Clinical observation of deteriorating frail older patients: Improving the competence of homecare professionals

Introduction: Homecare services are providing care to an increasing number of frail older patients with complex care needs. These patients are in a vulnerable state and have an increased risk of deterioration, and the early detection of changes in their clinical condition is highlighted as a means of preventing adverse health outcomes. Clinical observation is an essential prerequisite in identifying deteriorating patients. In homecare, clinical observation is currently insufficient, and little is known about homecare professionals’ detection of deteriorating patients. Therefore, the overall aim of this PhD project is to gain knowledge of clinical observation in homecare and to understand how a competence improvement programme can change homecare professionals’ clinical observation. Consequently, theories on competence and improvement in healthcare have been applied in the thesis. Methodology: This thesis adopted a multi-method qualitative, sequential design consisting of three phases: (1) before the implementation of a competence improvement programme (study 1), (2) during the implementation of the programme (study 2), and (3) after the implementation of the competence improvement programme (study 3), focusing on two homecare districts (homecare A, homecare B) in Norway. The programme was designed to improve homecare professionals’ competence and skills in recognising and responding to deteriorating frail older patients. The first study developed knowledge of homecare professionals’ observational competence in the early recognition of deterioration in frail older patients. Homecare professionals, including nurses, skilled health workers, and assistants were observed during their home visits to patients and interviewed in focus groups. The second study described and analysed the implementation of a competence improvement programme for the systematic observation of frail older patients. Participant observation was used during the implementation activities, and focus group and individual interviews were conducted to describe the experiences of the homecare professionals, managers, and development nurses with the implementation of the competence improvement programme. The third study described the outcomes of the competence improvement programme for the systematic observation of frail older patients. Homecare professionals were observed during their home visits to patients and interviewed in focus groups, while managers and development nurses were interviewed individually. Results: The studies included in this thesis contribute to longitudinal research on a competence improvement programme for the systematic observation of frail older patients in homecare and demonstrate that clinical observation is multifaceted and the improvement of this competence is challenging. In study 1, the homecare professionals’ observational competence before the competence improvement programme was characterised by a focus on patient-situated assessment of changed clinical conditions and how the organisational environment impacted the homecare professionals’ performance of clinical observation. Patients’ physical and mental conditions formed a vital basis for detecting clinical deterioration. Communicating with the patient was highlighted, together with precise nursing documentation. Basic understanding and use of vital sign measurements as part of clinical observation were insufficient in the two homecare districts. Pre-planned workplans organised the homecare professionals’ practice, but actions to follow up on patients’ changed conditions were not reflected in these plans. Collaboration with colleagues was seen as supportive of homecare professionals’ observational competence. In study 2, the homecare professionals perceived the competence improvement programme as important, as the programme would improve their observational competence and confidence in situations with deteriorating patients. However, the competence improvement programme consisted of several learning resources with complex content and was applied differently in the two homecare districts. The homecare professionals described the implementation process of the competence improvement programme as demanding and time-consuming. The homecare professionals were unfamiliar with simulation-based learning and found it more challenging than they had expected. Study 3 reported that two years after the implementation of the competence improvement programme, the frequency of vital signs measurements for the systematic observation of frail older patients varied between the two homecare districts. Although measurements of vital signs had increased for new patients and in the case of patient falls, situation awareness related to the clinical deterioration of patients remained insufficient. However, the homecare professionals reported improved coping with deteriorating patient situations. Regular programme activities integrated into the homecare professionals’ daily work routines sustained the competence improvement programme. Organisational issues affecting the sustainability of the competence improvement programme varied between the two homecare districts. Organisational needs were prioritised by homecare A, but sick leave, personnel turnover, busy work plans, and a change in managers in homecare B affected the maintenance of the programme. Conclusions: This thesis provides knowledge and understanding of homecare professionals’ clinical observation and how a competence improvement programme can change such observational competence. Clinical observation had a low priority before the competence improvement programme, and vital signs were rarely used to detect early deterioration in patients. The competence improvement programme changed clinical observation in defined situations; nevertheless, homecare professionals’ situation awareness of patients’ deterioration was insufficient. The PhD project demonstrates that the implementation of a competence improvement programme is influenced by factors regarding the programme itself, the professionals, the organisation and the external context

Homecare professionals’ observation of deteriorating, frail older patients: A mixed-methods study

Aim and objectives To develop knowledge about homecare professionals’ observational competence in early recognition of deterioration in frail older patients. Background The number of frail older patients in homecare has been rising, and these patients are at higher risk of deterioration and mortality. However, studies are scarce on homecare professionals’ recognition and response to clinical deterioration in homecare. Design This study applies an explorative, qualitative, mixed‐methods design. Methods The data were collected in two homecare districts in 2018 during 62 hr of participant observation, as well as from six focus group interviews. The data were subjected to qualitative content analyses. The Standards for Reporting Qualitative Research (SRQR) checklist was used to report the results. Results The data analyses revealed two main themes and five sub‐themes related to homecare professionals’ observational practices. The first main theme entailed patient‐situated assessment of changes in patients’ clinical condition, that is, the homecare professionals’ recognised changes in patients’ physical and mental conditions. The second theme was the organisational environment, in which planned, practical tasks and collaboration and collegial support were emphasised. Conclusions The homecare professionals in the two districts varied in their ability to recognise signs of patient deterioration. Their routines are described in detailed work plans, which seemed to affect assessment of their patients’ decline. Relevance for clinical practice The results can inform homecare services on how homecare professionals’ observational competence and an appropriate organisational system are essential in ensuring early detection of deterioration in frail older patients. What does this paper contribute to the wider global clinical community? Homecare professionals’ observational practice of detecting early deterioration in frail older patients is variable, and vital signs are measured infrequently. Improving homecare professionals’ observational competence by organising for timely and appropriate treatment is essential in successful recognition of deteriorating, frail older patients. This first known Norwegian study of homecare professionals’ observational competence in deteriorating frail older patients provide new knowledge to health professionals and policymakers engaged in homecare globally.publishedVersio

A competence improvement programme for the systematic observation of frail older patients in homecare: qualitative outcome analysis

Background The growth of frail older patients with extensive care needs in homecare creates a need for competence development. Improvement programmes are essential to fill this knowledge gap. However, the outcomes of such programmes remain unknown. Therefore, the aim of this study is to describe the outcomes of a competence improvement programme for the systematic observation of frail older patients in homecare. Methods This study applied a qualitative mixed-method design. Data were collected in two homecare districts using participant observation, focus group interviews, and individual interviews. Results The analysis revealed five concepts characterising the outcomes of the competence improvement programme: 1) frequency of vital sign measurements, 2) situational awareness, 3) expectations and coping level, 4) activities for sustained improvement, and 5) organisational issues affecting CIP focus. Substantial differences were revealed across the two homecare districts in how homecare professionals enacted new knowledge and routines resulting from the competence improvement programme. The differences were related to the frequency of vital sign measurements, coping levels, and situational awareness, in which successful outcomes were shaped by implementation issues and contextual setting. This involved whether routines and planned activities were set to follow up the improvement programme, or whether organisational issues such as leadership focus, resources, and workforce stability supported the programme. Conclusions This study documents the differences entailed in creating sustainable outcomes of an improvement programme for homecare professionals’ competence in recognising and responding to deteriorating frail older patients. Depending on the implementation process and the homecare context, professionals enact the activities of the improvement programme differently.publishedVersio

Lessons learnt from nursing home and homecare managers’ experiences with using the SAFE-LEAD guide

Background: In the SAFE-LEAD intervention we implemented a research-based guide (paper- and web-version) for managers to support their quality improvement work. This paper explores managers’ experiences with the SAFE-LEAD guide, and key factors of relevance for sustainability. Methods: Four Norwegian nursing homes and four homecare services participated, and 36 workshops with managers working together with researchers on the guide were conducted. After the intervention, nine focus groups with managers were conducted. Systematic text condensation was used for analysis. Results: Managers perceived the guide as useful in their quality improvement work. It helped create a systematic approach and overview of improvement activities. The guide supported collaborative reflections, awareness and fitted with their daily work. Most preferred the web-version, but technical adjustments were required to ease its use. Prioritization, anchoring, super users, and local adjustments were key factors for sustainability. Conclusion: Key factors for successful implementation were adapting the guide to the local context, access to supporting learning tools, thorough anchoring, acknowledging its benefits, and prioritizing. Further implementation studies should take technological maturity, ongoing changes and reorganizations in the sector and units into account. Careful planning and timing of the intervention, involving all relevant stakeholders at an early stage, is important.publishedVersio

Knowledge boundaries for implementation of quality improvement interventions; a qualitative study

IntroductionImplementation and adoption of quality improvement interventions have proved difficult, even in situations where all participants recognise the relevance and benefits of the intervention. One way to describe difficulties in implementing new quality improvement interventions is to explore different types of knowledge boundaries, more specifically the syntactic, semantic and pragmatic boundaries, influencing the implementation process. As such, this study aims to identify and understand knowledge boundaries for implementation processes in nursing homes and homecare services.MethodsAn exploratory qualitative methodology was used for this study. The empirical data, including individual interviews (n = 10) and focus group interviews (n = 10) with leaders and development nurses, stem from an externally driven leadership intervention and a supplementary tracer project entailing an internally driven intervention. Both implementations took place in Norwegian nursing homes and homecare services. The empirical data was inductively analysed in accordance with grounded theory.ResultsThe findings showed that the syntactic boundary included boundaries like the lack of meeting arenas, and lack of knowledge transfer and continuity in learning. Furthermore, the syntactic boundary was mostly related to the dissemination and training of staff across the organisation. The semantic boundary consisted of boundaries such as ambiguity, lack of perceived impact for practice and lack of appropriate knowledge. This boundary mostly related to uncertainty of the facilitator role. The pragmatic boundary included boundaries related to a lack of ownership, resistance, feeling unsecure, workload, different perspectives and a lack of support and focus, reflecting a change of practices.DiscussionThis study provides potential solutions for traversing different knowledge boundaries and a framework for understanding knowledge boundaries related to the implementation of quality interventions

Strategies and lessons learnt from user involvement in researching quality and safety in nursing homes and homecare

Purpose The purpose is to share strategies, rationales and lessons learnt from user involvement in a quality and safety improvement research project from the practice field in nursing homes and homecare services. Design/methodology/approach This is a viewpoint paper summarizing how researchers and co-researchers from the practice field of nursing homes and homecare services (nurse counsellors from different municipalities, patient ombudsman and next-of-kin representatives/and elderly care organization representant) experienced user involvement through all phases of the research project. The project included implementation of a leadership intervention. Findings Multiple strategies of user involvement were applied during the project including partnership in the consortium, employment of user representatives (co-researchers) and user-led research activities. The rationale was to ensure sound context adaptation of the intervention and development of tailor-made activities and tools based on equality and mutual trust in the collaboration. Both university-based researchers and Co-researchers experienced it as useful and necessary to involve or being involved in all phases of the research project, including the designing, planning, intervention implementation, evaluation and dissemination of results. Originality/value User involvement in research is a growing field. There is limited focus on this aspect in quality and safety interventions in nursing homes and homecare settings and in projects focussing on the leadership' role in improving quality and safety.publishedVersio

Mobilt Intensiv Team, en arena for sykepleiefaglig læring og kunnskapsformidling, en kvalitativ studie

Master's thesis in Health and social sciencesMobilt intensiv team (MIT) er et norsk navn på et verdensomspennende konsept hvor en på sykehus tidlig skal oppdage forverring hos pasient på post. Det omtales ved mange navn, blant annet Rapid Respons Team (RRT), Mobile Emergency Team (MET) og Rapid Medical Response Team (RMRT). Hensikten er å redusere antall hjertestans og dødsfall på sykehus, ved at ekspertise kommer til pasienten. Sykepleier på post observerer og ber om MIT etter gitte kriterier (Chan, Jain, Nallmothu, Berg, & Sasson, 2010; Jolley, Bendyk, Holaday, Lombardozzi, & Harmon, 2007). Jeg har gjort en kvalitativ eksplorerende studie hvor jeg har utført fokusgruppeintervjuer med sykepleiere ved to kirurgiske sengeposter og intensivsykepleiere ved intensivavdelingen. Mitt fokus ble rettet mot de som bruker teamet. Fokuset i studien var å se på MIT som en arena for læring og kunnskapsformidling for sykepleierne og intensivsykepleierne. I innholdsanalysen pekte det seg ut tre tema: 1) Fra kaos til system. 2) MIT et system å handle i og 3) Læring i MIT som team. Sykepleierne på sengepost beskrev en stor endring etter innføring av MIT i hvordan de håndterer den dårlige pasient på post. Kriteriene har ført til at sykepleiere og leger er enig i når pasienten er dårlig. Sykepleierne har klare rammer og retningslinjer som gir dem trygghet i hverdagen. De mente også at kriteriene har gitt dem systematisk erfaring, dokumentasjon og refleksjon rundt situasjonen til pasienten. Dette har gitt dem læring. Kriteriene er daglig observasjon av pasienten, så ved å ha pasienten i sentrum har de fått erfaring og kunnskap. Sykepleierne på post lærte også når teamet var samlet rundt den dårlige pasient. De mente de lærte konkrete prosedyrer og vurderinger. Intensivsykepleierne gav uttrykk for at den akutt dårlige pasient mestrer de, men at de lærte av å arbeide i team, på en ny arena og av å kommunisere. Intensivsykepleierne gav uttrykk for stor ydmykhet ved å være på en annen avdeling. De sammenlignet det som å gå på besøk. De var opptatt av å støtte, veilede og fremme mestring hos sykepleierne på sengepost. Informantene påpeker tre punkter som de mente fremmer og hemmer kunnskapsutviklingen i MIT. De mente det var situasjonsavhengig, at det avhenger om en får være deltaker i situasjonen og hvordan samarbeidet i teamet var.2015-06-1

Exploring Teacher Intervention in the Intersection of Digital Resources, Peer Collaboration, and Instructional Design

This paper reports on a case study of the teacher's role as facilitator in computer-supported collaborative learning (CSCL) settings in science. In naturalistic classroom settings, the teacher most often acts as an important resource and provides various forms of guidance during students’ learning activities. Few studies, however, have focused on the role of teacher intervention in CSCL settings. By analyzing the interactions between secondary school students and their teacher during a science project, the current study provides insight into the concerns that teachers might encounter when facilitating students’ learning processes in these types of settings. The analyses show that one main concern was creating a balance between providing the requested information and supporting students in utilizing each other's knowledge and understanding. Another concern was balancing support on an individual versus group level, and a third concern was directing the students’ attention to coexisting conceptual perspectives. Most importantly, however, the analyses show how teacher intervention constitutes the pivotal “glue” that aids students in linking and using coexisting aspects of support such as peer collaboration, digital tools, and instructional design

Supporting students' conceptual sense-making in computer-based settings in science. Exploring the support aspects of digital Tools, peer Collaboration, teacher intervention, and instructional design

The PhD work is conducted within the field of science education, and investigates how to support students’ conceptual sense-making in computer-based settings in science. More specifically the undertaken work focuses on how digital recourses, peer collaboration, instructional design and teacher interventions may facilitate students’ conceptual sense-making. The thesis consists of three studies which build on a socio-cultural perspective of learning and cognition. The three studies are case studies; two of them are qualitative, and one is a comparative mixed method study. The undertaken research can be described as design based research: Two computer-based learning environments have been developed and used as part of regular science instruction in grade 10 and 11 in Norwegian schools. Video recordings of student groups’ and the teachers’ interactions during the computer-supported science projects constitutes the main data material. Additionally pre- and posttest data targeting students’ understanding of a science related topic, and post interview data of students’ conceptual understanding of specific science concepts constitute central data. The main overall finding of the undertaken work is the significant role of the teacher in supporting students’ learning processes in computer-supported settings. The teacher constitutes the pivotal “glue” that enables students to link and make use of coexisting support aspects, such as digital resources, peer collaboration, and instructional design. Furthermore, the thesis also demonstrates that animations support students’ conceptual sense-making in different ways than static visualizations do, which may explain why students learning outcome is higher when working with animations versus static visualizations. The work is carried out at the Department of Teacher Education and School Research, University of Oslo