Using Failure Mode and Effects Analysis to Decrease Risk When Developing a Home Health Nurse Residency Program

BACKGROUND

New graduate nurses are traditionally not recruited for home health care (HHC).

LOCAL PROBLEM

Due to staffing shortages, a HHC agency was interested in hiring graduate nurses, but there was concern about associated risks.

METHODS

The purpose of this quality improvement project was to develop a nurse residency program to safely transition graduate nurses to the HHC setting. After initial program design, analysis using a failure mode effects analysis (FMEA) was conducted, and risk mitigation strategies were applied.

RESULTS

The overall risk of onboarding graduate nurses in HHC was reduced by 42% after applying harm reduction tactics identified from the FMEA.

CONCLUSION

The FMEA was found to be a useful tool to prospectively identify areas of concern and apply harm reduction tactics prior to nurse residency implementation.

Home health nurses for children with invasive mechanical ventilation (IMV): Perspectives on gaps and opportunities for recruitment

BACKGROUND

Children with medical complexity (CMC) dependent on invasive mechanical ventilation (IMV) often require private duty home nursing; however, there are ubiquitous shortages. Home health is an especially vulnerable nursing sector because of less competitive wages and less prominence during nursing education. We sought to understand nurses' perspectives on gaps and opportunities for recruiting home care nurses for children with IMV.

METHODS

Home health nurses experienced with children with IMV were recruited for semi-structured interviews. The interview guide served as the initial codebook which was iteratively modified as themes emerged. This study presents an analysis of quotes related to field entry and home health experiences.

FINDINGS

Twenty interviews were completed with primarily female (95%) participants. The majority worked full-time (60%) and had an average of 11 years of experience. During nursing education, participants described a lack of exposure to private duty home health nursing. Many entered the field serendipitously, because of a passion for care of CMC or to continue care for a hospitalized patient. Challenges to employment included lack of competitive wages and benefits. Nurses remained in the field because of the rewarding work with patients and families, schedule flexibility, slower pace, and one-on-one care.

DISCUSSION

Home health nurses for IMV describe lack of employment benefits. However, the opportunity to work longitudinally and individually with patients was rewarding.

APPLICATION TO PRACTICE

Creative solutions must be explored to recruit and sustain this essential workforce, including exposure during nursing education, improved training and benefits, and targeted recruiting.

Adaption of the Casey-Fink Survey Tool for Nurse Residency Programs: Making It Relevant for Hospice and Palliative Care Nurse Residency Programs

OBJECTIVE

This evaluation project focused on assessing the content validity of an adapted version of the Casey-Fink (CF) Graduate Nurse Experience Survey, which is aimed at measuring role transitions in nursing.

BACKGROUND

Registered nurses in the hospice and palliative care field need training and confidence to be proficient in core skills including communication, interprofessional competence, and clinical skills required to care for the dying patient. However, a review of the literature revealed a gap in the availability of survey instruments to measure the confidence of nurses entering the field of hospice and palliative care.

METHODS

Ten items from the CF survey were revised by the project team and then evaluated for relevance by a group of 7 national hospice and palliative experts. The content validity index (CVI) was used to determine item relevance.

RESULTS

Item-level CVI (I-CVI) calculations ranged from 0.57 to 1.0. The 8 items scored between 0.80 and 1.0 were retained as written. One item required further revision (I-CVI, 0.71), and 1 item revision was eliminated (I-CVI, 0.57). Experts also suggested 5 additional items in the original CF-survey need modification.

CONCLUSION

The adapted CF-survey tool is ready for further psychometric testing, and next steps include administration to a new sample of nurse residents to determine construct validity.

Home Care: Promoting Knowledge and Creating Impact among Nursing Students

Purpose: To determine the impact of an educational intervention on student nurse knowledge of and interest in home care careers.Methods: A quasi-experimental pre-test/post-test design was used among nursing students (N= 108) completing an online module and simulation.Analysis: T-tests measured knowledge changes and descriptive statistics measured home care career interest.Findings: Knowledge increased significantly (p=.000) while preferred work setting rankings remained stable with a minimal but potentially impactful increase in home care interest.Conclusion: More education and research is warranted given home care workforce shortages and the need to imbed home care education into nursing curricula.

Effectiveness of home health care in reducing return to hospital: Evidence from a multi-hospital study in the US

BACKGROUND

Home health care, a commonly used bridge strategy for transitioning from hospital to home-based care, is expected to contribute to readmission avoidance efforts. However, in studies using disease-specific samples, evidence about the effectiveness of home health care in reducing readmissions is mixed.

OBJECTIVE

To examine the effectiveness of home health care in reducing return to hospital across a diverse sample of patients discharged home following acute care hospitalization.

RESEARCH DESIGN

Secondary analysis of a multi-site dataset from a study of discharge readiness assessment and post-discharge return to hospital, comparing matched samples of patients referred and not referred for home health care at the time of hospital discharge.

SETTING

Acute care, Magnet-designated hospitals in the United States PARTICIPANTS: The available sample (n = 18,555) included hospitalized patients discharged from medical-surgical units who were referred (n = 3,579) and not referred (n = 14,976) to home health care. The matched sample included 2767 pairs of home health care and non- home health care patients matched on patient and hospitalization characteristics using exact and Mahalanobis distance matching.

METHODS

Unadjusted t-tests and adjusted multinomial logit regression analyses to compare the occurrence of readmissions and Emergency Department/Observation visits within 30 and 60-days post-discharge.

RESULTS

No statistically significant differences in readmissions or Emergency Department /Observation visits between home health care and non-home health care patients were observed.

CONCLUSIONS

Home health care referral was not associated with lower rates of return to hospital within 30 and 60 days in this US sample matched on patient and clinical condition characteristics. This result raises the question of why home health care services did not produce evidence of lower post-discharge return to hospital rates. Focused attention by home health care programs on strategies to reduce readmissions is needed.

The Journey of a Home Care Nurse Residency Program

UnityPoint at Home launched a Nurse Residency Program to attract newly licensed registered nurses to begin their career in home healthcare. The program broadened recruitment options by providing new graduates with a dedicated program to ease transition into the workforce, and allowed us to cultivate relationships with regional nursing education programs. Since its inception 3 years ago, the residency program has expanded to several organizational regions and added a hospice track. The 1-year retention rate is 93%, and for those who entered the program 2 or more years ago, the retention rate is 89%. The purpose of this article is to describe the journey of UnityPoint at Home's Nurse Residency Program, from development of the pilot to integration in several organizational regions.

VA Home Based Primary Care Teams: Partnering with and Acting as Caregivers for Veterans

The U.S. Department of Veterans Affairs' Home-Based Primary Care (HBPC) Interdisciplinary Team (IDT) provides in-home, primary care for medically complex Veterans. This study explores how HBPC and Veterans' caregivers partner to provide care. Interviews, focus groups, and field observations were conducted during eight HBPC site visits. Qualitative thematic analysis was performed. Caregivers/IDT member partnerships are important to care. Effective partnerships include: ease of communication; caregiver-centered support; and when no caregiver is present, IDTs providing more monitoring/services to Veterans and connection to community services. As this model expands, understanding dynamics between IDT members and caregivers will optimize the success of HBPC programs.

Home Health Staff Perspectives on Infection Prevention and Control: Implications for Coronavirus Disease 2019

Objectives

The role of home healthcare (HHC) services in providing care to vulnerable, often frail individuals with chronic conditions is critical. Effective infection prevention and control (IPC) in HHC is essential to keeping both healthcare workers and patients safe, especially in the event of an emerging infectious disease outbreak. Prior to the coronavirus disease 2019 pandemic, we explored successes and challenges with IPC from the perspectives of HHC staff.

Design

Qualitative descriptive study.

Setting and Participants

From May to November 2018, we conducted in-depth telephone interviews with 41 staff from 13 agencies across the nation.

Methods

Transcripts were coded by a multidisciplinary coding team, and several primary and subcategories were identified using directed content analysis.

Results

Four primary categories were generated including (1) uniqueness of HHC; (2) IPC as a priority; (3) importance of education; and (4) keys to success and innovation. Participants perceived that IPC plays a big part in patient safety and reducing rehospitalizations, and protection of patients and staff was a major motivator for compliance with IPC. The identified challenges included the unpredictability of the home environment, patient/family dynamics, the intermittent nature of HHC, and staffing issues. Education was seen as a tool to improve staff, patient, caregiver and families' compliance with IPC. Keys to success and innovation included a leadership focus on quality, using agency infection data to improve quality, and a coordinated approach to patient care.

Conclusions and Implications

This qualitative work identified barriers to effective IPC in HHC, as well as important facilitators that HHC agencies can use to implement policies and procedures to improve patient care and keep staff safe. Leadership prioritization of IPC is key to implementing appropriate IPC policies and may be especially important in midst of a crisis such as coronavirus disease 2019.

Bridging the Gap: A Hospice Nurse Residency Program

There are few formal training opportunities that exist for RNs interested in the rapidly growing field of hospice and palliative care. To address this, the curriculum for a nurse residency program was developed and delivered to 12 nurses over 1 year. The nurse residents, as well as their clinical supervisors and interprofessional colleagues, were surveyed to obtain feedback on the overall program. Skill acquisition of the nurses was also assessed. The results indicate that the nurse residents had increased levels of confidence in caring for dying patients, communication with other clinicians, and delegation and management of treatment teams and families. According to supervisors and colleagues, strengths of the program included support for new nurses, integration of the interprofessional team, and solid preparation for new hospice nurses. These findings provide nursing educators and administrators with needed insight into the development and evaluation of an RN residency program in hospice and palliative care. [J Contin Educ Nurs. 2020;51(8):371-376.].

Nurses' activities and time management during home healthcare visits

AIM

To describe nurses' activities and time management during HHC visits from the perspective of master's-level nursing students.

BACKGROUND

The shift from community-based hospitals to home-based, person-centred services for patients with a variety of acute or chronic health problems challenges nurses' professional competence and time management during home healthcare visits.

DESIGN AND METHODS

A cross-sectional study in accordance with STROBE guidelines. Observation sheets (n = 196) from two municipal home healthcare organisations were analysed with descriptive quantitative analysis.

ETHICAL ISSUES AND APPROVAL

While no external ethical committee evaluation was necessary for this quality improvement study, research ethical principles were followed.

RESULTS

The nurses spent 50% of each eight-hour shift on indirect patient contact activities and about 38% on direct patient contact activities. The majority of activities underlying the home visits could be linked to long-term illnesses: medication (57%), blood samples (23%), wound care (17%) or measurement of blood pressure (14%). Patient education was offered during only 3.5% of visits.

LIMITATIONS

The accuracy of the students' observations is related to their individual capacity to objectively and selectively observe.

CONCLUSIONS

There were a number of activities conducted for the patient, to promote continuous intra- and interprofessional patient care, but fewer nursing activities conducted with the patient. To ensure integrated, person-centred, safe patient care, vital reforms are needed.

RELEVANCE TO CLINICAL PRACTICE

The appropriate balance between indirect and direct patient contact activities should be discussed intra- and interprofessionally, delineated and made explicit in nurses' work plans and nursing documentation, alongside discussions pertaining to relevant resource allocation.

Working in home healthcare and suggestions for development

In order to describe nurses' experiences of working in home health care and their suggestions for the development of this public health-care sector, interviews with 18 home health-care nurses were analyzed with qualitative thematic content analysis. The nurses perceived the working shifts either affirmative or non-affirmative, depending on the contextual and organizational factors affecting nurses' workload. The more the nurses perceived they could influence their work, the more engaged they were in patient-related nursing activities, patient-centeredness, collaboration, and forward planning. Several concrete suggestions for the development of home healthcare on the organizational, interprofessional, team and individual levels were given.

The Future of Home Health Care: A Strategic Framework for Optimizing Value

The Future of Home Health project sought to support transformation of home health and home-based care to meet the needs of patients in the evolving U.S. health care system. Interviews with key thought leaders and stakeholders resulted in key themes about the future of home health care. By synthesizing this qualitative research, a literature review, case studies, and the themes from a 2014 Institute of Medicine and National Research Council workshop on "The Future of Home Health Care," the authors articulate a vision for home-based care and recommend a bold framework for the Medicare-certified home health agency of the future. The authors also identify challenges and recommendations for achievement of this framework.