Nurse Manager's Responsibilities in Creating Supportive Working Conditions Post Implementation of Everyday Coping: A Hermeneutic Research Study of District Nurses' Experiences

Aim

To gain knowledge about how district nurses experience changes in working conditions and discuss nursing manager's responsibility in facilitating working conditions for district nurses following the implementation of everyday coping.

Background

To overcome the challenges related to the sustainability of the healthcare sector, everyday coping was implemented in district nursing. The implementation was set by the government and implemented by the municipality. The nursing manager has an overall responsibility to facilitate working conditions so that everyday coping can be applied into district nursing practice.

Method

This descriptive and interpretative study involved 19 interviews and 19 observations on 10 nurses. Kvale and Brinkmann's three levels of understanding were employed in the analysis.

Results

Three categories were established based on the results of the data analyses: (i) time and space are not considered, (ii) crossfire of conflicting expectations, and (iii) nursing manager's commitment to everyday coping.

Conclusion

The working conditions of district nurses are not adapted for them to work according to the everyday coping mindset. The nursing manager has a key role in supporting nurses and addressing challenges the nurses meet in their daily work, where everyday coping is implemented. The study highlights the importance for healthcare managers, at various levels in the healthcare sector, to be conscious of the district nursing practice, its complexity, and quality of health services when implementing change. This knowledge is important when planning future healthcare and nursing practice.

Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Background

Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.

Objective(s)

To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.

Design

Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.

Setting

English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.

Participants

Managers, residents, families and care home staff.

Findings

Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.

Limitations

Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.

Conclusions

Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes.

Study registration

This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

'Fleeing' as a Strategy for Navigating Resistance in Patient Encounters within Forensic Care

The aim of this study was to describe the phenomenon of "fleeing the encounter when facing resistance" as experienced by carers working in forensic inpatient care. Qualitative analysis, namely reflective lifeworld research, was used to analyze data from open-ended questions with nine carers from a Swedish regional forensic clinic. The data revealed three meaning constituents that describe the phenomenon: shielding oneself from coming to harm or harming the other, finding one's emotional balance or being exposed, and offering the patient emotional space and finding patience. The carers described their approaches in the encounters with the patients as alternating between primitive instincts and expectant empathy in order to gain control and deal with the interaction for their own part, for that of the patient, and for that of their colleagues. The phenomenon of fleeing the encounter when facing resistance was intertwined with carers' self-perception as professional carers. Negative encounters with patients evoked feelings of shame and self-blame. A carer is a key person tasked with shaping the care relationship, which requires an attitude on the part of the carer that recognizes not only the patient's lifeworld but also their own.

Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review

BACKGROUND

Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.

OBJECTIVES

To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.

DESIGN

A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.

SETTING

Long-term residential care facilities PARTICIPANTS: Long-term care facility staff, residents, and relatives METHODS: The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.

RESULTS

66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.

CONCLUSION

Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.

Nurses striving to provide caregiver with excellent support and care at a distance: a qualitative study

Background

In Norway, changes in life expectancy have led to increased attention to older people who are ageing at home, by means of home care services, adapted technology and informal caregivers. The caring situation has become difficult for many caregivers. The use of telecare has now offered them the possibility to receive support at home. The purpose of this study was to explore how nurses provide support and care at a distance, using a web camera and a web forum in a closed telecare network for caregivers to persons suffering from stroke and dementia.

Methods

The study had an explorative design with a qualitative approach. The data sources consisted of interviews with nurses and excerpts from posts in a closed telecare network. Content analysis was used to analyse the text from the interviews and the text from the web forum.

Results

The main theme, “Balancing asymmetric and symmetric relationships” described nurses’ relationship with caregiver. Two categories, “Balancing personal and professional qualities” and “Balancing caregivers’ dependence versus independence” were identified. The first describing the tension in their dialogue, the second describing how nurses provided the caregivers with a sense of security as well as strengthening them to master their daily lives.

Conclusions

The nurses provided long distance support and care for the caregivers, by using computer-meditated communication. This communication was characterized by closeness as well as empathy. To strengthen the caregivers’ competence and independence, the nurses were easy accessible and provided virtual supervision and support. This study increases the knowledge about online dialogues and relationship between nurses and caregivers. It contributes to knowledge about balancing in the relationship, as well as knowledge about bridging the gap between technologies and nursing care as potential conflicting dimensions. Maintenance of ethical principles are therefore critical to be aware of.

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.

How Home Health Caregivers’ Perceive the Influence of Professionalism on Their Experienced Work Engagement

This article explores how the perception of increasing professionalism of home health-care influences caregivers’ experienced work engagement. A qualitative study including 24 interviews, 85 hours of observations and the think-aloud technique was applied in three Danish caregiving organizations. Using a consensual qualitative research approach, analysis of the data suggests that increasing professionalism is experienced among caregivers and influences caregivers’ engagement in three distinct ways: through their identification with their work, psychological safety, and feelings of insecurity. This article contributes by emphasizing an individual perspective of engagement and by providing empirical evidence of links between professionalism and engagement. Additionally, by focusing on relatively low-educated employees, the article highlights how professionalism challenges the perception of caregiving as a job rather than a career. Practically, the findings from the study suggest that caregiving organizations should communicate the reasons for the increasing professionalism so caregivers become aware of potential career options it provides.

Characteristics of the relationship that develops from nurse-caregiver communication during telecare

AIMS AND OBJECTIVES

To explore the relationship between nurses and caregivers using a web camera and web forum as the communication methods.

BACKGROUND

In Norway and other European countries, there is an increased focus on ageing at home, which is aided by technology, as well as formal and informal care. The literature reveals that caregivers endure physical and mental burdens. With computer-mediated communication, such as telecare, it is possible for nurses to provide supportive care to caregivers in their homes.

DESIGN

An explorative design using qualitative content analysis.

METHOD

Six nurses and nine caregivers with residential spouses suffering from stroke or dementia were interviewed two times over a six-month period.

RESULTS

The nurses responded dynamically to the information they received and helped to empower the individual caregivers and to strengthen the interpersonal relationships between the caregivers. While some participants thought that meeting in a virtual room was close and intimate, others wanted to maintain a certain distance. The participants' altered their roles as the masters and receivers of knowledge and experience; this variation was based on a relationship in which mutual respect for one another and an interest in learning from one another allowed them to work together as partners to demonstrate the system and to follow-up with new caregivers.

CONCLUSIONS

The flexibility of the service allows the possibility of engaging in a close, or to some extent, a more distant relationship, depending on the participants' attitudes towards using this type of service.

RELEVANCE TO CLINICAL PRACTICE

Nurses can provide close care, support and information to caregivers who endeavour to master their everyday lives together with their sick spouses. The support seems to help the caregivers cope with their own physical and emotional problems.

Carers’ ambivalence in conflict situations with older persons

The aim of this study was to illuminate the meaning of professional carers’ experiences in caring situations when a conflict of interest arises with the older person receiving care. The findings reveal the complexity of the carers’ ambivalence when facing a conflict of interest, weighing up between the older persons’ right to self-determination and external demands. The carers are alone in their ambivalence, and the conclusion is that they need help and support to be more present in the encounter. The implication for this study is to focus on care as a person-centered practice and to focus on people as interdependent on support carers to maintain older people’s right to self-determination in the relationship.

Forced relocation between nursing homes: residents' health outcomes and potential moderators

That transfer of older people from one institution to another is detrimental to well-being, health and survival has been reported for 50 years. This has led to fear, anger and legal challenges when closures occur. Previous reviews identified accounts of relocation followed by adverse outcomes and others where problems were avoided or benefits claimed. This paper reviews the last twelve years of literature on health outcomes following involuntary relocation between nursing homes. Reports of post-move mortality, physical or psychological health suggest and confirm that relocation without preparation carries higher risk of poor outcomes than moves that are orderly and include preparation. The literature on the care home closure process, admissions and individual transfers offers insights into practices that might help minimize adverse outcomes. A number of agencies have produced helpful guidelines. How these are implemented needs to be monitored and linked to in-depth studies of sample closures.

Health against the odds: experiences of employees in elder care from a gender perspective

Women-dominated elder care in Sweden is a low-paid, low-status job with a high prevalence of sick leave. Our aim was to analyze health experiences of employees in elder care from a gender perspective. All caregiving staff at two establishments providing care to the elderly were invited to participate in the study. A moderator led seven focus group discussions. Qualitative content analysis was used to analyze the transcribed focus groups. We identified two central themes in relation to the employees' health. "Working against the odds" describes gendered workplace stressors of a structural character, to a large extent triggered by societal processes outside the organization. "Making work matter" refers to gendered health resources with a relational character, constructed within the organization. Health-promoting programs directed toward women-dominated workplaces need to include a gender perspective, and focus on creating structural, supportive environments to avoid the negative health effects of the stressors.