CARE - Continuity and quality of care in nursing

Continuity of care

The present knowledge base regarding the concept of Continuity of Care within health service and nursing research reflects fragmented evidence whilst also highlighting an interchangeable use of different concepts such as transitional care, integrated care, coordinated care and continuity of care. At present Freeman and colleagues (2000; 2002) (1, 2) are those offering the most comprehensive definition of continuity of care. Their definition is yet to be explored and tested but it will initially offer a solid departure base for studying continuity (or discontinuity) of care. Considering the present evidence concerning the operationalisation and definition of Continuity of Care, each unique research project is therefore expected to, within its project design, to succinctly articulate its specific and wider contribution to the concept of Continuity of Care within health service research, nursing, nursing education and nursing research.

Multiaxial definition of Continuity of Care (1, 2)

Experienced: experience of a coordinated and smooth progression of care from the user’s point of view

Flexible: to be flexible and adjust to the needs of the individual over time

Cross-boundary: effective communication between professionals and services and with service users

Information: excellent information transfer following the service user

Longitudinal: care from as few professionals as possible, consistent with other needs

Relational: to provide one or more named individual professionals with whom the user can establish and maintain a therapeutic relationship

Long-term: uninterrupted care for as long as the service user requires it

Contextual: Care which should sustain a person’s preferred social and personal relationship in the community and enhance quality of life

Quality of Care

The second theoretical framework is a multidimensional health care quality model based on Institute of Medicine’s (IOM) quality model (2001) (3) and its six domains: Person-centredness, Timeliness, Efficiency, Effectiveness, Safety and Equity. In the new quality model proposed by Lachman and colleagues (2021) (4) five of the domains are kept and the domain Eco-friendly is added. Rather than being a separate domain, Person-centredness is the overarching “umbrella domain” in the new model and seen as a precondition for quality in all domains. Furthermore, the concept of "kin-centred care" is introduced, highlighting the shared humanity and interdependence of all individuals involved in healthcare, i.e. those who receive and those who deliver healthcare. Principles of Transparency and Leadership surrounds the domains. The model focuses co-creation of better health rather than disease management, in line with the holistic perspective of nursing. The new multidimensional model provides us with a theoretical framework for operationalising and defining quality of care and serves as a point of departure for studying quality of care as a concept and a phenomenon within nursing.

References

1. Freeman, G, Shepperd, S, Robinson, I, Ehrich, K, Richards, S. Continuity of Care: Report of a Scoping Exercise for the SDO Programme of NHS R&D. National Co-ordinating Centre for Service Delivery and Organisation: London; 2000.

2. Freeman, G, Weaver, T, Low, J, de Jonge, E, Crawford, M (2002). Promoting Continuity of Care for People with Severe Mental Illness whose Needs Span Primary, Secondary and Social Care. National Co-ordinating Centre for Service Delivery and Organisation: London; 2002.

3. Institute of Medicine (US) Committee on Quality of Health Care in America: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US): 2001.

4. Lachman, P., Batalden, P., & Vanhaecht, K. (2021). A multidimensional quality model: an opportunity for patients, their kin, healthcare providers and professionals to coproduce health. F1000Research. 2021, 9:1140. DOI: https://doi.org/10.12688/f1000research.26368.3

The projects within the platform will depart from a set of strategic methodological frameworks of importance for the development of sustainable research. Using a set of methodological frameworks will ensure that effectiveness and usability aspects are strong parts of our projects’ design. Each project will be designed with a strong external, but unique relation, to the overarching and unifying core concepts: Continuity of Care and Quality of Care. Amalgamating projects around the core concepts will support the development of an incremental knowledge loop (learn, create, share, and learn again) regarding the concepts per se and in relation. It will also contribute to a sustainable knowledge development within health services research, with the specific focus on nursing and nursing science, and the individual topics in foci.

Methodological frameworks (5, 6, 7)

Medical research Council’s Framework for Complex Interventions (MRC):

Adding value:
Ensuring quality in design and methods

Public, patient and Professional Involvement (PPPI):

Adding value:
Setting research agendas
Hight priority questions asked
Important outcomes assessed

Ensuring value in Research (EViR):

Ensuring value:
Setting justifiable research priorities

References:

5. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061. DOI: https://doi.org/10.1136/bmj.n2061

6. Gray R, Brasier C, Zirnsak T-M, Ng AH. Reporting of patient and public involvement and engagement (PPIE) in clinical trials published in nursing science journals: a descriptive study. Res Involv Engagem. 2021;7(1):88. DOI: https://doi.org/10.1186/s40900-021-00331-9

7. EViR Ensuring Value in Research. Southampton: EViR; 2022: https://evir.org

PhD student: Ida Røed Flyum

Main supervisor: Professor Edith Roth Gjevjon

Co-supervisors: Professor Gunilla Borglin, Associate professor Anna Josse Eklund and Dr. Veronica Pavedahl. 

Home care is a central part of our health services. Nevertheless, we have limited research-based knowledge about nursing practice itself in this complex context. Nursing practice in this context requires a high degree of security, knowledge and competence, especially when it comes to being able to detect and handle early signs of deterioration in the health condition of older service recipients. Considering the negative effects associated with functional ability limitations and frailty and the fact that nurses have a key responsibility related to detection and prevention it is vital that nurses are supported in their practice within the complex and often challenging context of homecare. Being able to fulfil their responsibilities in this context requires both qualified and competent professionals; consequently, a nursing practice characterised by systematic and evidence-based working modes. Recent research advocates that an internalised professional identity, that is, - think, act and feel like a nurse - is central related to the nurses practice (and activities), their decision-making, and their abilities to lead care. Therefore, this doctoral project has mapped published literature on how functional ability limitations and frailty among older people is described and identified models of care targeting these two conditions. Following this we will use observations and interviews to describe and explore nursing practice aimed at functional ability limitations and frailty among older people receiving home-based nursing care. The knowledge we gain from these observations and interviews will be used to develop an intervention: a program for strengthening the attention to and awareness of nurses' professional identity and clinical decision-making process.

One overarching goal of this PhD project is to generate research-based knowledge with the aim of strengthening and developing home-based nursing services. It is essential to effectively utilise the competencies of various healthcare personnel in this context. Doing so will aid in retaining and recruiting the expertise necessary for both the service and its recipients. A knowledge-based, systematic way of working will ensure that symptoms and signs of deterioration of health condition is detected and dealt with early. Such practice will save lives and finances as well as improve the quality of life and health among older people and significant others. This is how we believe and hope that the knowledge we develop through this project will be useful, both for those who perform and those who receive home-based nursing care.

PhD student: Ole Martin Nordaunet

Main supervisor: Professor Gunilla Borglin

Co-supervisors: Professor Edith Roth Gjevjon, Professor Hanne Aagaard, Professor Cecilia Olsson.

The core of nursing is addressing psychosocial, relational, and physical needs and are central to the scope of practice of nurses, here understood as registered nurses (RNs) or nursing associates, healthcare-workers and so on (i.e. non-RNs). Nurses scope of practice is defined as “the full spectrum of roles, functions, responsibilities, activities and decision-making capacity which individuals within the profession are educated, competent and authorised to perform”. Consequently, it is well within the role and function of RNs to evaluate, lead, co-ordinate, assess and plan nursing activities that focus on the patients’ fundamentals of care, regardless of context or patient groups. However, the scientific literature is to a lesser degree reflecting the unique role, function and activities of RNs in relation to the fundamentals of care, and this is especially the case for older people in facility-based care (i.e. nursing homes). This is troublesome as the residents living out their final days are considered frail, multimorbid and in are in a need of compensatory fundamental care that reflects continuity, that is, a precursor for high quality care.

As nursing practice does not occur in a vacuum, it is better viewed as an event within a complex system, hence, nursing practice is entangled in an intricate interrelationship between the activities focusing the fundamentals of care and the context in which the nurse conducts their practice. Consequently, a number of contextual modulators comes to play which modulate and affect nursing practice positively or negatively. Examples of contextual modulators are found on personal a personal level, such as professional identity in nursing, but modulators are also present in the organisational, leadership and organisational structural levels.

The overarching aim of this PhD project to explore and synthesize the scientific literature concerning the fundamentals of care, continuity of care as well as possible nursing interventions and/or activities targeting older people´s fundamentals of care in home- and facility-based care (PI). A second aim was to explore nursing practice, its modulators and decision-making processes related to the fundamentals of care targeting older people in facility-based care (PII). Lastly this thesis aimed to investigate how nurses, in non-dyadic pairs, described their practice per se and, in relation to older people’s fundamentals of care (PIII) as well as to explore dementia and geriatric care nurses’ perception of their professional identity (PIV).

PhD student: Caroline Kreppen Overen

Main supervisor: Professor Siren Eriksen

Co-supervisors: Professor Maria Larsson, Professor Cecilia Olsson, Associate professor Adelheid Hillestad

Symptom management is one of the main aspects of palliative care. People with dementia living in nursing homes often have high levels of pain. Untreated pain cause suffering and reduces quality of life. Pain is a subjective experience, and self-reported pain is the gold-standard of pain assessment. This is often challenging in the target population, due to reduced cognitive function and communication challenges, which highlights the importance of supporting people with dementia in communicating their experiences of pain. The aim of the project is two folded: (1) To generate new knowledge and perspectives about how people with dementia express pain, and how these expressions can be integrated in pain management in nursing homes and (2) bring about change through the development of an intervention with the aim to safeguard these processes.

The development of this intervention is rooted in the initial steps of the MRC framework for developing and evaluating complex interventions. The project includes a scoping review (study I), a focused ethnographic study (study II), an interview study using nominal grouping technique (study III) and a dyadic interview study (study IV).