Exploring care for older people : district nurses’ experiences and clinical practice

Background and aim: The health care system needs to prepare in order to provide highquality care to a growing older population. In Sweden, much primary health care for older people is the responsibility of district nurses (DNs), but research into DNs’ clinical care has not been extensive. The general aim of this thesis was therefore to explore the clinical care DNs provide to older people and DNs’ experiences of this care, focusing on preventive home visits (PHVs), medication management, and leg ulcer care. Material and methods: The thesis includes five studies. Study I used qualitative content analysis to analyze data from group interviews with 20 DNs about their experiences of PHVs. In Study II, DNs used the Safe Medication Assessment (SMA) tool in PHVs with 113 people to identify factors related to unsafe medication management and to describe interventions used to improve the safety of medication management. Study III employed data from the Swedish Prescribed Drug Register on 671,940 community-dwelling older people to examine the extent and quality oftheir drug use. In Study IV, the electronic records of 97 patients before and 96 after the intervention were used to evaluate DNs' leg ulcer management. In Study V, grounded theory method was used to collect and analyze data from group interviews with 30 DNs about providing leg ulcer care in accordance with guidelines. Results: Study I found facilitators of and barriers to a successful health dialogue in the PHV. Three main themes illustrated professional dilemmas in the health dialogue that the DNs had to resolve to achieve the purpose of the PHV. In Study II, DNs found several factors related to unsafe medication management when they used the SMA during PHVs. DNs intervened to improve medication management in more than two-thirds of the visits. Study III found that the prevalence of most drug groups and ofinappropriate drug use increased with age. Polypharmacy and use of potentially inappropriate medications were already prevalent in 75- year-olds. Study IV found that nurses' documentation ofleg ulcer management was sparse and far from consistent with clinical guidelines. Study V resulted in a theoretical model that illustrates how DNs balance compensating, motivating, and compromising strategies to follow clinical guidelines as far as possible and provide leg ulcer care that is good enough. Conclusions: DNs experience facilitators ofand barriers to health dialogues during PHVs and must balance a personal and a professional approach, a task-oriented and person-oriented approach, and a salutogenic and a pathogenic approach. The proportion of people who use drugs in most drug groups and who take inappropriate drugs increases with age. Using the SMA tool in PHVs may help improve the safety of medication management in older people and may be appropriate at age 75 and age 80. DNs cannot always follow guidelines but try to adhere to a treatment plan that is acceptable to patient and that hopefully can lead to a healed leg ulcer

A comparative effectiveness secondary data analysis: Selected short term economic and clinical outcomes of rapid surgical intervention in the geriatric fracture population

The percentage of the U.S. population that is over 65 years of age is expected increase to over 20% by 2040. Within that geriatric population, 50% of women and 20% of men will experience osteoporotic fractures. The cost of their care is estimated in billions of dollars annually. The outcomes from osteoporotic fractures account for more morbidity than all cancers, except lung cancer, combined. Rapid surgical intervention protocols, which reduce the time between fracture and surgical repair, are intended to improve outcomes and reduce costs. The protocols require intense care coordination and their effectiveness has not been unequivocally established. This study explored the relationships of rapid surgical intervention to the clinical outcomes of in-hospital delirium and pressure ulcer and the economic outcomes of post-procedure length of stay and total hospital charges. These outcomes were investigated through a secondary data analysis of the New York State administrative billing database (SPARCS) from a five-hospital system. The sample included 1,979 subjects from the years of 2010 through 2013; a modified Charlson Co-morbidity and Age Index score was applied to all subjects in order to approximate their admission health status. Rapid Surgical Intervention was a predictor (p \u3c .001) of lower post-procedure lengths of stay lower total hospital charges, and lower rates of pressure ulcer development. High Modified Charlson Index scores were predictive of higher mortality rates, longer lengths of stay, and higher total charges. Male gender was significant for higher lengths of stay, mortality rates, and pressure ulcer development. Femur/hip fractures were related to longer lengths of stay and higher total charges than other fracture sites, but were not a predictor of mortality or pressure ulcer development

Development of continuing education to support evidence based nursing care of patients with venous leg ulcers

Venous leg ulcers (VLUs) have extensive impact for patients and cause economic costs to healthcare, and the prevalence of VLUs is increasing as the population ages. Nursing care of a patient with VLU is complex requiring comprehensive knowledge of the patient’s unique situation. VLU can persist over a long time and patients report difficulties in living with VLU. The aim of this two-phase study (2012 - 2014) was to develop an internet-based continuing education (CE) to support evidence-based practice (EBP) in VLU nursing care in home health care (HHC) and to evaluate its' effectiveness. In Phase I integrative literature review was used to collect data about nurses’ knowledge of VLU nursing care. In Phases IIa and b knowledge tests, and nurses’ CE were firstly reviewed. In Phase IIa instruments to evaluate the effectiveness of CE were developed. In Phase IIb an internet-based learning program of evidence-based VLU nursing care (eVLU) was developed and in Phase IIc it was implemented in a quasiexperimental design. Cognitive, clinical and economic outcomes were evaluated three times during the study. Gaps in VLU nursing care were identified in nurses’ knowledge and skills in VLU pathophysiology and etiology, assessment, healing process, infection, topical care and compression treatment. eVLU had a positive effect on nurses’ cognitive outcomes. Nurses’ perceived and theoretical knowledge increased as did congruence between them. The effect on clinical and economic outcomes could not be statistically evaluated due to low number of participants. The results of this study suggest that eVLU has potential in improving EBP in VLU nursing care. Further studies are needed to determine whether the effects can be produced in diverse nursing care environments. In addition, the clinical and economic outcomes need to be studied further. The maintenance of EBP in VLU nursing care requires continuous effort from nurses and nursing managers. This includes awareness of existing gaps in knowledge and skills. Utilizing eVLU can be one option for them to ensure EBP in VLU nursing care.Terveysongelmana laskimohaava – Näyttöön perustuvan hoitotyön kehittäminen täydennyskoulutuksen avulla Laskimohaava aiheuttaa monenlaisia ongelmia potilaalle ja merkittäviä kustannuksia terveydenhuollolle. Se on yleensä pitkäaikainen terveysongelma, joka aiheuttaa potilaalle sosiaalisen elämän ongelmia ja elämänlaadun heikkenemistä. Tämän kaksivaiheisen tutkimuksen (2012–2014) tavoitteena oli kehittää internet-perustainen täydennyskoulutus (eVLU), jonka avulla voidaan tukea näyttöön perustuvaa toimintaa (NPT) laskimohaavan hoidossa kotihoidossa. Lisäksi tavoitteena oli arvioida koulutuksen vaikuttavuutta. Tutkimuksen ensimmäisessä vaiheessa kartoitettiin kirjallisuuskatsauksen avulla hoitajien tietoja laskimohaavan hoidosta. Toisessa vaiheessa kirjallisuuskatsauksen avulla selvitettiin hoitajien tietotestejä ja täydennyskoulutuksia. Saadun tiedon avulla kehitettiin internetperustainen täydennyskoulutusohjelma laskimohaavan hoidosta (eVLU), jonka vaikuttavuutta testattiin kvasikokeellisessa asetelmassa tutkimuksen viimeisessä vaiheessa. eVLU:n kognitiivisia, kliinisiä ja taloudellisia vaikutuksia arvioitiin kolme kertaa tutkimuksen aikana. Kirjallisuuskatsauksen perusteella hoitajilla on puutteita sekä laskimohaavaan liittyvissä tiedoissa että taidoissa. Nämä liittyivät laskimohaavan patofysiologiaan ja etiologiaan, arviointiin, paranemisprosessiin, infektioon, paikallishoitoon ja kompressiohoitoon. eVLU paransi hoitajien kognitiivisia tuloksia. Heidän itsearvioitu ja todellinen tietonsa lisääntyivät, samoin niiden välinen yhdenmukaisuus. Vaikutuksia kliinisiin ja taloudellisiin tuloksiin ei pystytty arvioimaan tilastollisesti vähäisen osallistujamäärän takia. Tulosten perusteella eVLU on potentiaalinen vaihtoehto kehitettäessä laskimohaavan NPT:aa. Jatkotutkimuksissa tulisi arvioida sen vaikutuksia erilaisissa hoitoympäristöissä. Lisäksi tulisi arvioida kliinisiä ja taloudellisia vaikutuksia. NPT:n ylläpitäminen vaatii sekä hoitajilta että hoitotyön johtajilta jatkuvaa panostusta. Tähän sisältyy tietoisuus olemassa olevista tiedon ja taidon puutteista. eVLU on yksi hyödynnettävä vaihtoehto NPT:n tukemisessa

Improving Wound Care using the TIME Framework

Abstract Background and purpose:Although wound care guidelines are available for primary care providers, barriers to assessment and treatment remain. This paper examines current evidence, guidelines, and discusses the need for improved training, education, and a simplified approach to wound management in primary care. The goal of the project was to increase the provider’s comfort level in assessing and initiating wound care treatment in the clinical setting. Methods:An evidence-based wound treatment framework, identified as the TIME (tissue, infection, moisture, epithelial) framework, was selected for the project. The framework was tailored by subject matter experts to provide a distinctive approach to the non-wound care expert allowing more diverse utilizations across the primary care spectrum. The modified TIME framework was shared with 29 providers over three educational sessions. Participants included Nurse Practitioners and Physicians. The knowledge attained and the usability of the framework was evaluated using a case study approach and self-reported comfort level relating to the assessment and initiation of wound treatment. Conclusion:After the educational sessions, the comfort level of all providers increased dramatically from pre- to post-assessment.Comfort level was self-reported on a 5-point Likert scale (1 = poor, 3 = average, 5 = excellent). Responses indicated that 42% of participants reported below average or poor comfort at the pretest, while 96% of participants reported average or above average comfort at the posttest. Comfort level related to knowledge gained in developing a treatment plan also increased: At pretest, 77% of participants reported below average comfort, while 96% of participants reported average or above average comfort at the posttest. Results also indicated a significant increase in wound care knowledge and understanding of wound care concepts related to the modified TIME framework, including identifying specific wounds and initiating treatment

Wound Care

Wounds and the many associated problems have challenged health care providers for centuries and today, despite the wealth of knowledge available, neither the incidence nor prevalence of wounds is reducing. Furthermore, in view of our changing demographic profile and the projected increase in the older population it is likely that wound management will become an ever increasing burden to the individual, health care services and society as a whole. The annual incidence of wounds in the EU-27 is approximately 4 million, and between 25% and 50% of acute hospital beds are occupied by patients with a wound, with up to 60% of these representing non-healing wounds (infected surgical wounds, pressure ulcers, leg/foot ulcers) The increasing prevalence and incidence of non-wounds healing is closely linked with quality of care and, as such, these rising figures reduce society’s confidence in the health service’s ability to deliver care that is timely, appropriate and effective. Thus, for those involved in this specialist area of clinical practice, the fundamental goal is to improve clinical outcomes, reduce the burden of wounds and improve health related quality of life. In this Special Issue “Wound Care” in Healthcare, we invited submission of manuscripts exploring contemporary issues in wound care. By devoting a special issue to wound care, we endeavoured to provide readers with a comprehensive reference source, outlining key areas of interest in this important aspect of clinical practice. The response to the call for manuscripts was fantastic and, as a result, we were able to include both original qualitative and quantitative research papers in addition to review papers, thereby providing readers with a wealth of valuable information pertinent to wound care

Predictors of Re-Hospitalization for Home Healthcare Patients

The overall purpose of this study was to examine the predictive capability of OASIS admission data for acute care re-hospitalization of home healthcare patients. Secondary data analysis using logistic regression was conducted on retrospective data from OASIS collected during the time period of July 1, 2006 to June 30, 2007. This study was conducted in a Medicare certified Home Health organization that is part of the largest public health system in California. The sample of 1802 patients with complete episodes of care was derived from a data set of 5,523 patients. All patients were included in the analysis and logistic regression model and the disease specific independent variables included patients with a primary or secondary diagnosis of diabetes and an open skin lesion or wound. The OASIS variables examined in the logistic regression model that showed significance as predictors of acute care re-hospitalization included a diagnosis of diabetes, overall prognosis, rehabilitation prognosis, existing dyspnea, existing urine and bowel incontinence, impairment in currently dressing the upper body and the ability to take own oral medications. These findings apply to all patients in the OASIS database as the logistic regression model included all patients. An interesting finding was that the presence of a lesion or open wound was not significant as a predictor of acute care re-hospitalization. Also of interest was the occurrence of re-hospitalization of 15% that is lower than that reported in the literature as well as the occurrence of diabetes of 14% which is lower than the population in the community. The study methodology related to the backwards method of logistic regression modeling was useful in being able to examine a large number of variables and their relationship to a dichotomous dependent variable. Since this design and method has not been described in the literature prior to this study it has interesting implications for future research using OASIS

Chronic wound management: A practice focused study

This thesis is being submitted in fulfilment of the requirements of a degree of Doctor of Professional Practice. This Doctorate consists of five practice based elements: A preface, case study, review of the literature, research report and dissemination artefact. These five practice focused elements are all related to my present position as a Nurse Consultant in Tissue Viability, and to the care of patients with chronic wounds. The preface sets out the starting point of the candidate and the rationale for the work undertaken. Each element of the Professional Doctorate will be outlined and the inter-relationship between each of these elements discussed. The case study is concerned with clinical practice and emphasises the knowledge and skills required to be a reflective practitioner. The study describes the case management of a patient referred to the tissue viability service with a leg ulcer associated with sickle cell disease. The Neuman Systems Model of Nursing (1989) and a case management approach to assessment and management using the SOAPIER format (Cox 1997) was utilized. The critical review of the literature evaluates the available literature pertaining to the use of antimicrobial therapy in wound management, focusing specifically on silver dressings. Clinical practice recommendations are made for the diagnosis and treatment of wound infection and appropriate use of topical antimicrobial dressings. The research project examines the impact of delivering an educational programme utilising the concept of Wound Bed Preparation (WBP) and the associated TIME framework on community nurses wound care knowledge and practice. WBP has gained international recognition as a concept that can provide a structured approach to wound management. The TIME framework was developed in 2002 by the International Advisory Board for WBP, as a practical tool for implementing the concept of WBP in clinical practice. TIME is an acronym summarising the four main components of WBP: • Tissue • Infection/inflammation • Moisture • Edge An experimentai pre-test post-test design using repeat measures was used for the study. The results showed that community nurses wound care knowledge and practice both improved after the educational intervention, and this improvement was found to be statistically significant (p<0.001). The dissemination artefact is made up of a number of publications and presentations from the work undertaken for this professional Doctorate

The Development and Validation of a Self-Efficacy Tool for People over 60 with Venous Leg Ulceration

Venous leg ulceration has a high recurrence rate. Patients with healed or frequently recurring venous ulceration are required to perform self-care behaviours to prevent recurrence or promote healing, but many find these difficult to perform. Bandura’s self-efficacy theory is a widely used and robust behaviour change model and underpins many interventions designed to promote self-care in a variety of chronic conditions. By identifying areas where patients may experience difficulty in performing self-care, interventions can be developed to strengthen their self-efficacy beliefs in performing these activities successfully. There are currently a variety of self-efficacy scales available to measure self-efficacy in a variety of conditions; but not a disease-specific scale for use with venous ulcer patients. The aim of this study, therefore, was to develop a disease-specific, patient-focused self-efficacy scale for patients with healed venous leg ulceration. Phase 1 consisted of a qualitative design and used focus group methodology to generate an item pool for potential inclusion into the scale from the patients’ perspective. In phase 2, factor analysis using equamax orthogonal rotation methods was used to reduce the items from 60 to 30, resulting in 5 major domains: general self-care; daily self-care tasks; normal living; developing expertise and avoiding trauma. Preliminary reliability studies indicated that the developed scale, VeLUSET© has good internal consistency, with an overall Cronbach alpha of .929 and a strong test-re-test reliability. Furthermore, correlation with the General Self-Efficacy Scale demonstrated a strong positive relationship between the two scales. These results indicate that the VeLUSET©, although still in the early validation stages, is a reliable instrument to measure venous leg ulcer patients’ self-efficacy in performing self-care tasks within clinical practice. The development of this disease-specific tool has now filled a gap in the research on managing patients with healed venous leg ulceration

The development of a wound care learning resource for registered nurses caring for patients experiencing acute surgical wounds

Surgical nursing practice is constantly changing due to the increasing complexity of surgical wounds; the increasing numbers and types of surgical wound care products, and the comorbidity, complexity and advancing age of surgical patients. Registered Nurses (RNs) need access to updated surgical wound care learning resources in the clinical setting. As the primary resource or RNs in Newfoundland and Labrador (NL), the NL Skin and Wound Manual (2008) should reflect the best practice guidelines for skin and wound care management in Canada. The purpose of this practicum was to demonstrate advanced nurse practice competences by developing a surgical wound care learning resource for RNs caring for patients experiencing acute surgical wounds by updating Section 6.4 of the provincial manual with Canadian best practice guidelines for preventing complications from surgical wounds