Hospital discharge of the elderly: an observational case study of functions, variability and performance-shaping factors

Background: Understanding and improving hospital discharge has assumed major importance since it represents an error-prone transition in care. One barrier to improvement is the lack of detailed understanding of how hospital discharge is organized, including its interdependencies and influential performance-shaping factors (PSFs). This study examines the discharge of elderly patients using the Functional Resonance Analysis Method, developed to analyze performance variability in complex systems. Our main aim was to identify hospital discharge functions, variability, and PSFs that may explain the variability and different outcomes in discharge practices by incorporating multiple-stakeholder perceptions (health-care providers, patients, next of kin). Methods: The data consisted of moderate participant observations of 20 elderly patients (>75) discharged from hospital to primary health care. The data comprised 90 hours’ observations at hospital wards, including 173 conversations with patients, next of kin, and health-care personnel involved in discharge. Results: We identified 10 common functions in the discharge of elderly patients to primary health care. We found substantial variability in terms of timing, duration, and precision. Duration is a significant source of variability, primarily determined by the time of day the patient was determined medically fit for discharge. Precision issues related to (1) decision-making criteria concerning the medical fitness decision and appropriate level of care, (2) quality of discharge planning, (3) degree of patient involvement, and (4) quality of information transfer. PSFs were temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability in municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin, doctor’s specialization) and regulatory influences (financial incentives). Conclusions: The study provides a detailed understanding of the discharge of elderly patients by describing common functions and variability in performance caused by multiple PSFs. Our findings indicate the necessity for studying multiple factors related to discharge, interdependencies, and their effects on a range of discharge outcomes incorporating a multiple-stakeholder perspective. We argue that the existing sequential approaches to the complexity surrounding hospital discharge are inadequate. Given the interdependencies among functions, there is a need for corresponding multi-factorial interventions

Exploring stakeholders’ experiences in co-creation initiatives for clinical nursing education: a qualitative study

Background Co-creation is an emerging approach in nursing education, wherein academics engage in multi-stakeholder collaborations to generate knowledge, ideate solutions, promote sustainability, and enhance educational quality. However, knowledge on stakeholders’ experiences in participation in co-creation initiatives for nursing education is scarce. This study aimed to explore the experiences of student nurses, nurse educators, and e-learning designers in co-creation initiatives to design and develop a digital educational resource for clinical nursing education. Methods The study adopted an exploratory qualitative design. Data were collected via three separate semi-structured focus group interviews with student nurses (n = 7), nurse educators (n = 8), and e-learning designers (n = 3) who participated in co-creation workshops. Collected data were then thematically analyzed. Results Three themes related to the participants’ experiences emerged: (1) The co-creation workshops were enjoyable, useful, and instructive; (2) power imbalances influenced the students’ engagement; and (3) contextual factors influenced the participants’ overall engagement. Conclusions This study shows that co-creation through workshops is a novel, enjoyable, and instructive approach that facilitates knowledge exchange. It also highlights the needs and experiences of stakeholders, especially student nurses. However, the use of co-creation in nursing education presents some challenges. Recognizing and managing power differentials are essential for successful co-creation in clinical nursing education, alongside a mindset of collaboration and mutuality. Future research is required to systematize knowledge about the benefits and impacts of the processes and outcomes of co-creation initiatives, including stakeholders’ motivation, barriers, and facilitators to participation in co-creation, to improve the quality of clinical nursing education.publishedVersio

An observational study of older patients' participation in hospital admission and discharge - exploring patient and next of kin perspectives

Aims and objectives. To explore older patients’ participation during hospital admission and discharge. Background. Patient participation is suggested as a means to improve the quality of transitional healthcare. Older people with chronic diseases, physical disabilities and cognitive impairments often need to transfer from primary to hospital healthcare and vice versa. Design. This study adopts a participant observational research design. Methods. Participant observations of 41 older patients (over 75 years of age) during hospital admission and discharge were conducted in two hospitals in Norway (in 2012). The observations included short conversations with the patient and their next of kin to capture their participation experiences. Systematic text condensation was used to analyse the data material from the field notes. Results. Varying degrees of information exchange between healthcare professionals and patients, and a lack of involvement of the patient in decision-making (in admission and discharge) were observed and experienced by patients and their next of kin. The next of kin appeared to be important advocates for the patients in admission and provided practical support both during admission and discharge. Data suggest that patient participation in admission and discharge is influenced by time constraints and the heavy workloads of healthcare professionals. Patients’ health conditions and preferences also influence participation. Conclusions. Several issues influence the participation of the older patients during hospital admission and discharge. Participation of the older patients needs continuous support from healthcare professionals that acknowledges both the individual patient’s preferences and their capacity to participate. Relevance to clinical practice. Study findings report discrepancies in the involvement of older people and their next of kin. There is a need to increase and support older patients’ participation in hospital admission and discharge.publishedVersio

A digital educational resource to support and enhance effective mentorship practices of nursing students in nursing homes: a qualitative study

There is a grooving body of evidence emphasising the need to support and enhance effective mentorship practices for nursing students in nursing home placements, including strengthening of the pedagogical competence of registered nurse mentors. Owing to the necessity for multifaceted mentoring competence and the challenges of workload registered nurses are facing, the use of flexible digital educational resources has been suggested. However, current knowledge on the effectiveness of digital educational resources in enhancing mentorship practices in nursing homes is scarce. This study aimed to explore the perception of registered nurse mentors regarding the effectiveness of a digital educational resource, particular its usability and value-in-use in supporting and enhancing mentorship practices in nursing homes. The study applied an exploratory descriptive qualitative design. Pre- and post-mentoring semi-structured focus group interviews were conducted among a total of 23 registered nurse mentors across three Norwegian nursing homes. The transcribed interviews were thematically analysed. Standards for reporting qualitative research were followed. The analysis yielded one pre-mentoring theme: (1) predominant enthusiasm and satisfaction and three post-mentoring themes: (2) enhanced confidence and motivation, (3) enhanced mentoring competence in supporting the nursing students’ learning process, and (4) factors influencing the value-in-use of the digital educational resource. Digital educational resources support effective mentorship practices by enhancing the confidence and motivation in the mentor role and by enabling more goal-oriented supervision and assessment tailored to the learning goals of students. The implementation of digital educational resources to support and enhance effective mentorship practices is an important avenue for further research towards achieving high-quality learning environments in clinical nursing education in general and nursing homes. Based on the study findings, nursing educational institutions should consider offering digital educational resources to develop, support, and advance mentorship training, which may more effectively impact and improvepublishedVersio

Improving quality in clinical placement studies in nursing homes (QUALinCLINstud):the study protocol of a participatory mixed methods multiple case study design

Introduction Improved quality in clinical supervision and assessment of student nurses in nursing home clinical placements is vitally important to effective recruitment and preparation for this healthcare sector. Knowledge regarding supervision and assessment practices within these settings is limited. Also, knowledge of evolving e-learning tools on the quality and effectiveness of these educational practices seems to be absent. Methods and analysis The aim of the “Improving quality in clinical placement studies in nursing homes” (QUALinCLINstud) study is to develop and evaluate how a web-based programme can optimise supervision, assessment and learning during nursing home placements. The study applies a participatory, mixed-methods case study design, organised in four work packages (WPs). WP1 will explore how the nurse education institution address the quality of student nurses’ clinical placements in nursing homes. In WP2, clinical supervision and assessment practices will be explored, and described from multiple stakeholder perspectives. In WP3, based on the findings from WP1 and WP2, a web-based pedagogical supervision and assessment programme will be developed through a developmental co-productive process between nurse education institutions, practice settings and student nurses. In WP4, the web-based programme will be pilot-tested and evaluated through a mixed-methods approach. A range of data collection procedures will be used throughout the project, for example, questionnaires, interviews, observations and workshops.publishedVersio

Supporting the nurse educator in clinical education – A qualitative evaluation of a digital educational resource DigiVIS

Despite the increased use of technology for teaching and learning in clinical nursing education, relatively little attention seems to be directed toward the usefulness of digital educational resources (DERs) to support nurse educators’ educational role in clinical nursing education. An interpretive descriptive qualitative study design was conducted to evaluate the usefulness of a DER to support nurse educators in clinical nursing education. Data were collected through two focus group interviews with part-time and novice educators (n = 5) and full-time, more experienced educators (n = 5), after they had overseen student nurses in nursing home placements. Data were analyzed using thematic analysis and Standards for Reporting Qualitative Research guidelines were used for this study. The analysis identified three themes related to nurse educators’ experiences of the usefulness of a DER to support their educational role while overseeing first-year students on clinical placements in nursing homes: (1) Provides academic support and a sense of security (2) promotes pedagogical efficacy, and (3) represents a flexible resource for educational planning. This study shows that a digital educational resource can be an efficient and useful supplementary strategy to support the nurse educator’s role in clinical nursing education. Future research is required to systematize knowledge about the impact of DERs on orientation and training, as well as motivation and facilitators for, and barriers to, their use to enhance quality and strengthen the nurse educator’s role in clinical nursing education.publishedVersio

Improving quality in clinical placement studies in nursing homes (QUALinCLINstud): The study protocol of a participatory mixed-methods multiple case study design

Brendan McCormack - ORCID: 0000-0001-8525-8905 https://orcid.org/0000-0001-8525-8905Introduction Improved quality in clinical supervision and assessment of student nurses in nursing home clinical placements is vitally important to effective recruitment and preparation for this healthcare sector. Knowledge regarding supervision and assessment practices within these settings is limited. Also, knowledge of evolving e-learning tools on the quality and effectiveness of these educational practices seems to be absent.Methods and analysis The aim of the “Improving quality in clinical placement studies in nursing homes” (QUALinCLINstud) study is to develop and evaluate how a web-based programme can optimise supervision, assessment and learning during nursing home placements. The study applies a participatory, mixed-methods case study design, organised in four work packages (WPs). WP1 will explore how the nurse education institution address the quality of student nurses’ clinical placements in nursing homes. In WP2, clinical supervision and assessment practices will be explored, and described from multiple stakeholder perspectives. In WP3, based on the findings from WP1 and WP2, a web-based pedagogical supervision and assessment programme will be developed through a developmental co-productive process between nurse education institutions, practice settings and student nurses. In WP4, the web-based programme will be pilot-tested and evaluated through a mixed-methods approach. A range of data collection procedures will be used throughout the project, for example, questionnaires, interviews, observations and workshops.Ethics and dissemination The ethical conduct of the study is approved by the Norwegian Centre for Research Data (2018/61309 and 489776). The results will be disseminated through scientific articles, three PhD theses, presentations at national and international conferences, and through publicly accessible trade journals and newspapers. The results will generate knowledge to inform supervision and assessment practices in nursing home placements. Moreover, the study will generate knowledge concerning the developmental process of a web-based supervision and assessment programme, and the value of e-learning tools applied in clinical nursing education.This work is supported by The Research Council of Norway (RCN) grant number 273558 and by the University of Stavanger, the University of South-Eastern Norway and the University of Agder.https://doi.org/10.1136/bmjopen-2020-04049110pubpu

Quality in transitional care of the elderly: Key challenges and relevant improvement measures

Introduction: Elderly people aged over 75 years with multifaceted care needs are often in need of hospital treatment. Transfer across care levels for this patient group increases the risk of adverse events. The aim of this paper is to establish knowledge of quality in transitional care of the elderly in two Norwegian hospital regions by identifying issues affecting the quality of transitional care and based on these issues suggest improvement measures. Methodology: Included in the study were elderly patients (75+) receiving health care in the municipality admitted to hospital emergency department or discharged to community health care with hip fracture or with a general medical diagnosis. Participant observations of admission and discharge transitions (n = 41) were carried out by two researchers. Results: Six main challenges with belonging descriptions have been identified: (1) next of kin (bridging providers, advocacy, support, information brokering), (2) patient characteristics (level of satisfaction, level of insecurity, complex clinical conditions), (3) health care personnel's competence (professional, system, awareness of others’ roles), (4) information exchange (oral, written, electronic), (5) context (stability, variability, change incentives, number of patient handovers) and (6) patient assessment (complex clinical picture, patient description, clinical assessment). Conclusion: Related to the six main challenges, several measures have been suggested to improve quality in transitional care, e.g. information to and involvement of patients and next of kin, staff training, standardisation of routines and inter-organisational staff meetings.publishedVersio

Legers arbeidstid og pasientsikkerhet

Master's thesis in Change managementDet er i dag et okende fokus pa pasientsikkerhet. Bade i helsevesenet og samfunnet for evrig, Dagens sikkerhetstenkning bygger pa en helhetlig tilneerming, En er opptatt av a finne de bakenforliggende arsakene til at det skjer uonskede hendelser, hvor menneskelig svikt ofte er en konsekvens av de ramrnebetingelsene man jobber under (Reason, 1997). Denne masteroppgaven studerer sykehuslegers arbeidstid og praktiseringen av disse. Sporsmalet som sakes besvart er hvorvidt rammebetingelser og dagens arbeidstidsbestemmelser paviker sikkerheten for pasientene. Av hensyn til sykehusdriften er leger som en av fa yrkesgrupper i Norge unntatt deler av arbeidsmiljoloven, gjennom de sakalte vemebestemrnelsene. Vemebestemmelsene innebeerer at legene kan jobbe 19 timer i strekk, og 60 timer i uken med loven i ryggen (Kvavik, 2007). Andre yrkesgrupper som piloter og langtransportsjeforer har strengere restriksjoner knyttet til arbeidstid med henvisning til sikkerhetsmessige forhold. Masteroppgaven inngar i et storrc forskningsprosjekt initiert av Helsetilsynet. Formalet med prosjektet og oppgaven har veert a utvikle et kunnskapsgrunnlag for risikovurdering knyttet til forholdet mellom legers arbeidstid og konsekvenser for sikker pasientbehandling. Studien er eksplorerende. Den bygger pa gjennomgang av intemasjonal forskningslitteratur, som studerer forholdet mellom arbeidstid og risiko. Det henvises til studier fra helsesektoren i den grad de foreligger. Kartlegging fra andre samfunnssektorer inngar ogsa i litteratursoket. En casestudie er gjennomfort ved Kirurgisk seksjon ved Stavanger Universitetssykehus for a fa et "temperaturmal" knyttet til norske forhold. Casestudien har en kvalitativ tilneerming og bestar av 16 dybdeintervjuer med tumusleger, assistentleger og overleger ved seksjonen. Casestudien avdekker at praktiseringen av arbeidstidsbestemmelsene ikke alltid korresponderer med de feringer som er lagt i lov- og avtaleverket. Utfordringer knyttet til bemanning og sykefraveer vektlegges som iirsakene til at bestemmelsene i stor grad ikke overholdes. Med stette fra forskningslitteraturen kan brudd pa vemebestemrnelsene utgjore en risiko for pasientene. Lange vakter med stor arbeidsbelastning kan pavirke legenes iirvakenhet, arbeidsutforelse og dommekraft. De star da i fare for a gjore feil som kan resulterer i uenskede hendelser. Spesieit utsatt er ferieavviklingen, der det fremkommer at vemebestemrnelsene ofte overskrides

Co-creating digital educational resources to enhance quality in student nurses' clinical education in nursing homes: Report of a co-creative process

To report a methodological, co-creative approach for developing an interactive digital educational resource to enhance the quality of student nurses' clinical education in nursing homes and to elucidate the lessons learned from this approach. This study applied a co-design methodology that builds on participatory design principles. Co-creating the digital educational resource included multiple sequential and interactive phases inspired by the design thinking framework. Workshops were employed as the primary co-creative activity. Seven separate homogenous or joint heterogeneous workshops were conducted with student nurses, nurse educators, registered nurse mentors and e-learning designers (n = 36) during the active stakeholder engagement phases to inform the educational content, design and functionality of the digital educational resource. These were informed by, and grounded in, learning theory and principles. Co-creative approaches in nursing education are an essential avenue for further research. We still lack systematic knowledge about the impact and benefits of co-created initiatives, stakeholders' motivations, barriers, facilitators to participation and the role of context in supporting effective co-creative processes to increase the quality of nursing education. This paper demonstrates how digital educational initiatives to enhance quality in clinical nursing education can be co-created with key stakeholders through a novel methodological approach inspired by design thinking. To date, the methodological development process of co-created educational interventions has received limited attention and compared with the content and theoretical underpinnings of such interventions, has rarely been addressed. Therefore, this paper facilitates knowledge exchange and documents vital aspects to consider when co-creating digital educational initiatives incorporating multistakeholder perspectives. This promotes a stronger academic–practice partnership to impact and enhance the quality of clinical nursing education in nursing homes. Student nurses, nurse educators, and registered nurse mentors worked alongside researchers and e-learning designers in the co-creative process.publishedVersio