Exploring challenges in quality and safety work in nursing homes and home care – a case study as basis for theory development

Abstract

Background: Management, culture and systems for better quality and patient safety in hospitals have been widely studied in Norway. Nursing homes and home care, however have received much less attention. An increasing number of people need health services in nursing homes and at home, and the services are struggling with fragmentation of care, discontinuity and restricted resource availability. The aim of the study was to explore the current challenges in quality and safety work as perceived by managers and employees in nursing homes and home care services. Method: The study is a multiple explorative case study of two nursing homes and two home care services in Norway. Managers and employees participated in focus groups and individual interviews. The data material was analyzed using directed content analysis guided by the theoretical framework 'Organizing for Quality', focusing on the work needed to meet quality and safety challenges. Results: Challenges in quality and safety work were interrelated and depended on many factors. In addition, they often implied trade-offs for both managers and employees. Managers struggled to maintain continuity of care due to sick leave and continuous external-facilitated change processes. Employees struggled with heavier workloads and fewer resources, resulting in less time with patients and poorer quality of patient care. The increased external pressure affected the possibility to work towards engagement and culture for improvement, and to maintain quality and safety as a collective effort at managerial and employee levels. Conclusion: Despite contextual differences due to the structure, size, nature and location of the nursing homes and home care services, the challenges were similar across settings. Our study indicates a dualistic contextual dimension. Understanding contextual factors is central for targeting improvement interventions to specific settings. Context is, however, not independent from the work that managers do; it can be and is acted upon in negotiations and interactions to better support managers' and employees' work on quality and safety in nursing homes and home care.

Lessons learnt from nursing home and homecare managers’ experiences with using the SAFE-LEAD guide

“…Although all managers agreed that the web-version required technical adjustments to ease its use, there were differences in technological skills and maturity across units and municipalities, indicating that some of the challenges were due to digital shortcomings in selected units. Several studies show that technological challenges and immaturity are common in the health care sector (Bates, 2015;Falconer et al, 2018;Gjestsen et al, 2017;Johannessen et al, 2020;Ree et al, 2019), making it especially important to adapt new technological interventions to the settings in which they are being implemented. Managers in our study emphasized that adjusting the SAFE-LEAD guide to their local context and work routines was important for successful implementation and sustainability.…”

What is the role of transformational leadership, work environment and patient safety culture for person‐centred care? A cross‐sectional study in Norwegian nursing homes and home care services

“…Previous studies show that managers influence the patient safety culture through their impact on work environmental factors (Boamah et al, 2018;Weng, Kim, & Wu, 2017), and based on our findings we can assume the same accounts for per- is possible to implement and practice. A number of studies show that the staff-patient relationship, having enough time to get to know the patients and good communication among employees, staff and next of kin are all key for patient-centred care (Angel & Frederiksen, 2015;Oxelmark, Ulin, Chaboyer, Bucknall, & Ringdal, 2018;Ree et al, 2020;Vennik, van de Bovenkamp, Putters, & Grit, 2016 (Johannessen, Ree, Aase, Bal, & Wiig, 2020;.…”

“…The main strength of this study is its originality in being the first to explore the role of patient safety culture, transformational lead- tices (Johannessen et al, 2020;Ree et al, 2019Ree et al, , 2020. Furthermore, managers should have access to and make use of support tools, for example surveys to map user experiences and opinions that can be used to inform and improve practice, ensuring that the services are aligned with the needs and preferences of the users and patients in the nursing homes and home care services.…”

Pasientsikre kommuner? – Hvor står vi? Hvor går vi?

“…Ansatte er ikke passive mottakere av forutbestemte endringer, men påvirker i stor grad utfallet av aktivitetene i organisasjonen. Johannessen et al (2020) viser at ansatte i sykehjem og hjemmetjenester blir demoraliserte av det de opplever som et vedvarende fokus på det som går galt. I stedet trenger både de og lederne å samarbeide for å forstå arbeidspraksisen og utfordringene, og framfor alt laere av de gode eksemplene.…”