Demographic, epidemiological, social and cultural trends are challenging the demand and supply of home care services (World Health Organisation [WHO], 2000: 1-2). Day surgeries, technological advances and new drugs have made it possible to receive care at home that was formerly available only in hospital. The ageing population, coupled with the tendency to discharge patients from hospitals at an earlier stage of recovery, has made the provision of health and other support services to the individual in their homes increasingly more important (WHO, 2008: 3). Moreover, socio-demographic changes and mobility trends are decreasing the availability of informal care.
Home care aims at meeting people's health and social needs in their home. The main aim of home care is to maintain peoples' health and independence, and preventing the need for unnecessary acute and long term institutionalisation (Care Quality Commission [CQC], 2010: 7). The United Kingdom regulator on health and social care recommends that this is achieved by focusing our care on the individual's needs rather than on the system needs (CQC, 2010: 7).
The Maltese Department of Health has embarked on a reform to strengthen the primary health care services. The purpose of this project is to reposition the primary health care in the center of our health system (Ministry for Social Policy. Mr. Dalli, 2009). The reform is aimed towards enhancing equity in access to care, promoting quality and excellence, and safeguarding sustainability. Moreover, since 2007 the government has created a regulator to ensure quality of care and patient safety at point of health care delivery (Directorate for Health Care Services Standards, 2009). Considering the above and the emphasis on long term care in the health spectrum in was deemed appropriate to evaluate the current services in Malta. This study will focus upon community nursing care services since they a form a major constituent of the Primary Health Care System and home care.
The Research Problem and Its Significance
Community nursing care in Malta is provided through both national and independent agencies. The Maltese national health system provides community care through an independent agency. A government agency (CommCare) refers individuals whose illness inhibits them to get the service elsewhere, for this service. It is provided free at the point of use and constitutes the largest proportion of community care in Malta. There are also private agencies employing nurses and carers who provide home care services at a cost.
The demand for such services is expected to grow as we enter an era of ageing population, and an ever increasing demand for hospital beds. The Maltese National Statistics Office (2009) estimates an increase of 20% in the elderly population by the year 2025. There is only one acute publicly funded hospital for the Maltese Islands, therefore reducing the number of unnecessary admissions and length of stay is imperative. In United Kingdom, the Care Quality Commission (2010: 7) estimated that £2 billion could have been saved from unnecessary hospital care of individuals that would otherwise be treated through home care services.
In times where health care expenditure is barely sustainable and in which quality is vital; one must ensure that the resources available are used in the most efficient and effective manner. In addition, the developments of standards for quality care and ensuring accountability from service providers are necessary requirements for the successful implementation of the reforms objectives. This can be achieved through continuous evaluation and monitoring of the service.
The purpose of this study is to evaluate the community nursing care service provided in Malta since no other systematic review could be found. A holistic perspective is essential in order to perform a proper evaluation and to be able to recommend the best strategy to move forward. The patients are important evaluators for the health services (Törnkvist, Gardulf, and Strender, 2000: 67). The level of users' satisfaction with the service is an important indicator of its quality, appropriateness and acceptability (Townsend & Kosloski, 2002: 91). Moreover, research shows that satisfied patients seem to be more willing to comply with professional advice and instruction. It is important to ensure that the service provided is meeting the objectives for which it has been established. The assessment of the service providers is necessary to identify current services available, resources, and their operations. These are useful in identifying gaps in the services, and quality of care provided. Finally, the views of the regulatory bodies are key areas to look at since they set the standards in which these agencies should work.
Research Aim
The aim of this research is to evaluate community nursing care services in Malta.
Research Objectives
The research objectives that this study will follow include:
To identify the services and assistance provided;
To assess the level of clients' satisfaction with community nursing care service;
To identify clients' needs for community care services;
To establish whether the current services are in line with the needs of users;
To determine how the nursing agencies are delivering the service; and
To gather data to serve as a guide for future development and improvement of service.
To identify the services and assistance provided;
To assess clients feedback on quality of service provided;
To determine the quality standards provided by the nursing agencies;
To establish whether the quality standards provided are in line with the clients feedback; and
To gather data to serve as a guide for future development and improvement of service.
Chapter 2: Literature Review
Chapter 2
Literature Review
Introduction
Conceptualisation of Home Care
Many researchers attempted to define and conceptualise the concepts of home and community care. Some have differentiated between qualified and unqualified professional and distinguished between these two terms as 'Home health care' referred to skilled medical services whilst 'home care' referring to personal care and supportive services. Yet, definitions within the literature overlap and there is no clear cut. The WHO (2008) acknowledges that home care involves a wide range of providers including a mix of professional and non professional's personnel including nurses, therapists, physicians, social workers, homemakers, volunteers, carers and home care assistants amongst others. Nurses constitute the largest group of all these professionals. There role varies from the provision of skilled nursing care to care managers where identification of needs is done.
Nursing in the Community
Community nursing is characterized by challenges, responsiveness and opportunities (St John & Keilher, ). It involves working outside of a hospital and an institutional setting. In this set up nurses are required to work independently, exercise independent judgment, coordinate and manage care teams, and to provide more sophisticated and advanced procedures (WHO, 2008).
The role of a community nurse varies whilst some have clear titles such as 'domiciliary nurse', 'school nurse', 'district nurse', and 'home health visitor' many do not, and fall under the umbrella of community nurse. The distinction between these roles lies in the aim of the service provided and the philosophy that guides them. For the purpose of this project community nursing and home care nurses will be used interchangeably. The focus of this role is to manage acute and chronic condition and promote self care. In order to be successful the home care nurse must incorporate the family or caregivers in their plan of care.
The practice of community nurses depends on a number of factors including the legal framework that allows the nurse to carry out in the home, ethical issues and finally the agency. The agency policy, procedures and standards of care are important determinants of the quality of care delivered in terms of equipment, supplies, funding and patient family systems. Moreover, they must view health from the patient perspective. This will allow the nurse to offer their services to assist patients in realizing their own potential for optimal health whether it is to regain independence or to die in dignity (Rice, 2006). The notion of patient involvement in his care is as important in the hospital as it is in the community. Unless the patient is an active part of the plan of care success is not likely to be achieved. Therefore it is essential that home care nurses work with the patient rather than for the patient.
The role of home health nursing is continuously changing. Treatment that was once administered only in a hospital setting is now available and integrated into home care (Ehrenfeld, 1998). Clients and families have increased responsibility for their own care placing the nurse in a unique position to assist these emerging needs. Since home health nursing care has become more comprehensive in its purpose ensuring its quality is becoming more important.
Defining Quality of Care
Defining quality of care has generated a lot of discussion and is largely dependent on the context it is being used. According to Donabedian (2005) quality of care is
"almost anything anyone wishes it to be, although it is, ordinarily, a reflection of values and goals current in the medical care system and in the larger society of which it is a part".
The Institute of Medicine defines quality of care as the
"quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge". IOM, 1990, p. 21
According to the Institute of Medicine (2005) and WHO (2008) this definition highlights many important factors including that:
It refers to a wide range of services and professionals;
It identifies both the individual and population as targets for quality of care;
Recognise that poor outcomes can still occur despite the best possible practice;
Services should provide more good than harm;
Emphasise the need to explore patient's values and preferences in order to identify desired outcomes; and
Emphasise that professionals must stay abreast with the rapidly expanding and changing knowledge base and to use such knowledge appropriately.
The above two definitions have been cited by the WHO (2008) as the most important in defining quality of health care and are therefore used as to guide this review.
Quality in Home Care Settings
The notion of quality of care has become an ever important issue in home care. The increase demand for the service, and the growing concern for value for money in health care are all putting pressure on governments, clinicians and health care providers to continuously evaluate services in order to identify the most effective and efficient practice of care (van Driel et al, 2004). Francis & Netten (2004) states that good quality home care is fundamental in maintaining people in their own homes and its' achievement is a matter of international concern.
Most researchers have defined quality of care by describing the concept in terms of a set of dimensions. The WHO (2008) cites a number of dimensions in quality of care including effectiveness, efficiency, access, safety, timeliness, acceptability, patient centred, satisfaction, continuity of care and improvement. The choice of dimensions in analysing quality of care is crucial as they will determine the health care policies adopted. Furthermore the setting up of standards of achievement for services is seen as fundamental to the achievement of quality as well as for evaluation purposes.
Standards in home care has been on the increase across
Evaluating the quality of services
Evaluation is defined as the systematic investigation of the merit, worth or significance of an object against a set of standards (REF).
Donabedian (1988) model for the analysis of quality of care is highly used in the evaluation process. This model consists of three main components including structure, process and outcomes, each with different determinants. Structure denotes the attributes of the setting in which care occurs. These attributes include material resources such as facilities, equipment and money, human resources and organisational structure. Process involves what is actually being done in giving and receiving care. These are classified into patient related such as intervention rates, number of visits, and organisation related including management of waiting times, collection funds, avoidance of waste, and risk reduction. The last component describes the effects of care on the health status of the patient and population. Outcomes include health improvements, meeting clients' expectations, and improved mortality and morbidity. Figure illustrates the quality dimensions that a good health system must have based on the Donabedian model (Shaw & Kalo, 2002).
Figure : Qualities of a health system. Adopted from Kalo & Shaw (2002)
Structure - availability of human, financial, technical resources (investment):
How they are allocated in terms of time, place and responsiveness to the needs of populations (access);
Fairness in sharing costs and benefits (equity).
Process - how the resources are applied (stewardship):
Use of time and resources (efficiency);
Avoidance of waste (economy);
Reduction of risk (safety);
Evidence-based practice (appropriateness);
Patient-focused care (continuity);
Public information (choice, transparency, accountability).
Outcome - what results are achieved (performance):
Population health (health improvement);
Clinical outcome (effectiveness);
Meeting expectations of public and workforce (satisfaction);
Value for money (cost-benefit).
This model of evaluating a service has been highly recommended in literature [reference]. Traditionally the focus was on the structural analysis however this is no longer advocated. Recent trends are focusing on measuring process and outcome in terms of quality of care. Donabedian (1988) argues that structural analysis is rather blunt in quality assessment but is important in system design. Process and outcome measures are still debatable especially if considered mutually exclusive. Outcome measurement is dependent on a number of factors outside the health care system. Mant (2001) categorise these factors in four categories as demonstrated in Table . Process measurements are more sensitive to quality of care issues nonetheless according to Mant (2001) they are more important for those providing the service rather than for the receivers. Donabedian (1988) suggested that any quality of care assessment should include the three elements in order to balance out the strengths and weaknesses of each approach. This model serves as a framework which investigators can use as a guide. They serve to define the standards and criteria upon which assessments are carried out.
Table : Factors influencing variations in outcomes (Mant, 2001)
Categories
Sources of Variation
Differences in type of patients
Confounded by patient characteristics
Differences in measurement
Ascertainment and definition of cases, outcome and risk factors
Chance
Random variation, Type II errors
Differences in quality of care
Use of proven intervention
The Donabedian model has been criticised on the fact that it measures quality from the perspective of the service provider. On this notion the service marketing approach was developed and looked at quality from the client point of view. Parsuraman et al, conducted an extensive research into the perceptions of services quality in 4 services industries and developed the SERVQUAL scale. This scale is based on five quality dimensions including:
Tangible
Reliable
Responsiveness
Assurance; and
Empathy
The use of this model in health care has been questioned because of the different nature of health care delivery setting. Ramsaran-Fowder (2005) stated than applying one generic measure of service quality for all services is inappropriate especially in health care industry where different attributes are present because of its differing nature.
Evaluation of home care services are challenging since they depend upon important factors including value for who, and by whom its value should be assessed. Aronson (2003) identified three different evaluators in health care quality including health economics, managerial and evidence-based. The author adds that from a health economic perspective the value of home care is determined in terms of its costs and cost savings from more expensive health services. From an evidence-based perspective the value is assessed upon improvements' in health or health functioning whilst from a managerial perspective its value depends on its ability to demonstrate efficiency. These approaches tend to be top down and away from the users perspectives they are serving. The drive towards a consumer driven health service acknowledging the clients feedback is essential (Coleman, 2000). This is especially important in view of the fact that home care service infringe into the most private arenas of people life.
Clients Satisfaction with the service
Measuring client satisfaction with the service is one way of assessing outcome of care. Bear & Bowers (1998) define client satisfaction as the user's perception of the quality of service they receive. When a service does not meet the needs and expectations of the service users' then it has failed to achieve one of the intrinsic functions of the service. Dissatisfied clients are unlikely to seek to use the service again. However this is a problem when the service users have no other alternatives. In this case it is up to the service provider and to the funder to ensure that the customers are satisfied. Client satisfaction is important both as a quality assurance measure as well as a marketing tool that agencies can utilize (Bear & Bowers, 1998; Keepnews, 2004). Moreover when seeking customer feedback about services it assists service providers in their endeavors to ensure that they are meeting clients' needs and expectations.
The notion of client oriented health care services has placed increasing importance on the measure of patient satisfaction. Indeed, soliciting patients' feedback conveys a message that the agency values their opinion (Keepnews, 2004). Clients have expectations regarding the service they are provided with, including the kind of service they receive, how they are being treated, the quality of care they receive and their expected improvements in health outcomes (Keepnews, 2004). Evaluation of the services including satisfaction surveys are a means of how these expectations are assessed (Keepnews, 2004).
Research on clients' satisfaction with home health nursing care consistently turns up with high level of satisfaction amongst users (Laferriere, 1993; Tornvists et al, 2000; more to add). Laferriere (1993) conducted a descriptive explanatory study using a revised instrument developed on client satisfaction in a home health agency in United States. Data collection was carried out using a mailed survey from seventy three randomly selected users. The questionnaire measured satisfaction on four domains including technical quality of care, communication, personal relationship between client and provider and delivery of services. The author reports a high degree of satisfaction amongst all respondents. Less satisfaction levels were identified in the information giving, ability to discuss changes, and understanding how to keep healthy.
Riccio (2000) assessed the level of satisfaction amongst physician, nurses and patients regarding home nursing care. 139 patients, 99 physicians and 20 nurses were randomly selected for the study. The instrument was a 33-item questionnaire based on the American Nurses Association community health nursing standards of care. Content validity was established though expert review. Factor analysis yielded 4 subscales including technical nursing care, professional nursing care, community/psychosocial skills, and teaching. Reliability was found to be 0.94 using a cronbach alpha test which is considerably high. The instrument used a Likert Scale for the closed ended questions and had an open ended question. The majority of physicians and patients rated undecided on total satisfaction scores of patients unlike the nurses. The highest satisfaction was on the professional nursing care whilst for the three other dimensions the patients were mostly undecided. In comparison, the physicians were mostly satisfied with the teaching that nurses carry out, whilst the nurses were mostly satisfied across all dimensions. Although the generalization of the study findings should be carried out with caution in view of the small sample and location, it is important to note that each stakeholder has a different perception of the service. This aspect is important because it highlights the need for the providers to receive feedback since their perceptions about the delivery of the service might be incongruent with what the service users are experiencing.
In another study, Townsend & Kosloski (2002) interviewed 1183 family caregivers to identify factors related to client satisfaction with community based respite services. There were three types of respite services including in-home, adult day care and institutional respite care. Overall client satisfaction was negatively skewed towards a high level of satisfaction across all types of services. The variables used to assess caregivers' satisfaction with services and their perceptions of service delivery were caregivers' expectations, community difficulties, access to services, and amount of red tape. Client satisfaction with the in-home respite revealed statistical differences across Hispanic ethnicity, the activities of daily living assistance, caregiver's expectations, access to services and the amount of red tape. Hispanic tended to be more satisfied than whites which may reflect the cultural differences rather than the service as such. As the patients' need for activities of daily living increased and the caregivers' expectations met so did the level of satisfaction. Those with increased access to the services had a higher level of satisfaction whilst those who had to pass through a lot of red tape were less satisfied.
Satisfied clients are the target of every organization yet the interpretations of satisfaction surveys must be carried out with caution. Keepnews (2004) categorized these problems into three groups including the lack of standardization of measurement tools, consistently high satisfaction rates, and challenges specific to home health care.
The lack of standardization across the studies makes it difficult to compare across research and between countries. Indeed, there is a drive towards standardizing tools for assessing community care with countries such as in the United Kingdom, United States and Australia. This assists individual users to decide which care agency they should go to. However, each agency can have their own unique measurements especially if they are from the private sector.
Concerns in types of bias, response rates, and sampling techniques have been raised in light to the high satisfaction levels achieved in research (Keepnews, 2004). The fact that most questionnaires are on predetermined items may not necessarily reflect what is significant to the client. The use of open ended questions is encouraged to allow customers to express what is also relevant to them. Besides, most studies use current users who may be reluctant to show dissatisfaction due to fear of losing the service. Some users prefer to have a service which may not be up to the required standard than nothing. On the other hand, using a retrospective sample may not provide a reflection of the true picture. If a client had a terrible experience but the health outcome was positive, the latter may be more predominant in the client's mind and therefore express a high level of satisfaction.
Lastly home health care faces unique challenges that are not present in other services. First it occurs at the providers' home and the health care provider is a visitor thus, is not in control of the environment. Second clients may be grateful or resentful to the worker per se and not the agency.
Another important aspect is that the contents of the satisfaction survey should reflect the dimensions of the service that will help to define the quality of the service.
Standards in home and community care
The developments of standards are useful for a number of reasons. First they set the necessary requirements that an organisation must possess in order to operate and to the achievement of quality. Second standards explicitly state what people have a right to expect thus providing grounds for complaints and redress. Finally they promote equity of provision, can help to empower users and can be seen as a basis for public accountability (Izard, ). In order to be consumer centred the standards set must be meaningful to them.
A number of studies looked at how patient defined quality of care. Sofaer & Firminger (2005) in their review of patient perception of quality grouped these perceptions into seven dimensions. The authors reviewed 11 different studies and found that they share similar definitions. The dimensions include patient-centred care, access, communication and information, courtesy and emotional support, technical quality, efficiency of care/organisation, and structure and facilities. Similar findings are found in Cheraghi-Sohi et al, (2006) study. The investigators mapped out seven major categories as the key attributes of patients preference concerning primary care. The categories included access, technical care, interpersonal care, patient-centred, continuity, outcomes, and hotel aspects of care. Both reviews used different studies including a diversity of countries, populations, and cultures. The fact that similar dimensions were established reinforces their actual representation of patient preference.
Two studies investigating users' values about home care service also revealed similar conclusion to the reviews mentioned above. Although the themes might be named differently the essence is still the same. Aronson (2003) conducted a qualitative study to explore service users' experience about reliance of care at home and to track their experiences and perspectives over a 4 year period. Twenty seven women were purposively selected form a community organisation in Ontario with twenty of them above the age of 65 years. There demographics varied substantially making the sample more diverse and therefore provide a wider perspective. The researcher, an independent agent from the home care sector, carried out semi-structured interviews twice a year. The users' values on the care providers and case managers were grouped into four themes including minimising exposure, being known, staying in charge, and being able to speak. Privacy, consistent personnel, and continuous care were under minimised exposure. Being known was particularly emphasised and they expected both the care worker and the case manager to know them and respected their needs. The issue of empowerment, and having care coordinated around their lives were stressed and placed under staying in charge. Moreover being informed about the time or arrival and time keeping were also valued. Awareness and appreciation of users' plan were considered very important for some. A quote to emphasise this goes to say "but my plans mean nothing - like I've no life to consider?". Issues under in being able to speak, included participation in decision making and feedback sought from the agency. In order for the service providers to know their clients they must seek feedback and be prepared to listen, although generalisation from an ethonograph study is limited the quality of the data is very reliable. Furthermore, these results are similar to Francis & Netton study (2004).
Francis & Netton (2004) carried out interviews with thirty two selected users using home care and fourteen home care agencies within one local authority in the United Kingdom. Service users were mostly older people above seventy five years of age from various ethnic origins. Twenty users had regular visits from the district nurse whilst the others from carers. The authors asked open questions on six key aspects of quality identified from previous literature including reliability, continuity, flexibility, communication, staff attitudes and skills and knowledge. Twenty users stressed the importance of timing however some were more concerned about the fact that the service was provided rather than the time. Users understood the fact that most carers were overloaded with work and they had to rush. The sample had mixed values in regards to continuity. Whilst some valued having a pool of carers who they became attached, for others this was not an issue. Communication was important as emphasized in other research. Being able to speak the same language was mentioned in view of the different ethnical background within the sample. Indeed this is essential for good communication to take place. The most crucial aspect to high quality for this sample was staff attitudes. They identified aspects such as respect, cheerfulness, happy, understanding and friendly as crucial attitudes home care workers should possess.
The drive towards a patient centered care as opposed to medically focused incorporate that care is tailored to patients' needs and preferences. Thus it is essential that these needs and preferences are known in order to provide the right standards for quality of care. Moreover Sofaer & Firminger (2005) adds that patient perceptions of quality care are powerful drivers of outcomes for various stakeholders including management, providers, patient themselves and the population as a whole.
Safety
Home care provides care in a different setting than other types of health care services. Whilst there is an overwhelming research on patient safety in institutional care this cannot be extended to the home care (Lang et al, 2009). Institutional health care are regulated system designed to provide care with professionals and support staff guided by supervision and administration. This cannot be transcribed for the home care environment (Lang et al, 2006). Taylor & Donnelly (2006) acknowledge that safety standards are necessary criteria in home care provision for a multiple of factors. These include client's vulnerability and the relative autonomy of client's home, professionals' values such as confidentiality and respect, increasingly sophisticated tasks, and provided in a complex arena of health and safety legislation. Several hazards have been identified in the literature including musculoskeletal problems, abuse both verbal and physical, equipment safety, and medication errors amongst others. Acknowledging these safety hazards and implementing actions to minimize them should be every provider priority.
Taylor & Donnelly (2006) conducted a qualitative grounded theory approach study to explore the perspective of risk on a number of professionals involved in the long term care of older people. Focus groups were carried in eleven different trusts in the United Kingdom. The workers identified risk such as hygiene and infection, manual handling, aggression and harassment, animals and safety of home equipment. The handling of hazards varied from the workers adapting to the needs of the patients themselves, to the case managers identification and managing of risks for the safety of the worker such as lifting equipment, and electricity check up in their initial assessment. There was a great reluctance to stop the service even if it was deemed to be unsafe amongst workers. This unwillingness was also noted in United States. Most workers would try to find alternatives but still carry out the work to respect clients' needs. The responsibility of risk acceptance varied across the trusts in question. Issues were raised when the standard or preferred choice of living of the client conflicts with health and safety for the workers. Accepting the client's right of choice and freedom to compromise the worker are usually issues of debate and controversy.
Taylor & Donnelly (2006) found that the setting of standards for safety varied amongst services provided in-house with those of private agencies. In-house services had more written standards to regulate the service and managers were more likely to take the responsibility to ensure a safe working environment than in the private sector. This study questioned professionals involved in the decision making including case managers and not the views of workers themselves. This could lead to biases in the result since there may more issues involved than the ones mentioned.
Stevenson et al (2008) conducted a participatory action research approach to explore staff and client safety risks in the community home health care. The authors focused their exploration on what constitutes safety, what are the priority areas, and to identify the type of risk that would help them prepare adequately to meet their clients and own needs. The 39 participants identified poor communication, working alone, mobility, medication concerns, lack of pre-screening of clients' homes and health workers accepting high degree of risk. The researchers concluded that risks for the worker were almost always a risk for the client therefore tackling them was beneficial for both. The authors concluded that the workers accepted a high risk tolerance and despite that safety standards were present they were hardly used. Home workers expressed their concern over the lack of information they receive regarding safety issues. This issue places an emphasis on the need of good communication between the managers and the staff.
Marck et al (2010) states that it is time that safety is viewed from a new lens in order to address the complexity, multidimensionality and distinctiveness that home care services provides. Lang et al (2009) in a pilot study conducted with 14 participants found that providers safety concerns were mostly geared towards the physical safety similar to the institutional arena. These included risk assessment to prevent falls, ways to minimize medication errors, and ensuring clients used proper disposal containers for syringes and needles. On the other hand, clients' perception of safety was rather vague. In this pilot study participants could not identify safety issues. Indeed home is usually seen as safe haven from the owner point of view therefore they might not be able to point unsafe things. This pilot study points to two important issues with the safety standard, first that providers must look beyond the physical aspect only and secondly the term safety might not be the appropriate word to use within research involving clients.
Reference List
Reference List
