Care-planning meetings with stroke survivors: nurses as moderators of the communication

A Seat at the Table: The Positioning of Families During Care Conferences in Nursing Homes

BACKGROUND AND OBJECTIVES

Current nursing home policy emphasizes the need for collaborative, team-based care planning in which families and/or residents are actively involved. Resident care conferences are common where care providers, families, and/or residents discuss and coordinate resident care needs and evaluate care goals. This study critically examines the process, structure, and content of care conferences to expand our understanding of how resident care is negotiated among care providers and families in this context.

RESEARCH DESIGN AND METHODS

This study was part of a larger critical ethnography examining the negotiation of care work among care providers, families, and residents in three purposively selected nursing homes in British Columbia, Canada. Thirty-seven care conferences were observed. Field notes and interview data were thematically analyzed with a focus on what was said, who said what and to whom, whose voice was privileged, and how power manifested between care providers, families, and/or residents.

RESULTS

As illustrated by three key themes, Exclusion by Process-Following Script, Exclusion by Content-Scripted Reports, and Exclusion through Devalued Knowledge, families were overtly and covertly excluded from contributing to the care conferences. As such, families' presence did not guarantee open communication or active solicitation of their perspectives.

DISCUSSION AND IMPLICATIONS

The use of predetermined agendas and processes, clinically generic reporting, and technical jargon reproduced the structural inequality between care providers and families making collaboration difficult to effectively negotiate. For care conferences to meaningfully contribute to person-centered care, it is imperative that mutual exchange be promoted and families empowered to participate as equals.

How are people with dementia involved in care-planning and decision-making? An Irish social work perspective

In recent years, there have been national and international policy advances around capacity and decision-making and an apparent burgeoning rights-based approach to the issue, all of which have the potential to impact on the experience for people with dementia in Ireland. There is little evidence however on whether these policies and principles are being translated into practice and whether traditional paternalistic approaches to decision-making are being challenged. To gain insight into current practice, research was undertaken with social workers working with older people in Ireland; reporting on the involvement of people living with dementia in care-planning processes. Data collection included a mixed method approach; an on-line survey of social workers from across the country who reported on their open caseload during the month of June 2015 (N = 38 social workers reporting on the experiences of 788 older people, of which 39% of older people had a formal diagnosis of dementia). In addition, semi-structured telephone interviews were conducted with social workers working in the nine Community Health Organisation areas (N = 21). Findings show that people with dementia were high users of social work services, accounting for 44.5% of the client group. Social workers reported that there were no standardised approaches to how Health and Social Care Professionals involved people with dementia in care planning and decision-making. Overall, people with dementia were more likely to be excluded from decision-making processes due to (i) assumptions that they lacked capacity, (ii) family members preferences that the person was not involved, (iii) communication difficulties, (iv) time constraints, (v) little or no opportunity given or (vi) the person delegated decision-making to others. Good practices were identified through multidisciplinary team approaches and formal care planning meetings. This research highlights variability in how people with dementia participate in decision-making around their care. It sheds light on existing barriers which challenge the full implementation of the Irish Assisted Decision-Making legislation; highlighting the need for appropriate guidance and education for Health and Social Care Professionals. The findings also show that family dynamics and existing relationships can play a role in how people with dementia participate and are involved. To ensure consistent opportunities for participation, effective practices and approaches to supporting the participation of people living with dementia in care planning needs to be developed and rolled out in all care settings through increased training and adoption of standardised approaches.

Nursing practice in stroke rehabilitation: systematic review and meta-ethnography

AIMS AND OBJECTIVES

To identify and synthesise the available research evidence in order to generate an explanatory framework for nursing practice in stroke rehabilitation.

BACKGROUND

Although nurses are the largest professional group working with stroke survivors, there is limited understanding of nursing practice in stroke units. In particular, there is currently very little evidence in respect of nurses' involvement in poststroke rehabilitation.

DESIGN

Meta-ethnography.

METHOD

A systematic review was undertaken. The review question was: 'What is the nature of nursing practice in the care and rehabilitation of inpatient stroke survivors?' Searches of 12 electronic databases identified 14,655 publications, and after screening, 778 remained; 137 papers were obtained and 54 retained for mapping. Sixteen qualitative studies were included in the meta-ethnography.

RESULTS

Nurses' involvement in poststroke rehabilitation was limited. Contextual factors impacted on nurses' perceptions and practice. Nurses' integration of rehabilitation skills was perceived to be contingent on adequate nurse staffing levels and management of demands on nurses' time. Team working practices and use of the built environment indicated separation of nursing and therapy work. Physical care and monitoring were prioritised. Stroke-specific education and training was evident, but not consistent in content or approach. Stroke survivors and families needed help to understand nurses' role in rehabilitation.

CONCLUSION

The review provides compelling evidence that there is an need to re-examine the role of nurses in contributing to poststroke rehabilitation, including clarifying when this process can safely begin and specifying the techniques that can be integrated in nurses' practice.

RELEVANCE TO CLINICAL PRACTICE

Integrating stroke-specific rehabilitation skills in nurses' practice could contribute substantially to improving outcomes for stroke survivors. The explanatory framework developed from the review findings identifies issues which will need to be addressed in order to maximise nurses' contribution to the rehabilitation of stroke survivors.

The impact of concordant communication in outpatient care planning - nurses' perspective

AIM

To elucidate registered nurses' experiences of coordinated care planning in outpatient care.

BACKGROUND

Coordinated care planning has been studied from the perspectives of both patients and nurses in inpatient care, but it is deficient in outpatient care.

METHOD

Qualitative content analysis of interviews with 10 registered nurses participating in two focus groups.

RESULTS

An overall theme was identified: creating concordant communication in relation to patient and health-care providers. The result is based on four categories and nine subcategories.

CONCLUSIONS

Nurses need extraordinary communication skills to reach concordance in outpatient care planning. In addition to involving and supporting the patients and next of kin in the decision-making process, the outcome of the nursing process must be understood by colleagues and members of other professions and health-care providers (non-nursing).

IMPLICATIONS FOR NURSING MANAGEMENT

An effective outpatient care-planning process requires that care managers understand the impact of communicating, transferring information and reaching consensus with other health-care providers, actively supporting employees in the outpatient care-planning process and contributing to the development of common goals and policy documents across organisational boundaries.

The quality of home care nurses' documentation in new electronic patient records

AIMS

The present study explores how community nurses addressed patient care in the EPR and the comprehensiveness of their documentation.

BACKGROUND

The need for comprehensive nursing documentation in home health care is considerable and quality is regarded as a prerequisite for continuity of care. Documentation according to the nursing process is considered to be of good quality due to its logical structure. Nurses in home health care face different challenges than nurses in institutionalised care because of long-term patient situations and a focus on chronic illness rather than acute disease.

DESIGN

Retrospective study.

METHOD

The study was performed on a sample of 91 patient records. Data were analysed in three phases: (1) systematising the unstructured text, (2) structuring the text according to the nursing process and (3) assessing the comprehensiveness using a validated instrument.

RESULTS

The home care nurses documented patient care chronologically along a time axis rather than using a logical structure according to the nursing process. The documentation reflected today's overall emphasis on patient participation, as more than 70% of the notes on nursing status were connected to subjective nursing status. Paradoxically, the nurses showed a lack of attention to the patients' ability to communicate. Only two of 264 documented nursing diagnoses were connected to communication. The comprehensiveness of the documentation, however, was incomplete.

CONCLUSIONS

Home health care nurses are attentive to patient participation but fail to address patients' needs with regard to communication. The documentation is incomplete when assessed according to the steps of the nursing process. A question that arises is whether the nursing process may be a limitation for the quality of the nursing documentation.

RELEVANCE TO CLINICAL PRACTICE

The study contributes to identifying areas of improvement in documentation by nurses in home health care.

The effects of social support and confidence in the health care system on the likelihood of hiring a health advocate

BACKGROUND

In response to the increasing complexity of the health care system, the field of health advocacy has emerged. However, little is known about factors that may influence a person's likelihood of hiring a health advocate.

PURPOSE

This study was designed to examine factors that influence a person's likelihood of hiring a health advocate.

METHODS

The participants were 889 randomly selected community members who were assigned to read one of six vignettes. Social support and confidence in the health care system were manipulated in the vignettes. Social support was either high or low and overall confidence was high, moderate, or low. The dependent variables were participants' likelihood of hiring a health advocate and the hourly rate participants were willing to pay for a health advocate for six different services.

RESULTS

The results indicated that social support did not affect the likelihood of hiring a health advocate; however, confidence in the health care system did affect the likelihood of hiring a health advocate. Participants who read vignettes, in which the patient was described as having lower overall confidence levels, indicated a greater likelihood of hiring a health advocate than participants who read the vignettes in which the patient was described as having high confidence.

CONCLUSIONS

More research is needed to determine other factors that may influence the likelihood of hiring a health advocate and whether hiring a health advocate is a cost-effective way to improve the quality of health care by reducing the number of medical mistakes and improving patient-provider communication.