Ariella Lang

Perinatal loss and parental grief: the challenge of ambiguity and disenfranchised grief.

Following perinatal loss, a type of ambiguous loss, bereaved couples struggle with and experience distress due to various forms of ambiguity. Moreover, the juxtaposition of their grief with societys minimization often disenfranchises them from traditional grieving processes. The purpose of this study was to explore sources of ambiguity and disenfranchised grief related to perinatal loss. Audio-taped interviews with 13 bereaved couples at 2, 6, and 13 months following the death of their fetus or infant were analyzed. Several categories of ambiguity and disenfranchised grief emerged, pertaining to: (a) the viability of the pregnancy; (b) the physical process of pregnancy loss; (c) making arrangements for the remains; and (d) sharing the news. This study uncovers the many sources of ambiguity and disenfranchised grief that bereaved couples face in interactions with family, friends, society, and healthcare professionals. These insights may inform healthcare professionals in their attempts to ease distress related to perinatal loss.

Examining markers of safety in homecare using the international classification for patient safety

BackgroundHomecare is a growth enterprise. The nature of the care provided in the home is growing in complexity. This growth has necessitated both examination and generation of evidence around patient safety in homecare. The purpose of this paper is to examine the findings of a recent scoping review of the homecare literature 2004-2011 using the World Health Organization International Classification for Patient Safety (ICPS), which was developed for use across all care settings, and discuss the utility of the ICPS in the home setting. The scoping review focused on Chronic Obstructive Pulmonary Disease (COPD), and Congestive Heart Failure (CHF); two chronic illnesses commonly managed at home and that represent frequent hospital readmissions. The scoping review identified seven safety markers for homecare: Medication mania; Home alone; A fixed agenda in a foreign language; Strangers in the home; The butcher, the baker, the candlestick maker; Out of pocket: the cost of caring at home; and My health for yours: declining caregiver health.MethodsThe safety markers from the scoping review were mapped to the 10 ICPS high-level classes that comprise 48 concepts and address the continuum of health care: Incident Type, Patient Outcomes, Patient Characteristics, Incident Characteristics, Contributing Factors/Hazards, Organizational Outcomes, Detection, Mitigating Factors, Ameliorating Actions, and Actions Taken to Reduce Risk.ResultsSafety markers identified in the scoping review of the homecare literature mapped to three of the ten ICPS classes: Incident Characteristics, Contributing Factors, and Patient Outcomes.ConclusionThe ICPS does have applicability to the homecare setting, however there were aspects of safety that were overlooked. A notable example is that the health of the caregiver is inextricably linked to the wellbeing of the patient within the homecare setting. The current concepts within the ICPS classes do not capture this, nor do they capture how care responsibilities are shared among patients, caregivers, and providers.

Researching triads in home care: perceptions of safety from home care clients, their caregivers, and providers

Home care demand in Canada has more than doubled in recent years. While research related to safety in home care is growing, it lags behind that of patient safety in institutional settings. One of the gaps in the literature is the study of the perceptions of home care triads (clients, their unpaid caregivers, and paid providers). Thus, the objectives of this qualitative study were to describe the safety challenges of home care triads and to further understand the multiple dimensions of safety that contribute to or reduce safety concerns for these triads. Findings indicate that clients, unpaid caregivers, and providers struggle in the home care system. Home care models that are client centered need to be considered to provide seamless, quality, sustainable home care.

Home Care Safety Markers: A Scoping Review

Safety in home care is a new research frontier, and one in which demand for services continues to rise. A scoping review of the home care literature on chronic obstructive pulmonary disease and congestive heart failure was thus completed to identify safety markers that could serve to develop our understanding of safety in this sector. Results generated seven safety markers: (a) Home alone; (b) A fixed agenda in a foreign language; (c) Strangers in the home; (d) The butcher, the baker, the candlestick maker; (e) Medication mania; (f) Out of pocket: The cost of caring at home; and (g) My health for yours: Declining caregiver health.

Seniors managing multiple medications: using mixed methods to view the home care safety lens

BackgroundPatient safety is a national and international priority with medication safety earmarked as both a prevalent and high-risk area of concern. To date, medication safety research has focused overwhelmingly on institutional based care provided by paid healthcare professionals, which often has little applicability to the home care setting. This critical gap in our current understanding of medication safety in the home care sector is particularly evident with the elderly who often manage more than one chronic illness and a complex palette of medications, along with other care needs. This study addresses the medication management issues faced by seniors with chronic illnesses, their family, caregivers, and paid providers within Canadian publicly funded home care programs in Alberta (AB), Ontario (ON), Quebec (QC) and Nova Scotia (NS).MethodsInformed by a socio-ecological perspective, this study utilized Interpretive Description (ID) methodology and participatory photographic methods to capture and analyze a range of visual and textual data. Three successive phases of data collection and analysis were conducted in a concurrent, iterative fashion in eight urban and/or rural households in each province. A total of 94 participants (i.e., seniors receiving home care services, their family/caregivers, and paid providers) were interviewed individually. In addition, 69 providers took part in focus groups. Analysis was iterative and concurrent with data collection in that each interview was compared with subsequent interviews for converging as well as diverging patterns.ResultsSix patterns were identified that provide a rich portrayal of the complexity of medication management safety in home care: vulnerabilities that impact the safe management and storage of medication, sustaining adequate supports, degrees of shared accountability for care, systems of variable effectiveness, poly-literacy required to navigate the system, and systemic challenges to maintaining medication safety in the home.ConclusionsThere is a need for policy makers, health system leaders, care providers, researchers, and educators to work with home care clients and caregivers on three key messages for improvement: adapt care delivery models to the home care landscape; develop a palette of user-centered tools to support medication safety in the home; and strengthen health systems integration.

Applying Risk Society Theory to findings of a scoping review on caregiver safety

Chronic Illness represents a growing concern in the western world and individuals living with chronic illness are primarily managed at home by family caregivers. A scoping review of the home-care literature (2004-2009; updated with review articles from 2010 to January 2013) on the topic of the caregiver revealed that this group experiences the following safety-related concerns: caregivers are conscripted to the role, experience economic hardship, risk being abused as well as abusing, and may well become patients themselves. Methodology and methods used in the scoping review are presented as well as a brief overview of the findings. The concepts of risk and safety are defined. Risk Society Theory is introduced and used as a lens to view the findings, and to contribute to an understanding of the construction of risk in contemporary health-care.

Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design

BackgroundPalliative care clients with complex needs are increasingly choosing to remain at home for their care. Home represents familiarity, presence of supportive family and friends, potential for normalcy and, a safe haven. The palliative care literature although robust is hardly ever linked with safety and home care. Patient safety has been focused predominantly on institutions without a corresponding level of research or safety initiatives in the home care sector. Although a growing body of research has begun to highlight the complexity and multidimensionality of home care safety there is a dearth of understanding of safety issues from the perspectives of clients, caregivers, and paid providers who are responsible for managing and coordinating palliative home care. The aim of this study was to describe the experiences, challenges, and insights regarding safety for adults receiving and providing palliative home care services.MethodsMixed method design was used to capture the multiple meanings and influences on the broadened conceptualization of home care safety including emotional, social, and functional safety. There were three types of participants in this multi-site study namely palliative home care clients, caregivers, and paid providers. Individual interviews (n = 33) were conducted in the client’s home followed by a photo “walkabout” to describe their daily experiences and routines. Focus groups, three with experienced professionals (n = 25) and two with home support workers (n = 11) were also conducted.ResultsThis study supports the broadened conceptualization of home care safety namely that: the safety of the client and caregiver are inextricably linked; the home is an unregulated and uncontrolled site for providing palliative home care in contrast to hospitals or other institutional settings; and clients and caregivers have the autonomy to live and take risks in their own home.ConclusionTo ensure quality in palliative home care and to mitigate safety risks the client and caregiver(s) should be considered as the unit of care; caregivers need to be better prepared and trained to manage the complexity of issues; and regular assessments are imperative to monitor and detect changes in the unit of care and their changing needs while respecting their autonomy to make less than safe choices.

Confirming Delivery Understanding the Role of the Hospitalized Patient in Medication Administration Safety

The purpose of our study was to gain an understanding of current patient involvement in medication administration safety from the perspectives of both patients and nursing staff members. Administering medication is taken for granted and therefore suited to the development of theory to enhance its understanding. We conducted a constructivist, grounded theory study involving 24 patients and 26 nursing staff members and found that patients had the role of confirming delivery in the administration of medication. Confirming delivery was characterized by three interdependent subprocesses: engaging in the medication administration process, being “half out of it” (patient mental status), and perceiving time. We believe that ours is one of the first qualitative studies on the role of hospitalized patients in administering medication. Medication administration and nursing care systems, as well as patient mental status, impose limitations on patient involvement in safe medication administration.

Homecare safety and medication management with older adults: a scoping review of the quantitative and qualitative evidence

Background Healthcare safety is a current national and international priority, and within healthcare safety, one of the most prevalent, high‐risk issues is medication safety. While medication safety in general demands consideration, there is a critical gap in our understanding of medication safety in the homecare sector. Understanding what factors contribute to, and/or reduce the risk of adverse drug events in the home setting will enable the identification and promotion of safer medication administration practices. Objectives In this review we focused on the pertinent issues specifically related to medication management for individuals living at home and receiving homecare services. Inclusion criteria Types of participants We considered studies that included older individuals, mean age 65 years or older, who were receiving homecare services. Types of intervention(s)/phenomena of interest We considered studies that focused on individuals living at home and receiving homecare services and evaluated the process of medication management involving either providers (licensed and unlicensed) or caregivers (family/friends paid or unpaid). Types of studies We included all quantitative and qualitative research designs. Types of outcomes The purpose of this review was to map existing literature on this topic and to identify what outcomes were being measured by the current research. Research to date has identified outcomes such as: death, re‐hospitalization, emergency room use and adverse drug reactions; adherence; deterioration in primary condition; and experience of medication management (individual report and/or provider/caregiver report). Search strategy A three‐step search strategy was utilized in this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles were searched for additional studies. Studies published in English and French were considered for inclusion in this review. No date limitation was imposed. Methodological quality This review is a scoping review to provide a broader picture of the existing literature on this topic. Hence, assessment of methodological quality was not performed to exclude studies based on quality scores. Data collection Data was extracted using an expanded extraction tool from the Joanna Briggs Institute Meta‐Analysis of Statistics Assessment and Review Instrument (JBI‐MAStARI). Data synthesis The findings are presented in narrative form including tables and figures to aid in data presentation where appropriate. Results Thirty‐six studies published in English were included in this review. No French studies were located. Research designs of the included studies are heavily weighted in descriptive designs (n=28), one randomized controlled trial, three controlled before and after designs, three pre‐post designs and one qualitative design. There was a single mixed methods study combining results from a pre‐post (not controlled) investigation and qualitative focus groups. There was a single qualitative study using interpretive qualitative methods. Following the three research questions proposed for this review, three main categories were analyzed: issues (including contributing factors and risk factors) (n=21 studies), documented adverse events or errors that occur in the homecare environment (n=13 studies), and strategies or interventions to prevent the occurrence of errors in the homecare environment (n=11 studies). Conclusions In this scoping review, we sought to gather information to shed light on the current evidence related to medication management in the homecare setting. This is an area of emerging evidence on both the issue and risks in this context, as well interventions to ameliorate the problems. There was a common theme that did emerge across the study designs with respect to polypharmacy, which is recognized as a significant issue and predictor of medication errors, and/or potential inappropriate medication use. Benefits were reported by two experimental studies with the inclusion of a pharmacist to assess medications: improvements in medication use and increased coordination of information between healthcare providers and individuals. Further evidence describing and substantiating the issues and problems specific to home care and medication management is needed to develop and test appropriate interventions in this setting.

Making research integral to home care services.

Home care is the fastest growing segment of the Canadian healthcare system, yet research on patient safety has been conducted predominantly in institutional settings. This is a case example of how Victorian Order of Nurses Canada, a national not-for-profit home and community care provider, embedded a nurse researcher to create an environment in which health services research flourished. This model strategically propelled important issues such as home care safety on to the national research and policy agendas and helped leverage change in multiple levels of the healthcare system. This is a call to action for building partnerships to have a researcher as an integral team member in organizations providing home care services.