Karina Aase

Interventions to improve patient safety in transitional care – a review of the evidence

When a patients transition from the hospital to home is less than optimal, the repercussions can be far-reaching - hospital readmission, adverse medical events, and even mortality. Elderly, especially frail older patients with complex health care problems appear to be a group particularly at risk for adverse events in general, and during transitions across health providers in particular. We undertook a systematic review to identify interventions designed to improve patient safety during transitional care of the elderly, with a particular focus on discharge interventions. We searched the literature for qualitative and quantitative studies on the subject published over the past ten years. The review revealed a set of potential intervention types aimed at the improvement of communication that contribute to safe transitional care. Intervention types included profession-oriented interventions (e.g. education and training), organisational/culture interventions (e.g. transfer nurse, discharge protocol, discharge planning, medication reconciliation, standardized discharge letter, electronic tools), or patient and next of kin oriented interventions (e.g. patient awareness and empowerment, discharge support). Results strongly indicate that elderly discharged from hospital to the community will benefit from targeted interventions aimed to improve transfer across healthcare settings. Future interventions should take into account multi-component and multi-disciplinary interventions incorporating several single interventions combined.

Investigating the use of patient involvement and patient experience in quality improvement in Norway: rhetoric or reality?

BackgroundPatient involvement in health care decision making is part of a wider trend towards a more bottom-up approach to service planning and provision, and patient experience is increasingly conceptualized as a core dimension of health care quality.The aim of this multi-level study is two-fold: 1) to describe and analyze how governmental organizations expect acute hospitals to incorporate patient involvement and patient experiences into their quality improvement (QI) efforts and 2) to analyze how patient involvement and patient experiences are used by hospitals to try to improve the quality of care they provide.MethodsThis multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews and non-participant observation of key meetings and shadowing of staff at the meso and micro levels in two purposively sampled Norwegian hospitals. Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011–2012).ResultsGovernmental documents and regulations at the macro level demonstrated wide-ranging expectations for the integration of patient involvement and patient experiences in QI work in hospitals. The expectations span from systematic collection of patients’ and family members’ experiences for the purpose of improving service quality through establishing patient-oriented arenas for ongoing collaboration with staff to the support of individual involvement in decision making. However, the extent of involvement of patients and application of patient experiences in QI work was limited at both hospitals. Even though patient involvement was gaining prominence at the meso level − and to a lesser extent at the micro level − relevant tools for measuring and using patient experiences in QI work were lacking, and available measures of patient experience were not being used meaningfully or systematically.ConclusionsThe relative lack of expertise in Norwegian hospitals of adapting and implementing tools and methods for improving patient involvement and patient experiences at the meso and micro levels mark a need for health care policymakers and hospital leaders to learn from experiences of other industries and countries that have successfully integrated user experiences into QI work. Hospital managers need to design and implement wider strategies to help their staff members recognize and value the contribution that patient involvement and patient experiences can make to the improvement of healthcare quality.

Norwegian nursing and medical students' perception of interprofessional teamwork: a qualitative study.

BackgroundLittle is known about the ways in which nursing and medical students perceive and understand their roles in interprofessional teamwork. A 2010 report by the World Health Organization highlights the importance of students’ understanding of teamwork in healthcare, and their ability to be effective team players. This study aims at describing nursing and medical students’ perceptions of interprofessional teamwork, focusing on experiences and recommendations that can be used to guide future educational efforts.MethodsThe study uses a qualitative research design. Data were collected from four focus group interviews: two homogenous groups (one with medical students, one with nursing students) and two mixed groups (medical and nursing students).ResultsThe results show that traditional patterns of professional role perception still prevail and strongly influence students’ professional attitudes about taking responsibility and sharing responsibility across disciplinary and professional boundaries. It was found that many students had experienced group cultures detrimental to team work. Focusing on clinical training, the study found a substantial variation in perception with regard to the different arenas for interprofessional teamwork, ranging from arenas with collaborative learning to arenas characterized by distrust, confrontation, disrespect and hierarchical structure.ConclusionsThis study underlines the importance of a stronger focus on interprofessional teamwork in health care education, particularly in clinical training. The study results suggest that the daily rounds and pre-visit “huddles,” or alternatively psychiatric wards, offer arenas suitable for interprofessional training, in keeping with the students’ assessments and criteria proposed in previous studies.

Teaching interprofessional teamwork in medical and nursing education in Norway: A content analysis

The notions of interprofessional education and interprofessional teamwork have attained widespread acceptance, partly because lack of teamwork has been tentatively linked to adverse incidents in healthcare. By analyzing data from 32 educational institutions, this study identifies the status of interprofessional teamwork in all nursing and medical education in Norway. The study programs issued by the 32 educational institutions were subject to content analysis, distilling the ambitions and goals for teaching interprofessional teamwork. Study program coordinators were approached and asked to what degree interprofessional teamwork was actually introduced in lecturing and clinical training. Results indicate that the medical and nursing schools clearly aspire to teach interprofessional teamwork and that this has largely been achieved when it comes to theoretical teaching. Although three of the four medical programs have integrated interprofessional teamwork into their clinical training, there is a gap in the nursing programs where introduction of interprofessional teamwork in clinical training has been limited. Current challenges are related to organizational issues (e.g. lack of institutional collaboration), practical difficulties (e.g. finding time to bring students of various professions together) and possibly managerial issues (e.g. lack of strategic perspective and change management).

A review of the literature on patient participation in transitions of the elderly

Patient participation is highlighted in healthcare policy documents as an important area to address in order to improve and secure healthcare quality. The literature on healthcare quality and safety furthermore reveals that transitional care carries a risk of adverse events. Elderly persons with co-morbidities are in need of treatment and healthcare from several care professionals and are transferred between different care levels. Patient-centered care, shared decision-making and user involvement are concepts of care that incorporate patient participation and the patients’ experiences with care. Even though these care concepts are highlighted in healthcare policy documents, limited knowledge exists about their use in transitions, and therefore points to a need for a review of the existing literature. The purpose of the paper is to give an overview of studies including patient participation as applied in transitional care of the elderly. The methodology used is a literature review searching electronic databases. Results show that participation from elderly in discharge planning and decision-making was low, although patients wanted to participate. Some tools were successfully implemented, but several did not stimulate patient participation. The paper has documented that improvements in quality of transitional care of elderly is called for, but has not been well explored in the research literature and a need for future research is revealed. Clinical practice should take into consideration implementing tools to support patient participation to improve the quality of transitional care of the elderly.

An antimicrobial stewardship program initiative: a qualitative study on prescribing practices among hospital doctors

BackgroundNorway has a low, but increasing prevalence of resistance and few antimicrobial stewardship initiatives. When developing stewardship interventions, an understanding of the determinants of antimicrobial prescribing is needed. We report on the first qualitative study investigating factors influencing doctors’ antimicrobial prescribing practices in Norwegian hospitals.MethodsQualitative semi-structured interviews were conducted with 15 Norwegian hospital doctors prescribing antimicrobials to adult patients. Interviews were transcribed verbatim and thematic analysis was applied to analyse the data.ResultsColleagues, in particular infectious disease specialists, microbiology test results and the newly published national guideline on antimicrobials were identified as key factors influencing antimicrobial prescribing practices. Delayed availability was a barrier for the utilization of microbiology test results and increasing clinical experience overrides the influence of the national guideline.Patient assessment, informal training by experienced colleagues, and infectious disease specialists replacing managers in promoting prudent prescribing policies, also influenced prescribing practices.ConclusionThis study identified the following contextual factors that need to be addressed when developing antimicrobial stewardship programs in Norway: a common work practice for seeking collegial advice, logistics of microbiology test results, and formal leadership and systematic training on prudence. Other countries initiating stewardship programmes may benefit from performing a similar mapping of facilitators and barriers, to identify important stakeholders and organisational obstacles, before developing sustainable and tailored antimicrobial stewardship interventions.

Quality and safety in transitional care of the elderly: the study protocol of a case study research design (phase 1)

Introduction Although international studies have documented that patients’ transitions between care providers are associated with the risk of adverse events and uncoordinated care, research directed towards the quality and safety of transitional care between primary and secondary health and care services, especially for the elderly receiving care from multiple healthcare providers due to complex health problems, is lacking. This study investigates how different aspects of transitional care can explain the quality and safety of elderly healthcare services in Norway. The overall aim of the study was to explore different aspects of transitional care of the elderly, in different contexts and how they might explain the quality and safety of care. Methods and analysis The study applies a case study design. Two cases are chosen: one city-based hospital and one rural hospital with associated nursing homes and home-based nursing services. Admission and discharge to/from hospital to/from nursing homes or home-based nursing services constitute the main focal areas of the study, including the patient, next-of-kin and the professional perspective. The qualitative methods employed include participant observation, individual interviews and document analysis. To ensure trustworthiness in the data analysis, we will apply analyst triangulation and member checks. A total impression of the data material will first be created in a systematic text condensation approach. Second, the qualitative data analysis will involve in-depth analyses of two specific themes: the risk perspective and the patient perspective in transitional care. Ethics and dissemination The study is approved by the Norwegian Regional Committees for Medical and Health Research Ethics. The study is based on informed written consent, and informants can withdraw from the study at any point in time. Interview and observation data material will be managed confidentially. Results It will be disseminated at research conferences, in peer-reviewed journals and through public presentations to people outside the academic community.

A comparative study of safety climate differences in healthcare and the petroleum industry

Aim The aim of this article is to compare safety climate in healthcare and the petroleum industry by collecting empirical evidence of differences between the two sectors. Methods The Hospital Survey on Patient Safety Culture (HSOPSC) is used to measure the safety climate in two organisations operating in the two different sectors: (1) a large Norwegian university hospital offering a wide range of hospital services and (2) a large Norwegian petroleum company producing oil and gas worldwide. Results and discussion Statistical analyses supported the expected hypotheses that safety climate is positively related to outcome measures and that the level on safety climate and outcome measures are generally higher in the petroleum sector. Empirical findings indicate that healthcare should learn from the petroleum industry regarding safety improvement efforts, and the implication of this is discussed in the paper.

How can students contribute? A qualitative study of active student involvement in development of technological learning material for clinical skills training

BackgroundPolicy initiatives and an increasing amount of the literature within higher education both call for students to become more involved in creating their own learning. However, there is a lack of studies in undergraduate nursing education that actively involve students in developing such learning material with descriptions of the students’ roles in these interactive processes.MethodExplorative qualitative study, using data from focus group interviews, field notes and student notes. The data has been subjected to qualitative content analysis.ResultsActive student involvement through an iterative process identified five different learning needs that are especially important to the students: clarification of learning expectations, help to recognize the bigger picture, stimulation of interaction, creation of structure, and receiving context- specific content.ConclusionThe iterative process involvement of students during the development of new technological learning material will enhance the identification of important learning needs for students. The use of student and teacher knowledge through an adapted co-design process is the most optimal level of that involvement.

Applying different quality and safety models in healthcare improvement work: Boundary objects and system thinking

A number of theoretical models can be applied to help guide quality improvement and patient safety interventions in hospitals. However there are often significant differences between such models and, therefore, their potential contribution when applied in diverse contexts. The aim of this paper is to explore how two such models have been applied by hospitals to improve quality and safety. We describe and compare the models: (1) The Organizing for Quality (OQ) model, and (2) the Design for Integrated Safety Culture (DISC) model. We analyze the theoretical foundations of the models, and show, by using a retrospective comparative case study approach from two European hospitals, how these models have been applied to improve quality and safety. The analysis shows that differences appear in the theoretical foundations, practical approaches and applications of the models. Nevertheless, the case studies indicate that the choice between the OQ and DISC models is of less importance for guiding the practice of quality and safety improvement work, as they are both systemic and share some important characteristics. The main contribution of the models lay in their role as boundary objects directing attention towards organizational and systems thinking, culture, and collaboration.