substitution of nurses by ancillary health professionals

BACKGROUND

Demographic changes and shorter hospital stays have made community-based homecare nursing an increasingly important part of the healthcare organisation. This development may also impact the secondary healthcare system. Optimal use of resources is key to meeting the future challenges. Nevertheless, the research-based knowledge on homecare nursing is scarce. The aim of this study was to examine factors related to homecare nursing tasks that could have been performed by ancillary health professionals.

METHODS

A population-based survey involving all homecare nurses in the homecare services in one municipality in Denmark was performed. The nurses registered all contacts during daytime for one week using a registration form with a series of items to identify factors related to possible substitution of nurse-performed tasks. Statistical analyses were used to identify associations between specific factors and potential substitution of the performing type of healthcare professional. The study was approved by and is registered at VIA University College in accordance with the General Data Protection Regulation of the EU.

RESULTS

Homecare nurses registered 941 representative visits in the municipality. Substitution by ancillary health professionals was considered a possibility by the nurses in 28.3% of the cases. When adjusting for age, gender, type of visit, need for extra healthcare services and vulnerability, we established that the nurses more often found that ancillary health professionals could have provided the care in unplanned visits and in visits to patients above 90 years of age.

CONCLUSIONS

The results indicate potential for optimising the available nursing resources as substitution by ancillary health professionals was considered possible in numerous visits. In view of the increasing demands for community-based homecare nursing, it is important to make the most of the available resources in the future. Substitution of nurses for some tasks could be a feasible solution.

Experiences of home care assistants providing social care to older people: A context in transition

AIM

The aim was to describe home care assistants' (HCA) experiences of providing social care in older people's own homes.

BACKGROUND

With the increase in average life expectancy and related growth of the elder population, addressing geriatric care needs has become an increasingly vital issue. However, the frontline workforce faces major challenges in meeting these needs, including a lack of trained professionals entering the field.

DESIGN

A qualitative inductive design was used.

METHODS

A descriptive, qualitative study using focus group interviews and content analysis.

FINDINGS

The findings revealed that HCAs are active in an area facing challenges due to an older home-dwelling generation. Transfer of tasks should be reviewed considering changes to the workforce's skill mix brought on by task shifting.

CONCLUSIONS

Certain prerequisites are needed to enable unlicensed assistive personnel to perform a good job; they also need to receive affirmation that they are a crucial workforce carrying out multifaceted tasks. To improve and maintain the pull factors of social care work, it is crucial to clarify how older people's requirements influence the daily care relation.

IMPLICATIONS FOR PRACTICE

The findings highlight HCAs' blurred responsibility when providing nursing and care to older people with multiple chronic conditions and functional disabilities. Increasing expectations are placed upon HCAs to cope with practical situations that are theoretically outside the bounds of social care. The findings contribute knowledge to further development of collaboration between social and health care providers as well as the important affirmation of this unlicensed personnel group in transition. A long-term plan is therefore needed to provide HCAs with the skills and tools they need to deliver care and support to older people with a variety of needs.

Home care assistants' perspectives on detecting mental health problems and promoting mental health among community-dwelling seniors with multimorbidity

INTRODUCTION

Elderly people with multiple chronic conditions, or multimorbidity, are at risk of developing poor mental health. These seniors often remain in their homes with support from home care assistants (HCAs). Mental health promotion by HCAs needs to be studied further because they may be among the first to observe changes in clients' mental health status.

AIM

To describe HCAs' perspectives on detecting mental health problems and promoting mental health among homebound seniors with multimorbidity.

METHODS

We applied a descriptive qualitative study design using semi-structured interviews. Content analyses were performed on five focus group interviews conducted in 2014 with 26 HCAs.

RESULTS

Most HCAs stated that they were experienced in caring for clients with mental health problems such as anxiety, depression, sleep problems, and high alcohol consumption. The HCAs mentioned as causes, or risk factors, multiple chronic conditions, feelings of loneliness, and social isolation. The findings reveal that continuity of care and seniors' own thoughts and perceptions were essential to detecting mental health problems. Observation, collaboration, and social support emerged as important means of detecting mental health problems and promoting mental health.

CONCLUSION

The HCAs had knowledge of risk factors, but they seemed insecure about which health professionals had the primary responsibility for mental health. They also seemed to have detected early signs of mental health problems, even though good personal knowledge of the client and continuity in home visits were crucial to do so. When it came to mental health promotion, the suggestions related to the aim of ending social isolation, decreasing feelings of loneliness, and increasing physical activity. The results indicate that the HCAs seemed dependent on supervision by district nurses and on care managers' decisions to support the needed care, to schedule assignments related to the detection of mental health problems, and to promote mental health.

Evaluation of a support worker role, within a nurse delegation and supervision model, for provision of medicines support for older people living at home: the Workforce Innovation for Safe and Effective (WISE) Medicines Care study

Background

Support with managing medicines at home is a common reason for older people to receive community nursing services. With population ageing and projected nurse shortages, reliance on nurses may not be sustainable. We developed and tested a new workforce model: ‘Workforce Innovation for Safe and Effective (WISE) Medicines Care’, which enabled nurses to delegate medicines support home visits for low-risk clients to support workers (known as community care aides [CCAs]). Primary study aims were to assess whether the model increased the number of medicines support home visits conducted by CCAs, explore nurses’, CCAs’ and consumers’ experiences with the CCAs’ expanded role, and identify enablers and barriers to delegation of medicines support.

Methods

A prospective before-after mixed-methods study was conducted within a community nursing service that employed a small number of CCAs. The CCAs’ main role prior to the WISE Medicines Care model was personal care, with a very limited role in medicines support. CCAs received training in medicines support, and nurses received training in assessment, delegation and supervision. Home visit data over two three-month periods were compared. Focus groups and interviews were conducted with purposive samples of nurses (n = 27), CCAs (n = 7) and consumers (n = 28).

Results

Medicines support visits by CCAs increased from 43/16,863 (0.25 %) to 714/21,552 (3.3 %) (p < 0.001). Nurses reported mostly positive experiences, and high levels of trust and confidence in CCAs. They reported that delegating to CCAs sometimes eliminated the need for duplicate nurse and CCA visits (for people requiring personal care plus medicines support) and enabled them to visit people with more complex needs. CCAs enjoyed their expanded role and were accepted by clients and/or carers. Nurses and CCAs reported effective communication when medicine-related problems occurred. No medication incidents involving CCAs were reported. Barriers to implementation included the limited number of CCAs employed in the organisation and reluctance from some nurses to delegate medicines support to CCAs. Enablers included training and support, existing relationships between CCAs and nurses, and positive staff attitudes.

Conclusions

Appropriately trained and supervised support workers can be used to support community nurses with providing medicines management for older people in the home care setting, particularly for those who are at low risk of adverse medication events or errors. The model was acceptable to nurses, clients and carers, and may offer a sustainable and safe and effective future workforce solution to provision of medicines support for older people in the home care setting.

Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care

Growing healthcare costs have caused home-care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home-care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home-care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010-2011. Using a purposive sampling strategy, semi-structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home-care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust-based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.

Unlicensed personnel administering medications to older persons living at home: a challenge for social and care services

BACKGROUND

Administration of medication to care recipients is delegated to home-care assistants working in the municipal social care, alongside responsibility for providing personal assistance for older people. Home-care assistants have practical administration skills, but lack formal medical knowledge.

AIM

The aim of this study was to explore how home-care assistants perceive administration of medication to older people living at home, as delegated to them in the context of social care.

METHODS

Four focus groups consisting of 19 home-care assistants were conducted. Data were analysed using qualitative content analysis.

RESULTS

According to home-care assistants, health and social care depends on delegation arrangements to function effectively, but in the first place it relieves a burden for district nurses. Even when the delegation had expired, administration of medication continued, placing the statutes of regulation in a subordinate position. There was low awareness among home-care assistants about the content of the statutes of delegation. Accepting delegation to administer medications has become an implicit prerequisite for social care work in the municipality.

CONCLUSIONS

Accepting the delegation to administer medication was inevitable and routine. In practice, the regulating statute is made subordinate and consequently patient safety can be threatened. The organisation of health and social care relies on the delegation arrangement to meet the needs of a growing number of older home-care recipients.

IMPLICATIONS FOR PRACTICE

This is a crucial task which management within both the healthcare professions and municipal social care needs to address, to bridge the gap between statutes and practice, to create arenas for mutual collaboration in the care recipients' best interest and to ensure patient safety.