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

Delegation of medication administration from registered nurses to non-registered support workers in community care settings: A systematic review with critical interpretive synthesis

INTRODUCTION

Healthcare workforces are currently facing multiple challenges, including aging populations; increasing prevalence of long-term conditions; and shortfall of registered nurses. Employing non-registered support workers is common across many countries to expand service capacity of nursing teams. One task delegated to non-registered support workers is medication administration, which is considered a complex task, with associated risks. This is an important topic given the predicted global increase in patients requiring assistance with medication in community settings. This review explores the evidence on delegation of medication administration from registered nurse to non-registered support workers within community settings, to better understand factors that influence the process of delegation and its impact on service delivery and patient care.

METHODS

The review followed key principles of Critical Interpretative Synthesis and was structured around Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Literature searches were conducted in MEDLINE, CINAHL, Embase, and ProQuest-British Nursing Index databases. Twenty studies were included.

RESULTS

Findings are reported under four themes: 1, Regulatory and contextual factors; 2, Individual and team level factors; 3, Outcomes of delegation; and 4, Process of implementation and evaluation. Delegation was found to be a complex phenomenon, influenced by a myriad of interconnecting factors at the macro, meso, micro level. At the macro level, the consistency and clarity of government and state level regulations was found to facilitate or impede delegation of medication administration. Lack of clarity at the macro level, impacted at meso and micro levels, resulting in confusion around what medication administration could be delegated and who held responsibility. At the micro level, central to the interpretation of success was the relationship between the delegator and delegatee. This relationship was influenced by personal views, educational and systems factors. Many benefits were reported as an outcome of delegation, including service efficiency and improved patient care. The implementation of delegating medication administration was influenced by regulatory factors, communication, stakeholder engagement, and service champions.

CONCLUSION

Delegation of medication administration is a complex process influenced by many interrelating factors. Due to the increased risk associated with medication administration, clear and consistent regulatory and governance frameworks and procedures are crucial. Delegation of medication administration is more acceptable within a framework that adequately supports the process, backed by appropriate policy, skills, training, and supervisory arrangements. There is a need for further research around implementation, clinical outcomes and medication errors associated with delegation of medication administration.

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.

Medication errors in homecare setting: An Italian validation study

OBJECTIVE

Medication errors are a concern in overall the world. Although there are studies that investigate what may be the main causes that lead to the genesis of the medication error in the home care setting, there is no tool that correlates knowledge, attitudes, and behavior to medication errors in the context of home care. This study aimed to psychometrically test to the questionnaire on knowledge, attitudes, and behaviors in the administration of medication in the new setting: home care setting.

DESIGN

This observational study was reported according to the STROBE checklist.

SAMPLE

Sixty two nurses working in home care setting responded to the online survey.

MEASUREMENT

The face and content validity of the items generated was assessed. An Exploratory Factorial Analysis descriptive statistical analysis was conducted. The final questionnaire is composed of 20 items.

RESULTS

The results of the statistical analyses allowed to validate the questionnaire, ensuring good internal consistency and reliability. Most of the sample pointed out that the use of electronic health record, medication reconciliation and the pharmacist's figure are all useful strategies for reducing the risk of medication errors.

CONCLUSION

The questionnaire is reliable to measure knowledge, attitude, and behavior about medication errors prevention in home care settings.

Recommendations to Deliver Person-Centered Long-Term Care for Persons Living With Dementia

Person-centered care (PCC) is the standard for the delivery of long-term services and supports (LTSS). In this article, we summarize the state of the science on meaningful outcomes and workforce development and discuss what is needed to ensure that person-centered LTSS becomes a universal reality. These 2 themes are intimately related: the dementia care workforce’s capacity cannot be improved until care processes and outcomes that are significant to PCC are explicated. The LTSS workforce needs training in PCC as well as pragmatic measures to assess the quality of the care they provide. We conclude with several recommendations for future policy and practice-oriented workforce research.

From village health volunteers to paid care givers: the optimal mix for a multidisciplinary home health care workforce in rural Thailand

BACKGROUND

Thailand is a rapidly aging society, which places high demand on home health care services for the elderly. The shortage of health care workforce in rural areas is a crucial obstacle to the delivery of adequate home health care services. The appropriate skill-mix between multidisciplinary health team and care givers (CGs) is an attractive solution for improving home health care services in rural Thailand. This study assessed the potential of trained CGs to provide home health care services and projected what the optimal mix for a multidisciplinary home health care team in rural Thailand would be in 2030.

METHODS

Eleven pilot districts in Thailand were recruited for the study. Secondary data were collected along with surveys of home health care providers. A total of 130 care managers (nurses) and 351 care givers (CG) were recruited for the survey. Workload, skill-mix potential, and acceptance of care givers were assessed in the surveys. The results from secondary data and the survey were used to project the health workforce requirements in 2030.

RESULTS

It is projected that in 2030 the number of elderly living in rural areas will be 7,156,700 (27% of the projected rural population). Of this, 20.3% will be home-bound, 1.1% will be bed-ridden and 1.6% will need rehabilitation. The main members of the multidisciplinary health workforce involved in home health care were nurses, doctors, and physiotherapists. The home health care services that were provided by the multidisciplinary health workforce included patient assessment, development of a care plan and case conference, home visits, and teaching and supervision of CGs. The CGs were village health volunteers trained to carry out regular home visits to patients. The CGs provided assistance with the activities of daily living, basic health services, moral support to patients and relatives, and surveillance of the home environment during home visits. CGs were well accepted by both the health professionals and the patients. Projections showed that 16,094 nurses, 1,542 doctors, 1,022 physiotherapists and 50,148 CGs will be required in 2030 to meet the needs of the dependent elderly for home health care in rural Thailand.

CONCLUSION

With the increased need for home health care services in the future, appropriate team work between the members of the multidisciplinary health team and the CGs in the community is the appropriate solution for likely shortages of health professional workforce.

Challenges and barriers associated with medication management for home nursing clients in Australia: a qualitative study combining the perspectives of community nurses, community pharmacists and GPs

BACKGROUND

Increasing numbers of older people are receiving home nursing support for medication management to enable them to remain living at home. Home nursing clients frequently experience medication errors and adverse medication events. There has been little study of how medication management processes and interdisciplinary teamwork impact on medication management in the home nursing setting.

OBJECTIVE

To explore medication management processes and describe barriers and challenges from the perspective of community nurses, community pharmacists and GPs involved in the provision of medication management services for home nursing clients.

METHODS

Focus groups, in-depth interviews and stakeholder consultations were conducted with a convenience sample of community nurses, community pharmacists and GPs. Data were analysed using the framework approach (a deductive thematic analysis) to identify issues affecting the delivery of medication management services.

RESULTS

Ten focus groups, 12 in-depth interviews and 5 stakeholder consultation meetings were conducted with 86 health practitioners (55 community nurses, 17 GPs, 10 community pharmacists and 4 nurse managers). Participants highlighted a range of barriers and challenges associated with medication management for home nursing clients, including deficiencies in interdisciplinary communication; problems related to organizational or workplace policies, processes and systems; and ineffective team function. The negative impacts of these were recognized as compromised client safety, reduced workforce efficiency and productivity and compromised interprofessional relationships.

CONCLUSION

Barriers and challenges with medication management for home nursing clients and associated negative impacts were identified. Strategies are needed to improve interdisciplinary medication management and medication safety in the home nursing setting.

Faster clinical response to the onset of adverse events: A wearable metacognitive attention aid for nurse triage of clinical alarms

Objective

This study evaluates the potential for improving patient safety by introducing a metacognitive attention aid that enables clinicians to more easily access and use existing alarm/alert information. It is hypothesized that this introduction will enable clinicians to easily triage alarm/alert events and quickly recognize emergent opportunities to adapt care delivery. The resulting faster response to clinically important alarms/alerts has the potential to prevent adverse events and reduce healthcare costs.

Materials and methods

A randomized within-subjects single-factor clinical experiment was conducted in a high-fidelity 20-bed simulated acute care hospital unit. Sixteen registered nurses, four at a time, cared for five simulated patients each. A two-part highly realistic clinical scenario was used that included representative: tasking; information; and alarms/alerts. The treatment condition introduced an integrated wearable attention aid that leveraged metacognition methods from proven military systems. The primary metric was time for nurses to respond to important alarms/alerts.

Results

Use of the wearable attention aid resulted in a median relative within-subject improvement for individual nurses of 118% (W = 183, p = 0.006). The top quarter of relative improvement was 3,303% faster (mean; 17.76 minutes reduced to 1.33). For all unit sessions, there was an overall 148% median faster response time to important alarms (8.12 minutes reduced to 3.27; U = 2.401, p = 0.016), with 153% median improvement in consistency across nurses (F = 11.670, p = 0.001).

Discussion and conclusion

Existing device-centric alarm/alert notification solutions can require too much time and effort for nurses to access and understand. As a result, nurses may ignore alarms/alerts as they focus on other important work. There has been extensive research on reducing alarm frequency in healthcare. However, alarm safety remains a top problem. Empirical observations reported here highlight the potential of improving patient safety by supporting the meta-work of checking alarms.

Perspectives on the delegation of hygienic care in the context of home nursing: a qualitative study

BACKGROUND

In light of current trends and healthcare evolutions, delegation of patient care from home nurses to health care assistants (HCAs) is increasingly important. Hygienic care is an essential component of nursing education and practice, yet it has rarely been the subject of scientific literature.

AIM

To understand the opinions and experiences of home nurses and policy makers with regard to the meaning of hygienic care and the delegation of these acts in the context of home nursing.

METHODS

A descriptive qualitative study (six focus groups with home nurses and two with policy makers from the Belgian home nursing sector). Content analysis of the data and the use of NVivo 11.0 software.

FINDINGS

Hygienic care is a cyclical care process of continuously investing in a trusting relationship with a patient, assessing their care needs and ability for self-care and taking action and evaluating care as situations change. All of this must be mutally agreed with the patient and should consider their environment and lifestyle. The decision to delegate hygienic care is based on patient assessments and the patient's specific care needs using nursing diagnoses and indicators. Finally, barriers and facilitating factors for both delegating and providing hygienic care were addressed.

CONCLUSION

Hygienic care is a crucial component of nursing care, that can be delegated to HCAs with the necessary supervision.

Measuring quality in community nursing: a mixed-methods study

Background

High-quality nursing care is crucial for patients with complex conditions and comorbidities living at home, but such care is largely invisible to health planners and managers. Nursing care quality in acute settings is typically measured using a range of different quality measures; however, little is known about how service quality is measured in community nursing.

Objective

To establish which quality indicators (QIs) are selected for community nursing; how these are selected and applied; and their usefulness to service users (patients and/or carers), commissioners and provider staff.

Design

A mixed-methods study comprising three phases. (1) A national survey was undertaken of ‘Commissioning for Quality and Innovation’ indicators applied to community nursing care in 2014/15. The data were analysed descriptively using IBM SPSS Statistics 20.0 (IBM Corporation, Armonk, NY, USA). (2) An in-depth case study was conducted in five sites. Qualitative data were collected through observations, interviews, focus groups and documents. A thematic analysis was conducted using QSR NVivo 10 (QSR International, Warrington, UK). The findings from the first two phases were synthesised using a theoretical framework to examine how local and distal contexts affecting care provision impacted on the selection and application of QIs for community nursing. (3) Validity testing the findings and associated draft good practice guidance through a series of stakeholder engagement events held in venues across England.

Setting

The national survey was conducted by telephone and e-mail. Each case study site comprised a Clinical Commissioning Group (CCG) and its associated provider of community nursing services.

Participants

Survey – 145 (68.7%) CCGs across England.

Case study

NHS England national and regional quality leads (n = 5), commissioners (n = 19), provider managers (n = 32), registered community nurses (n = 45); and adult patients (n = 14) receiving care in their own homes and/or carers (n = 7).

Findings

A wide range of indicators was used nationally, with a major focus on organisational processes. Lack of nurse and service user involvement in indicator selection processes had a negative impact on their application and perceived usefulness. Indicator data collection was hampered by problematic information technology (IT) software and connectivity and interorganisational system incompatibility. Front-line staff considered indicators designed for acute settings inappropriate for use in community settings. Indicators did not reflect aspects of care, such as time spent, kindness and respect, that were highly valued by front-line staff and service user participants. Workshop delegates (commissioners, provider managers, front-line staff and service users, n = 242) endorsed the findings and drafted good practice guidance.

Limitations

Ongoing service reorganisation during the study period affected access to participants in some sites. The limited available data precluded an in-depth documentary analysis.

Conclusions

The current QIs for community nursing are of limited use. Indicators will be enhanced by involving service users and front-line staff in identification of suitable measures. Resolution of connectivity and compatibility challenges should assist implementation of new IT packages into practice. Modifications are likely to be required to ensure that indicators developed for acute settings are suitable for community. A mix of qualitative and quantitative methods will better represent community nursing service quality.

Future work

Future research should investigate the appropriate modifications and associated costs of administering QI schemes in integrated care settings.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Development of a clinical pharmacy model within an Australian home nursing service using co-creation and participatory action research: the Visiting Pharmacist (ViP) study

OBJECTIVE

To develop a collaborative, person-centred model of clinical pharmacy support for community nurses and their medication management clients.

DESIGN

Co-creation and participatory action research, based on reflection, data collection, interaction and feedback from participants and other stakeholders.

SETTING

A large, non-profit home nursing service in Melbourne, Australia.

PARTICIPANTS

Older people referred to the home nursing service for medication management, their carers, community nurses, general practitioners (GPs) and pharmacists, a multidisciplinary stakeholder reference group (including consumer representation) and the project team.

DATA COLLECTION AND ANALYSIS

Feedback and reflections from minutes, notes and transcripts from: project team meetings, clinical pharmacists' reflective diaries and interviews, meetings with community nurses, reference group meetings and interviews and focus groups with 27 older people, 18 carers, 53 nurses, 15 GPs and seven community pharmacists.

RESULTS

The model was based on best practice medication management standards and designed to address key medication management issues raised by stakeholders. Pharmacist roles included direct client care and indirect care. Direct care included home visits, medication reconciliation, medication review, medication regimen simplification, preparation of medication lists for clients and nurses, liaison and information sharing with prescribers and pharmacies and patient/carer education. Indirect care included providing medicines information and education for nurses and assisting with review and implementation of organisational medication policies and procedures. The model allowed nurses to refer directly to the pharmacist, enabling timely resolution of medication issues. Direct care was provided to 84 older people over a 15-month implementation period. Ongoing feedback and consultation, in line with participatory action research principles, informed the development and refinement of the model and identification of enablers and challenges.

CONCLUSIONS

A collaborative, person-centred clinical pharmacy model that addressed the needs of clients, carers, nurses and other stakeholders was successfully developed. The model is likely to have applicability to home nursing services nationally and internationally.

Health and safety matters! Associations between organizational practices and personal support workers' life and work stress in Ontario, Canada

Background

The home and community care sector is one of the fastest growing sectors globally and most prominently in mature industrialized countries. Personal support workers (PSWs) are the largest occupational group in the sector. This paper focuses on the emotional health of PSWs working in the home and community care sector in Ontario, Canada. The purpose of this paper is to present evidence on the associations between PSWs’ life and work stress and organizational practices of full-time and guaranteed hours, and PSWs’ perceptions of support at work and preference for hours.

Methods

Data come from our 2015 survey of 1543 PSWs. Dependent variables are life and work stress. Independent variables are: objective organizational practices of full-time and guaranteed hours, and subjective organizational practices of perceived support at work, and preferred hours of work. Descriptive statistics, correlations and ordinary least square regression analyses with collinearity tests are conducted.

Results

Organizational practices of employing PSWs in full-time or guaranteed hours are not associated with their life and work stress. However, those who perceive support from their organizations are also the ones reporting lower life and work stress. In addition, those PSWs perceiving support from their supervisor report lower work stress. PSWs would like to work in their preferred hours, and those who prefer to work more hours report lower life and work stress, and conversely, those who prefer to work less hours report life and work stress.

Conclusion

For PSWs in home and community care, perceived support from their organizations and supervisors, and employment in preferred hours are important factors related to their life and work stress.

A systematic review evaluating the impact of paid home carer training, supervision, and other interventions on the health and well-being of older home care clients

BACKGROUND

Interventions to support and skill paid home carers and managers could potentially improve health and well-being of older home care clients. This is the first systematic review of interventions to improve how home carers and home care agencies deliver care to older people, with regard to clients' health and well-being and paid carers' well-being, job satisfaction, and retention.

METHODS

We reviewed 10/731 papers found in the electronic search (to January 2016) fitting predetermined criteria, assessed quality using a checklist, and synthesized data using quantitative and qualitative techniques.

RESULTS

Ten papers described eight interventions. The six quantitative evaluations used diverse outcomes that precluded meta-analysis. In the only quantitative study (a cluster Randomized Controlled Trial), rated higher quality, setting meaningful goals, carer training, and supervision improved client health-related quality of life. The interventions that improved client outcomes comprised training with additional implementation, such as regular supervision and promoted care focused around clients' needs and goals. In our qualitative synthesis of four studies, intervention elements carers valued were greater flexibility to work to a needs-based rather than a task-based model, learning more about clients, and improved communication with management and other workers.

CONCLUSIONS

There is a dearth of evidence regarding effective strategies to improve how home care is delivered to older clients, particularly those with dementia. More research in this sector including feasibility testing of the first home care intervention trials to include health and life quality outcomes for clients with more severe dementia is now needed.