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Improving quality and safety in nursing homes and home care: the study protocol of a mixed-methods research design to implement a leadership intervention.

ABSTRACT: INTRODUCTION:Nursing homes and home care face challenges across different countries as people are living longer, often with chronic conditions. There is a lack of knowledge regarding implementation and impact of quality and safety interventions as most research evidence so far is generated in hospitals. Additionally, there is a lack of effective leadership tools for quality and safety improvement work in this context. METHODS AND ANALYSIS:The aim of the 'Improving Quality and Safety in Primary Care-Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) study is to develop and evaluate a research-based leadership guide for managers to increase quality and safety competence. The project applies a mixed-methods design and explores the implications of the leadership guide on managers' and staffs' knowledge, attitudes and practices. Four nursing homes and four home care services from different Norwegian municipalities will participate in the intervention. Surveys, process evaluation (interviews, observations) and document analyses will be conducted to evaluate the implementation and impact of the leadership intervention. A comparative study of Norway and the Netherlands will establish knowledge of the context dependency of the intervention. ETHICS AND DISSEMINATION:The study is approved by the Norwegian Centre for Research Data (2017/52324 and 54855). The results will be disseminated through scientific articles, two PhD dissertations, an anthology, presentations at national and international conferences, and in social media, newsletters and in the press. The results will generate knowledge to inform leadership practices in nursing homes and home care. Moreover, the study will build new theory on leadership interventions and the role of contextual factors in nursing homes and home care.

SUBMITTER: Wiig S

PROVIDER: S-EPMC5875614 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Improving quality and safety in nursing homes and home care: the study protocol of a mixed-methods research design to implement a leadership intervention.

Wiig Siri S Ree Eline E Johannessen Terese T Strømme Torunn T Storm Marianne M Aase Ingunn I Ullebust Berit B Holen-Rabbersvik Elisabeth E Hurup Thomsen Line L Sandvik Pedersen Anne Torhild AT van de Bovenkamp Hester H Bal Roland R Aase Karina K

BMJ open 20180328 3

<h4>Introduction</h4>Nursing homes and home care face challenges across different countries as people are living longer, often with chronic conditions. There is a lack of knowledge regarding implementation and impact of quality and safety interventions as most research evidence so far is generated in hospitals. Additionally, there is a lack of effective leadership tools for quality and safety improvement work in this context.<h4>Methods and analysis</h4>The aim of the 'Improving Quality and Safe ...[more]

PMID: 29599394

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Project description:In 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing.Administrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement.No significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication.Participants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention is working and how it might work better. Qualitative results suggest the lack of early changes observed in prescribing may reflect the number of upstream factors that need to change for APM rates to decrease.ClinicalTrials.gov, NCT02604056.

Project description:ObjectiveTo describe the design of a leadership intervention for nursing home and home care, including a leadership guide for managers to use in their quality and safety improvement work. The paper reports results from the pilot test of the intervention and describes the final intervention programme.DesignQualitative design, using the participation of stakeholders.MethodsThe leadership guide and intervention were designed in collaboration with researchers, coresearchers and managers in nursing homes and home care organisations, through workshops and focus group interviews. The pilot test consisted of three workshops with managers working on the leadership guide, facilitated and observed by researchers, and evaluated by means of observation and focus group interviews with the participants. The analysis combined the integration of data from interviews and observations with directed content analysis.SettingNorwegian nursing homes and home care services.ParticipantsManagers at different levels in three nursing homes and two home care services, coresearchers, and patient and next-of-kin representatives.ResultsThe managers and coresearchers suggested some revisions to the leadership guide, such as making it shorter, and tailoring the terminology to their setting. Based on their suggestions, we modified the intervention and developed learning resources, such as videos demonstrating the practical use of the guide. Evaluation of the pilot test study showed that all managers supported the use of the guide. They adapted the guide to their organisational needs, but found it difficult to involve patients in the intervention.ConclusionsA participatory approach with stakeholders is useful in designing a leadership intervention to improve quality and safety in nursing homes and home care, although patient participation in its implementation remains difficult. The participatory approach made it easier for managers to adapt the intervention to their context and to everyday quality and safety work practice.

Project description:BackgroundPeople living with dementia in nursing homes are most likely to be restrained. The primary aim of this mixed-method education intervention study was to investigate which factors hindered or facilitated staff awareness related to confidence building initiatives based on person-centred care, as an alternative to restraint in residents with dementia in nursing homes. The education intervention, consisting of a two-day seminar and monthly coaching sessions for six months, targeted nursing staff in 24 nursing homes in Western Norway. The present article reports on staff-related data from the study.MethodsWe employed a mixed-method design combining quantitative and qualitative methods. The P-CAT (Person-centred Care Assessment Tool) and QPS-Nordic (The General Nordic questionnaire for psychological and social factors at work) instruments were used to measure staff effects in terms of person-centred care and perception of leadership. The qualitative data were collected through ethnographic fieldwork, qualitative interviews and analysis of 84 reflection notes from eight persons in the four teams who facilitated the intervention. The PARIHS (Promoting Action on Research Implementation in Health Services) theoretical framework informed the study design and the data analysis. Six nursing homes were selected for ethnographic study post-intervention.ResultsQualitative data indicated increased staff awareness related to using restraint - or not- in the context of person-centered care. A slight increase in P-CAT supported these findings. Thirteen percent of the P-CAT variation was explained by institutional belonging. Qualitative data indicated that whether shared decisions of alternative measures to restraint were applied was a function of dynamic interplay between facilitation and contextual elements. In this connection, the role of the nursing home leaders appeared to be a pivotal element promoting or hindering person-centered care. However, leadership-staff relations varied substantially across individual institutions, as did staff awareness related to restraint and person-centeredness.ConclusionsLeadership, in interplay with staff culture, turned out to be the most important factor hindering or promoting staff awareness related to confidence building initiatives, based on person-centered care. While quantitative data indicated variations across institutions and the extent of this variation, qualitative data offered insight into the local processes involved. A mixed method approach enabled understanding of dynamic contextual relationships.Trial registrationThe trial is registered at Clinical Trials gov. reg. 2012/304 NCT01715506.

Project description:BackgroundOne in four Americans, and 70% of people who have dementia, will spend their final days in nursing home care. Clinical research, particularly clinical trials, rarely includes this population due to unique challenges in research methods and ethics. Families of advanced dementia patients make choices about tube feeding and other feeding options with limited access to information or communication. The cluster randomized trial, Improving Decision Making about Feeding Options for Dementia Patients, tests a decision aid intervention to improve the quality of decision making for this choice.PurposeOur objectives are (1) to describe the methods used in this trial; (2) to describe challenges and strategies for effective nursing home and nursing home resident recruitment and retention; and (3) to describe research ethics approaches to minimize harms and maximize benefits for this population.MethodsThe study is a cluster randomized trial of a decision aid to inform and support the choice between tube feeding and assisted oral feeding in advanced dementia. Study subjects are paired surrogate decision makers and residents with advanced dementia and feeding problems, enrolled from nursing homes in North Carolina.ResultsThis trial enrolled 256 paired surrogate decision makers and residents in 24 nursing home sites, and 99% completed participation through the 3-month study period. The research team had prior clinical and investigative experience in this setting, and used multiple strategies to recruit and retain nursing home sites, providers, surrogates, and the residents for whom they spoke. Informed consent and human subjects' protections were designed to address the vulnerability of this population.LimitationsCluster randomization was necessary to avoid contamination between control and intervention subjects, but may introduce confounding by site and intracluster correlation effects in analyses.ConclusionsStrategies that facilitate nursing home recruitment, participant recruitment and protection of human subjects for a vulnerable population may be used by future investigators to expand the research evidence base for nursing home and dementia care.

Project description:IntroductionImproved 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 analysisThe 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 disseminationThe 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.

Project description:IntroductionDespite the abundance of existing literature on evidence-based nursing practice, knowledge regarding evidence-based leadership, that is, leadership supported by an evidence-based approach, is lacking. Our aim is to conduct a mixed-methods systematic review with qualitative and quantitative studies to examine how evidence is used to solve leadership problems and to describe the measured and perceived effects of evidence-based leadership on nurses and nurse leaders and their performance as well as on organisational and clinical outcomes.Methods and analysisWe will search the following databases with no year limit or language restrictions: CINAHL (EBSCO), Cochrane Library, Embase (Elsevier), PsycINFO (EBSCO), PubMed (MEDLINE), Scopus (Elsevier) and Web of Science. In addition, the databases for prospectively registered trials and other systematic reviews will be screened. We will include articles using any type of research design as long as the study includes a component of an evidence-based leadership approach. Three reviewers will independently screen all titles, abstracts and full-text articles and two reviewers will extract the data according to the appropriate checklists. The quality of each study will be appraised using specific appraisal tool fitting in study design used in each study. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) grid, PRISMA Protocols, Synthesis Without Meta-analysis and ENTREQ will guide the study process and reporting. Outcomes related to individual or group performance of nurses or nurse managers regarding leadership skills (e.g., communication skills), organisational outcomes (e.g., work environment, costs) and clinical outcomes (e.g., patient quality of life, treatment satisfaction) will be extracted and synthesised.Ethics and disseminationThis systematic review will not include empirical data, and therefore, ethics approval will not be sought. The results of the review will be disseminated in a peer-reviewed scientific journal and in a conference presentation.Prospero registration numberCRD42021259624.

Dataset Information

Improving quality and safety in nursing homes and home care: the study protocol of a mixed-methods research design to implement a leadership intervention.

Publications

Improving quality and safety in nursing homes and home care: the study protocol of a mixed-methods research design to implement a leadership intervention.

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