Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed method study

'We just have to make it work': a qualitative study on assistant nurses' experiences of patient safety performance in home care services using forum play scenarios

OBJECTIVE

Safety is essential to support independent living among the rising number of people with long-term healthcare and social care needs. Safety performance in home care leans heavily on the capacity of unlicensed staff to respond to problems and changes in the older patients' functioning and health. The aim of this study is to explore assistant nurses' adaptive responses to everyday work to ensure safe care in the home care context.

DESIGN

A qualitative approach using the drama-based learning and reflection technique forum play with subsequent group interviews. The audio-recorded interviews were transcribed and analysed with thematic analysis.

SETTING

Home care services organisations providing care to older people in their private homes in two municipalities in southern Sweden.

PARTICIPANTS

Purposeful sampling of 24 assistant nurses and three managers from municipal home care services and a local geriatric hospital clinic.

RESULTS

Home care workers' adaptive responses to provide safe home care were driven by an ambition to 'make it work in the best interests of the person' by adjusting to and accommodating care recipient needs and making autonomous decisions that expanded the room for manoeuvrability, while weighing risks of a trade-off between care standards and the benefits for the community-dwelling older people's independent living. Adaptations to ensure information transfer and knowledge acquisition across disciplines and borders required reciprocity.

CONCLUSIONS

Safety performance in home care service is dependent on the staff closest to the older people, who deal with safety risks and ethical dilemmas on a day-to-day basis and their access to information, competence, and resources that fit the demands. A proactive leadership characterised by mutual trust and adequate support for decision making is suggested. Managers and decision-makers across healthcare and social care need to consider how they can develop interprofessional collaborations and adaptive routines supporting safety from a broader perspective.

Perceptions of providing safe care for frail older people at home: A qualitative study based on focus group interviews with home care staff

BACKGROUND

Providing safe care is a core competence in healthcare. The concept usually refers to hospitals but, consistent with the increasing importance of integrated care, the provision of safe care needs to be extended to the context of home care, and more research is needed concerning home healthcare providers' perspectives in this context.

AIM

The aim of this study was to describe care providers' perceptions of providing safe care for frail older persons living at home.

METHOD

A qualitative methodology was chosen. In total, 30 care providers agreed to participate. Data were collected through five focus group interviews and analysed using a phenomenographic approach.

RESULTS

Three themes regarding care providers' perceptions of providing safe care emerged from the data: 'safe care is created in the encounter and interaction with the older person', 'safe care requires responsibility from the caregiver' and 'safe care is threatened by insufficient organisational resources'. The findings show that providing safe care is an endeavour that requires a holistic view among the care providers as well as effective collaboration within the team, but insufficient competence or a lack of time can make it difficult to safeguard the psychological and existential needs of older persons.

CONCLUSION

Providing safe care in home environments encompasses more than just risk reduction. The findings highlight the importance of establishing and integrating team-based and person-centred care into home care settings. Traditional communication structures for inpatient care also need to be adapted to the cross-disciplinary work in municipalities. Care providers should be given the opportunity to develop and maintain their competences and to prioritise relationship-oriented care.

What constitutes feeling safe at home? A qualitative interview study with frail older people receiving home care

Aim

To highlight experiences of what constitutes feeling safe at home among frail older people receiving home care.

Design

Qualitative descriptive study.

Methods

The sample consists of 12 individual recorded interviews with frail older people in their homes. Interviews were transcribed verbatim and analysed using qualitative content analysis. The data collection was performed in spring 2018.

Results

The analysis resulted in three categories: "Having a feeling of 'at-homeness'" describes the older people's surrounding environment and their efforts to maintain independence; "being able to influence" describes the importance for older people to shape their care by being in control and having an opportunity for self-determination in the context of home care; and "being able to trust staff" relates to expecting staff's knowledge and skills and to appreciating the staff's ability to create positive relations.

Exploring patient safety in Swedish specialised home healthcare: an interview study with multidisciplinary teams and clinical managers

OBJECTIVE

Home healthcare is the fastest growing arena in the healthcare system but patient safety research in this context is limited. The aim was to explore how patient safety in Swedish specialised home healthcare is described and adressed from multidisciplinary teams' and clinical managers' perspectives.

DESIGN

An explorative qualitative study.

SETTING

Multidisciplinary teams and clinical managers were recruited from three specialised home healthcare organisations in Sweden.

METHODS

Nine focus group interviews with multidisciplinary teams and six individual interviews with clinical managers were conducted, in total 51 participants. The data were transcribed verbatim and analysed using qualitative content analysis.

RESULTS

Patient safety was inherent in the well-established care ideology which shaped a common mindset between members in the multidisciplinary teams and clinical managers. This patient safety culture was challenged by the emerging complexity in which priority had to be given to standardised guidelines, quality assessments and management of information in maladapted communication systems and demands for required competence and skills. The multiple guidelines and quality assessments that aimed to promote patient safety from a macro-perspective, constrained the freedom, on a meso-level and micro-level, to adapt to challenges based on the care ideology.

CONCLUSION

Patient safety in home healthcare is dependent on adaptability at the management level; the team members' ability to adapt to the varying conditions and on patients being capable of adjusting their homes and behaviours to reduce safety risks. A strong culture related to a patient's value as a person where patients' and families' active participation and preferences guide the decisions, could be both a facilitator and a barrier to patient safety, depending on which value is given highest priority.

[Patient safety in home care : A review of international recommendations]

BACKGROUND

In recent years there has been a growing trend towards nursing care at home in general as well as towards intensive home care being provided by specialized home care services in Germany. However, resulting challenges for patient safety have rarely been considered. Against this background we aimed to explore whether international recommendations for patient safety in home care in general and in intensive home care in particular already exist and how they can stimulate further practice development in Germany.

METHODS

A review of online English documents containing recommendations for patient safety in intensive home care was conducted. Available documents were analyzed and compared in terms of their form and content.

RESULTS

Overall, a small number of relevant documents could be identified. None of these documents exclusively refer to the intensive home care sector. Despite their differences, however, the analysis of four selected documents showed similarities, e. g., regarding specific topics of patient safety (communication, involvement of patients and their relatives, risk assessment, medication management, qualification). Furthermore, strengths and weaknesses of the documents became apparent: e. g., an explicit understanding of patient safety, a literature-based introduction to safety topics or an adaptation of the recommendations to the specific features of home care were occasionally lacking.

CONCLUSIONS

This document analysis provides interesting input to the formal and content-related development of specific recommendations and to practice development in Germany to improve patient safety in home care.