Prerequisites for sustainable care improvement using the reflective team as a work model

Managers' experiences of ethical problems in municipal elderly care: a qualitative study of written reflections as part of leadership training

Background: Managers in elderly care have a complex ethical responsibility to address the needs and preferences of older persons while balancing the conflicting interests and requirements of relatives' demands and nursing staff's work environment. In addition, managers must consider laws, guidelines, and organizational conditions that can cause ethical problems and dilemmas that need to be resolved. However, few studies have focused on the role of health care managers in the context of how they relate to and deal with ethical conflicts. Therefore, the aim of this study was to describe ethical problems experienced by managers in elderly care. Methods: We used a descriptive, interpretative design to analyze textual data from two examinations in leadership courses for managers in elderly care. A simple random selection of 100 out of 345 written exams was made to obtain a manageable amount of data. The data consisted of approximately 300 pages of single-spaced written text. Thematic analysis was used to evaluate the data. Results: The results show that managers perceive the central ethical conflicts relate to the older persons' autonomy and values versus their needs and the values of the staff. Additionally, ethical dilemmas arise in relation to the relatives' perspective of their loved one's needs and preferences. Legislations, guidelines, and a lack of resources create difficulties when managers perceive these factors as conflicting with the care needs of older persons. Conclusion: Managers in elderly care experience ethical conflicts that arise as unavoidable and perennial values conflicts, poorly substantiated values, and problematic organizational conditions. Structured approaches for identifying, reflecting on, and assessing ethical problems in the organization should therefore be implemented.

Management Practices Promoting Sustained Implementation of the Quality Register Senior Alert for Older Adults in Municipal Care in Sweden

Background:

Senior Alert is a national quality register aimed at supporting a standardized, structured, and systematic preventive care process for adults aged 65 and over in the areas malnutrition, pressure ulcers, falls, problems with oral health and bladder dysfunction. Therefore, the quality register is particularly suitable for older adults with multimorbidity.

Aim:

The aim was to describe management practices that contributed to the sustained implementation of the quality register Senior Alert in municipal elderly care in Sweden.

Methods:

The design of this pilot study was descriptive and inductive. The sample of n = 12 included managers (n = 7) and care staff (n = 5) at seven municipal care homes for older adults in Sweden. The study was performed between April 2014 and June 2014 using two methods: Individual interviews and nonparticipant unstructured observations. Data were analyzed using qualitative content analysis.

Results:

The analysis led to the following generic categories: leading teamwork, leading a preventive care process and leading a supportive organizational structure, and to one main category: management promoting learning and quality improvement.

Conclusion:

To be sustainable, Senior Alert implementations in municipal elderly care need management. Management, by leading teamwork, a preventive care process and a supportive organizational structure, is essential for achieving learning and quality improvement.

Understanding the impact of eating disorders: using the reflecting team as a learning strategy for students

This article outlines how the application of a reflecting team from systemic family therapy practice was used as a learning strategy for a postgraduate programme for healthcare students. The programme was designed to increase the students' skills, knowledge and awareness of the needs of people with eating disorders, and their families. There were some benefits to this learning strategy. Students reported that the use of a reflecting team enabled them to gain a deep understanding of the emotional impact of eating disorders on individuals and their carers. However, as this method of learning was new to the students, they needed some initial instruction on the approach. During the programme of study, it became evident that the health professionals were deeply affected by the experiences of people with eating disorders. This would suggest that possibly it was the presence of the sufferers themselves as part of the reflecting team that provided the pivotal learning opportunity, rather than the reflecting team per se.

Self-organizing Development Teams for Innovative Nursing Care

The purpose of this study was to describe the participation of nurses and nurse leaders in self-organizing teams formed to develop innovative nursing care. The theoretical perspective combines Bondas' caritative theory on nursing leadership with Waterman's and Dolan's work on ad hoc organizations. Seven self-organizing teams participated in a 2-year action research project. Data were collected through fieldwork, formal and informal individual and group interviews, and diaries. Analytical abstraction methodology described by Miles et al was used. The metaphor "overcoming the jet lag of bureaucracy" is based on 5 themes: struggling to design the new team; investing time and self; needing research and leadership support; evolving collegial collaboration, professional growth, and pride; and growing professional security and the will to continue education as a result of learning.

Reducing Blood Testing in Pediatric Patients after Heart Surgery: Proving Sustainability

Introduction

Frequent blood testing increases risk of iatrogenic anemia, infection, and blood transfusion. This study describes 3 years of sustained blood testing reduction from a quality improvement (QI) initiative which began in 2011.

Methods

The cohort consisted of postop children whose surgery had a Risk Adjustment for Congenital Heart Surgery (RACHS) classification consecutively admitted to a tertiary Cardiac Intensive Care Unit. Data were collected for a 2010 preintervention, 2011 intervention, and 2012-13 postintervention periods, tabulating common laboratory studies per patient (labs/pt) and adjusted for length of stay (labs/pt/d). The QI initiative eliminated standing laboratory orders and changed to testing based on individualized patient condition. Adverse outcomes data were collected including reintubation, central line-associated bloodstream infections and hospital mortality. Safety was measured by the number of abnormal laboratory studies, electrolyte replacements, code blue events, and arrhythmias.

Results

A total of 1169 patients were enrolled (303 preintervention, 315 intervention, and 551 postintervention periods). The number of labs/pt after the QI intervention was sustained (38 vs. 23 vs. 23) and labs/pt/d (15 vs. 11 vs. 10). The postintervention group had greater surgical complexity (P = 0.002), were significantly younger (P = 0.002) and smaller (P = 0.008). Children with RACHS 3-4 classification in the postintervention phase had significant increased risk of reintubation and arrhythmias.

Conclusions

After the implementation of a QI initiative, blood testing was reduced and sustained in young, complex children after heart surgery. This may or may not have contributed to greater reintubation and arrhythmias among patients with RACHS 3-4 category procedures.

Nurses' competencies in home healthcare: an interview study

Background

Nurses working in Home healthcare (HHC) are facing major challenges since more advanced care and treatment are increasingly being carried out in patients’ homes. The aim of this study has been to explore how nurses experience their competencies in HHC situations.

Methods

This study has a qualitative and explorative design. Ten nurses were interviewed and data was analyzed using content analysis.

Results

The themes “Being a capable nurse”, “Being a useful nurse” and “Being a subordinate and dependent nurse” were identified. Nurses want to be capable of taking care of patients, to develop their competencies and to perform their duties in the way required. They also want their work to be useful and to provide good and safe HHC. Finally, nurses want to improve HHC care by applying their competencies. Simultaneously, they are subordinate and dependent in relation to their manager and also dependent upon their manager’s interest in encouraging nurses’ competence development.

Conclusions

Nurses in HHC are responsible for many seriously ill patients and they want to contribute to good and safe patient care. To maintain patient safety, reduce the risk for burnout and staff turnover as well as to contribute to a sustainable development of the work, strategies for transferring competencies between nurses and efforts for competence development are needed.