Patient safety and feeling of safety when telecare is used among home-dwelling older adults : A qualitative study

Background The use of telecare technologies is regarded as an important measure in meeting future healthcare challenges, and is a major focus area both in Norway and internationally. With the help of telecare, older individuals with chronic illnesses and impaired functioning shall better master their illness and everyday life and be able to live at home for as long as possible. Home-dwelling older adults are an important target - and user group. An important intention for the implementation and use of telecare technologies is to contribute to increased patient safety and feeling of safety. However, there is a lack of research concerning patient safety and feeling of safety when telecare is used among older adults in a municipal context. Aim The overarching aim of this thesis was to contribute to more insight and knowledge regarding patient safety and feeling of safety when telecare is used among home-dwelling older adults, by exploring the perceptions and experiences of homecare professionals, managers, and older telecare users. Methodology This qualitative study has an exploratory, inductive design. A total of 29 participants from a total of ten Norwegian municipalities participated in the study. The participants had practical and/or administrative experience within a total of 12 different telecare devices. Data were collected using focus groups and individual interviews. All data were analyzed using qualitative content analysis. The collected data formed the basis for three research papers (Paper I, II, and III). Findings Paper I presents the findings from focus group interviews with in total 10 homecare professionals (nine registered nurses and one occupational therapist). The research question was: How do homecare professionals perceive safety in relation to older adults’ use of telecare? The analysis identified two themes that illustrate the participants’ perceptions. The first theme, A protection against injury and insecurity, was based on the two categories Preventing harm and Feeling safe. The second theme, Involves challenges that could lead to harm, was based on the two categories Technological limitation and Difficulties managing and understanding the technology. The findings show that the participants perceived that the use of telecare protects older adults against injury and insecurity by preventing harm and giving them a feeling of safety. However, they also perceived that the use of telecare involves challenges that could lead to harm, related to technological limitations and difficulties managing and understanding the technology. Paper II presents the findings from focus group interviews with in total 20 participants, including ten homecare professionals (nine registered nurses and one occupational therapist), and ten managers (eight health and care managers and two telecare project group managers). The research question was: What do managers and homecare professionals perceive as important for safe and secure use of telecare for older adults in community homecare services? The analysis identified three categories that refer to the participants’ perceptions: Sufficient knowledge, Close follow-up, and Meet the needs of the users. The findings show that the participants considered it important that both healthcare personnel and service users receive essential information and training about the telecare technologies in use. Furthermore, it was deemed vital that both the technology and its use are closely followed up and that the solutions offered complies with the service users’ individual desires, needs, and resources. The participants also referred to the significance of increased attention to early initiatives and the use of telecare in a preventative perspective. Paper III present the findings from individual interviews with nine older telecare users (seven service users and two spouses). The research question was: How do older adults experience safety when using a telecare at home? The analysis identified one theme that illustrates the participants’ experiences: Feeling free and protected from danger. The theme was based on the three categories Being protected against harm, Trusting and managing the device, and Becoming more independent. The findings show that the participants experienced an increased feeling of safety by using their mobile safety alarm with GPS or electronic medicine dispenser. This was linked to a sense of being protected from physical harm, and finding their device reliable and easy to use and understand. Moreover, the findings reveal that the increased feeling of safety was significant in that the participants could maintain their daily activities and live more independently at home. Conclusions This thesis has demonstrated how both technological, individual, and organizational conditions have importance for patient safety and feeling of safety in telecare use. The thesis has revealed how patient safety and feelings of safety are promoted by functionalities related to the telecare devices. The enhanced feeling of safety from using telecare devices has significance to that home-dwelling older adults can maintain their activities and live more independently at home. Thus, this thesis provides insight and knowledge on what feeling of safety from using telecare devices mean for older adults who use the technologies in their everyday lives. The findings of this thesis suggests that telecare can be a significant tool to prevent injury among home-dwelling older adults, and allow them to feel safer and live more independently at home. However, this thesis has revealed how patient safety and feelings of safety are challenged by technological inadequacies and limitations, and difficulties for some older users to understand and manage telecare functionalities. Thus, this thesis provides important insight and knowledge regarding technological vulnerabilities. This thesis has further revealed how patient safety and feelings of safety are promoted by organizational conditions in terms of telecare routines, drills, and targeted training. Furthermore, the thesis has emphasized the importance of ensuring that telecare solutions fit the users’ individual needs and prerequisites. Moreover, the thesis has highlighted homecare professional’s crucial role and function by facilitating patient safety and feelings of safety when telecare is used among home-dwelling older adults.NORSK SAMMENDRAG: Bruk av velferdsteknologi (VT) anses som et viktig tiltak i møtet med framtidige utfordringer innen helsetjenesten, og er et stort satsingsområde både i Norge og internasjonalt. Ved hjelp av velferdsteknologi skal eldre personer med kronisk sykdom og nedsatt funksjonsevne bli bedre i stand til å kunne mestre sin sykdom og hverdag, og kunne bo hjemme så lenge som mulig. Hjemmeboende eldre er en viktig mål - og brukergruppe. En viktig intensjon for implementering og bruk av velferdsteknologiske løsninger er å øke pasientsikkerheten og følelsen av trygghet. Det er imidlertid mangel på forskning vedrørende pasientsikkerhet og følelse av trygghet når velferdsteknologi benyttes blant hjemmeboende eldre i en kommunal kontekst. Mål Det overordnede målet med denne avhandlingen var å bidra til mer innsikt og kunnskap vedrørende pasientsikkerhet og følelse av trygghet når velferdsteknologi benyttes blant hjemmeboende eldre, ved å utforske opplevelsene og erfaringene til helsepersonell, ledere og eldre VTbrukere. Metode Denne kvalitative studien har et eksplorativt, induktivt design. Totalt 29 deltagere fra til sammen ti norske kommuner deltok i studien. Alle deltagerne hadde praktisk og/eller administrativ erfaring med til sammen 12 ulike velferdsteknologiske løsninger. Data ble samlet inn ved bruk av fokusgrupper og individuelle intervju. Alle data ble analysert ved hjelp av kvalitativ innholdsanalyse. De innsamlede dataene dannet grunnlag for tre forskningsartikler (Artikkel I, II & III)

Challenges of Mainstreaming Telecare. Exploring Actualization of Telecare Affordances in Home Care Services

Application of telecare has received increased attention as a means to address the future care needs in home care services. However, the uptake of telecare has been slow and fewer solutions than expected have been implemented. Healthcare employees’ perspectives on telecare and organizational issues have not received appropriate attention in earlier research. There is a need to understand the challenges related to telecare services. Through the lens of affordance theory, the present study aims to explore municipal employees` experiences of TCS. The study contributes to affordance theory by developing an understanding of the collective actualization process. Focus group interviews were conducted with 26 employees involved in telecare services in eight municipalities in Southern Norway. Findings reveal that successful actualization of the seven perceived telecare affordances required involvement of several actors, new ways of working and close cooperation within the municipalities across units and disciplines. Furthermore, the actualization process was strongly influenced by contextual factors. The most prominent factors included anchoring and cooperation, competence and knowledge, and routines and follow-up. Findings indicate that specific focus on these factors is needed in order to succeed with mainstreaming of telecare in home care services

Implementation of Multidose Drug Dispensing in a Home Care Setting: Changes in Safety of Medicines Management

Doktorgradsavhandling som beskriver studier av kvaliteten og sikkerheten i legemiddelhåndteringen for pasienter i hjemmetjenesten før og etter innføringen av multidose.Multidose dispensed drugs are drugs machine-packed into dose unit bags for each time of administration. Trondheim municipality decided in 2005 to implement Multidose Drug Dispensing (MDD) in home care services. At that time, there was a lack of scientific knowledge about the effects of MDD. The health care management of Trondheim therefore decided to study the implementation in collaboration with NTNU. MDD was adopted gradually during 2006. Three studies were conducted with the common main aim of investigating the safety of medicines management during the implementation of MDD. A complex intervention was designed, including both internal and external controls, and pre-post-examinations. Qualitative as well as quantitative data was gathered, forming a method-, data source-, and observer-triangulation. The introduction of MDD reduced the discrepancies between the medication lists at the general practitioners (GPs), and in the home care services, and even moreso between the GPs and the pharmacies. However, for patients with multidose dispensed drugs, a corresponding improvement also occurred for drugs they received outside the MDD system (e.g. eye drops and inhalers). This finding suggests that new routines, and better collaboration between health practitioners, more than the MDD system by itself, contributed to the improvements. Nevertheless, even if the number of discrepancies between medication lists were reduced, the discrepancies continued to be high, demonstrating that more efforts are needed. Other reported improvements also occurred. Both the general practitioners and the pharmacists reported a better overview of the patients’ medication and thus a better control. The involved health care practitioners also stated an increased trust in each other, as well as in the MDD system, as better collaboration emerged. However, trust in the MDD system was challenged by a loss of flexibility to make changes in medication/dosage compared to the manual system. The nurses in the home care services expressed that the automation would decrease their knowledge of patients’ drug intake, and thus make them less trusted in observing patients. The GPs believed that electronic communication could improve the exchange of information and updating, and thus produce an even better effect from the MDD system. The GPs in Trondheim showed a positive attitude to MDD. Increased workload was reported, but still most GPs wanted the system to be continued. The decision to only allow the patient’s GP to prescribe multidose dispensed drugs contributed to the improvements seen in routines of prescription, communication, and cooperation. The decision made the GPs take on a greater responsibility with their patients’ medications, and made the coordination in the MDD system less complex. However, the improved routines and collaboration between GPs and home care services and pharmacies, only related to patients receiving multidose dispensed drugs. The improvements were not transferred to other patients on the GP’s list having drugs administered by the home care services. The introduction of MDD in Trondheim was followed by improved quality in the medicines management. This thesis shows, however, that the main contribution to improved safety was emphasizing the different steps of the medicines management, to improvements in communication and cooperation between health care practitioners, and the clarifying of roles and responsibilities. The findings cannot be generalized straight forwardly. However, insights from the three studies presented in this thesis should be valid for others planning to implement an MDD system, or already using MDD in the home care services

Medication Safety in Municipal Health and Care Services

Medicines constitute an essential part of healthcare delivery and help to prevent or treat illness, influence quality of life, and generally increase life expectancy. However, medications can also cause harm if prescribed irrationally, dispensed or used incorrectly, and monitored or followed up insufficiently. In this anthology, we showcase the challenges of medication management and the rational use of medicines in municipal health and care services, and present various strategies and measures related to medication safety. The contributors are researchers representing a wide range of disciplines, with experience from different levels of healthcare services and different areas within the research and education sectors. We hope to raise awareness, engage and enable discussion of initiatives and strategies to improve patient safety related to medications in municipal health and care services, and create a basis for further research to promote safe medication management and rational use of medicines. This anthology will be of interest to anyone involved in or concerned with medication safety, primarily healthcare professionals, academic staff, researchers, policymakers, and managers in healthcare services

Medication Safety in Municipal Health and Care Services

Medicines constitute an essential part of healthcare delivery and help to prevent or treat illness, influence quality of life, and generally increase life expectancy. However, medications can also cause harm if prescribed irrationally, dispensed or used incorrectly, and monitored or followed up insufficiently. In this anthology, we showcase the challenges of medication management and the rational use of medicines in municipal health and care services, and present various strategies and measures related to medication safety. The contributors are researchers representing a wide range of disciplines, with experience from different levels of healthcare services and different areas within the research and education sectors. We hope to raise awareness, engage and enable discussion of initiatives and strategies to improve patient safety related to medications in municipal health and care services, and create a basis for further research to promote safe medication management and rational use of medicines. This anthology will be of interest to anyone involved in or concerned with medication safety, primarily healthcare professionals, academic staff, researchers, policymakers, and managers in healthcare services

The case for investment in technology to manage the global costs of dementia

Worldwide growth in the number of people living with dementia will continue over the coming decades and is already putting pressure on health and care systems, both formal and informal, and on costs, both public and private. One response could be to make greater use of digital and other technologies to try to improve outcomes and contain costs. We were commissioned to examine the economic case for accelerated investment in technology that could, over time, deliver savings on the overall cost of care for people with dementia. Our short study included a rapid review of international evidence on effectiveness and cost-effectiveness of technology, consideration of the conditions for its successful adoption, and liaison with people from industry, government, academic, third sector and other sectors, and people with dementia and carers. We used modelling analyses to examine the economic case, using the UK as context. We then discussed the roles that state investment or action could play, perhaps to accelerate use of technology so as to deliver both wellbeing and economic benefits

Digitalization and Public Services: A Labour Perspective

This report was commissioned by PSI. In addition to an extensive literature review, the study finds its main sources in interviews and information gathered from trade union representatives from PSI-affiliated organizations in different public service sectors around the world, including in Africa (Burkina Faso, Morocco), Asia (South Korea, Singapore, India), North America (Canada, United States), South America (Argentina, Brazil) and Europe (Denmark, France, Germany, Norway, Spain, and the United Kingdom). The interviewees represent a wide range of public services from central administration and local and regional government to health and care services, hospitals, utilities, police, emergency services and education and cultural services.info:eu-repo/semantics/publishedVersio

Health care professionals’ caretaking of persons with dementia who use dietary supplements

Persons with dementia experience progressive loss of cognitive functioning and increasing need for help with activities of daily living, including help with administering their prescribed drugs (PD). This thesis describes the use of dietary supplements (DS) (including herbs) by persons with dementia and the risk related to their use, as DS may cause adverse effects. It further describes the awareness of this risk and the attributed responsibility by relevant health care professionals in primary health care. The study methods used were questionnaire-surveys of patients with dementia (n=151), employees in pharmacy (n=105) and home care service (HCS) (n=231), and individual interviews with general practitioners (GPs) (n=14). Forty-six percent of the persons with dementia used DS and 11% had potentially clinically relevant interactions between DS and PD. Only one-third of the patients received help with the administration of their DS. Several of the patients who did not receive help had cognitive decline, indicating a need for such help. Only one-third of the patients with dementia and half of their caretakers knew that DS may impose a health-risk. Half of the general practitioners (GPs) and the employees in home care service (HCS), but few pharmacy employees, expressed that they had been worried about patients’ DS use. One-third of the employees in HCS and two-third of the GPs had intervened because of possibly dangerous use. None of the studied health care professionals attributed the responsibility for the safety of these patients to their own profession. The main reason why the GPs did not want to take on the responsibility was the lack of available information about safety, effect and sometimes even DS-content. Conclusion: DS use are common in patients with dementia and may represent a risk to them, but no group of health care professionals wants to take the responsibility to increase their safety

Role of Community Pharmacists in Optimizing Opioid Therapy for Chronic Non-malignant Pain Patients in Pakistan

Background Chronic Non-Malignant Pain (CNMP) is one of the most common conditions in both high-income countries (HICs) and low middle-income countries (LMICs). CNMP can have a substantial impact on people, communities and puts an economic burden on the society. Opioids are commonly used worldwide for CNMP management. However, their use might have contributed to opioid use-related harm and increased mortality. There have been substantial reports of opioid diversion and misuse in Pakistan. Community pharmacists (CPs) might be able to help optimise the use of opioids in CNMP management but there is no regularised CP-based patient-centred services in Pakistan. Aim and objectives The aim of the study was to explore the potential role of CPs in opioid optimisation in people with CNMP in Pakistan. Objectives of this study included systematically exploring the role of CPs in opioid optimisation in CNMP management, exploring the current use of opioids in Pakistan and identify the role CPs can play to optimise the use of opioids in people with CNMP and explore factors that might influence the development and delivery of role of CPs in an opioid optimisation service. Methodology Conceptual guiding framework The UK Medical Research Council (MRC) guidelines for complex interventions was used as conceptual guiding framework for exploring the aim of this study. The data was collected in two phases: Phase 1: Systematic review The systematic review followed the 27-item PRISMA guidelines and studies between January 1990-June 2020 were included. All studies where pharmacists in ambulatory care settings helped in optimisation of opioids in the treatment of CNMP, as individuals or as part of a team were included and were descriptively synthesized. Phase 2: In-depth qualitative methods (Interviews, focus groups and case studies) Two studies were conducted to collect the data. The first study constituted of semi-structured interviews and focus groups from four stakeholder groups: pharmacy policy makers, people with CNMP, doctors and CPs. The second study included non-participant multiple case study observations in six community pharmacies. The data in phase two was collected from November 2019–December 2020. Data analysis Interviews and focus groups with all stakeholders in phase two were inductively analysed using reflexive thematic analysis using N-Vivo 12. For case studies, reflexive thematic analysis as well a cross case synthesis method using explanation building technique was used to analyse the data across six cases. Data triangulation Findings from both studies in phase two were triangulated using two steps; comparing, and categorising. Any code or subtheme about a particular phenomenon or a theme across both studies were brought together using one sheet one paper data visualisation technique. Diagrammatic model development Schematic diagrammatic models were developed in this thesis usual process mapping data visualisation technique. This was done selecting and representing events and situating data in time/process meaningfully. Results In this study 98 stakeholders participated (38 females). A total of 240 hours (40 hours/case) were observed during a six-week period of non-participant observational case studies in six community pharmacies. Phase 1: Systematic review In the systematic review 14 studies were included in the final data synthesis (total number of participants n=1175). Interventions by pharmacists decreased opioid dose in four studies and improved patient opioid safety in five studies. Qualitative studies showed positive perception of stakeholders for the development of CP role in optimisation of opioid therapy for people with CNMP. No actual interventions involving CPs or studies form LMICs were identified. Phase 2: Focus groups, interviews and case studies These studies were able to identify reasons contributing towards the non-availability of opioids, factors contributing towards the unsafe use of opioids and certain actions that can be taken by CPs to overcome existing barriers contributing to the unsafe use of opioids and help optimise their use. These studies also highlight advantages and benefits of developing the role of CPs in optimising opioid use in people with CNMP. In addition, these studies identified multiple level barriers and facilitators for the development and delivery of CP opioid service. They also helped identify strategies to overcome the perceived barriers and to leverage the facilitators in order to develop and deliver an opioid service. Data visualisation helped develop diagrammatic models after triangulation. Firstly, a logic model was developed that identifies the possible actions that can be undertaken by CPs to help overcome the barriers causing/contributing towards unsafe use of opioids. Secondly a CP proposed opioid service model was developed, tailored to the health system of Pakistan, that is anticipated to help optimise the use of opioids in people with CNMP. Finally, a CP opioid service logic model was developed that shows strategies perceived to develop and improve the capability of CPs to deliver the opioid service and help optimise the use of opioids. Conclusion This thesis explored the process, the need and service delivery of CP role in opioid optimisation. This thesis identified factors contributing towards unsafe use of opioids (logic model), what can be done by CPs to help people use opioids in an optimised manner (CP proposed service model), what challenges might CPs face while delivering the service and what can be done to improve the development and delivery of a CP opioid service for people with CNMP using opioids (CP service logic model). The findings provide policy makers with possible steps and actions that may be followed to facilitate the development and delivery of a CP service for opioid optimisation in Pakistan