Care Home Sector Research Articles

Ethical Dilemmas in Home Palliative Care

Abstract Background In the past two decades, there has been a noticeable shift towards home-based care, reflecting the broader trend among OECD countries to prioritize a comprehensive approach to health and well-being. This approach emphasizes preventive and proactive measures, often relying on home-based care delivered by multidisciplinary teams providing both curative and palliative care. However, the unique nature of providing care in a home environment raises ethical questions among healthcare providers, necessitating high levels of attentiveness and sensitivity from the caregiving team to address them effectively. Research Objectives This study aims to identify ethical challenges encountered by a multidisciplinary team, as perceived by managers of an organization offering home palliative services in Israel. Methods A qualitative study was conducted, involving interviews with nine key managers to explore prevalent ethical issues in delivering home-based care. Findings Thematic analysis unveiled common ethical dilemmas in providing Home Palliative Care. These dilemmas include balancing patient preferences with professional obligations, addressing the needs of both patients and their families, navigating caregiver-patient relationships, understanding patients’ cultural backgrounds, and advocating for home care as the preferred option while considering alternative treatment approaches. Conclusions Home palliative care poses ethical dilemmas for caregiving teams. It’s imperative for organizations in the home care sector to devise strategies aimed at assisting teams in navigating these challenges while upholding the autonomy and dignity of patients within their home environment. Key messages • Home-based care faces ethical challenges, requiring strategies to balance patient preferences and professional duties. • Ethical home hospice care needs strategies that respect patient autonomy and dignity.

Interprofessional collaboration during a specialised mobile palliative care service pilot in the rural area of Lucerne.

Interprofessional collaboration in outpatient palliative care is critical to ensuring good quality of care in the home care sector. We investigated facilitators and barriers (FaBs) of interprofessional collaboration among healthcare professionals who participated in a 6-month pilot of a newly implemented specialised mobile palliative care service (SMPCS) in rural Lucerne. This study used a mixed-methods approach to collect (i) qualitative data on FaBs as perceived by nurses and primary care physicians (PCPs), and (ii) quantitative data across the entire interprofessional collaboration using a validated questionnaire expanded with 10 specific questions about the pilot. Identified facilitators of interprofessional collaboration were (i) use of standardised documents, (ii) clear allocation of responsibilities, (iii) regular exchange and clear communication and (iv) consideration of care coordination. Reported barriers were (i) a deficit of knowledge and experience of palliative care among PCPs and (ii) time constraints. This study provides valuable insights into FaBs of interprofessional collaboration in palliative care. Several recommendations can be drawn for how interprofessional collaboration may be optimised. Awareness of FaBs and their consideration in the implementation phase of new services can strengthen the foundation for a successful interprofessional collaboration.

On-Demand and Marketplace Platforms: Gig Care Work Conditions on Two Digital Labour Platform Care Models

With worker shortages and the need for care workers projected to grow, personal care work through digital labour platforms (DLPs) is important to understand. This paper considers DLPs used by gig care workers providing personal care in Ontario, Canada. We recruited 20 women gig care workers for interviews. We examined socio-technical processes such as signing up on platforms, creating profiles, and searching for jobs. We draw on Institutional Ethnography to study the actual work on the following two DLP models: marketplace and on-demand. Marcusean theory provides a lens for the critical examination of DLP care work. We found job inequity between DLPs operating in the homecare sector, compared to DPs used in institutional settings. Jobs had disparate quality between the two platform types. Workers on both DLP types remained vulnerable to fluctuations in demand and had limited social security protections, and both models of DLP institutionalised precarity.

Burnout and occupational stress of home care rehabilitation professionals transitioning out of the COVID-19 pandemic in Ontario, Canada

Introduction: The COVID-19 pandemic has significantly impacted the home healthcare industry, with increased rates of burnout and stress among homecare rehabilitation professionals (hcRPs). This study aimed to (1) examine the nature of burnout and occupational stress among homecare rehabilitation professionals at a large home care organization in Ontario, Canada, transitioning out of the pandemic, and (2) assess its impact on work participation and engagement. Methods: We conducted a cross-sectional survey using the National Institute for Occupational Safety and Health Generic Job Stress Questionnaire and Copenhagen Burnout Inventory to examine burnout and job stress. Results: One hundred thirty-nine participants identified that work stress and burnout are more likely to occur when one struggles to cope, experiences unexpected circumstances, and feels a lack of control, which can lead to anger and emotional exhaustion. The adjusted odds ratio for emotional exhaustion was 5.46, indicating that the probability of experiencing work stress among homecare rehabilitation professionals increases as emotional exhaustion increases. Significant associations were found between coping with daily tasks and levels of burnout. Conclusion: Work stress and burnout influence coping, unexpected circumstances in homecare rehabilitation professionals work–life. Furthermore, highlighting the need to provide organizational support and policies that specifically address these issues in the home care sector.

WHO, WHEN, HOW: a scoping review on flexible at-home respite for informal caregivers of older adults

BackgroundAs the world population is aging, considerable efforts need to be put towards developing and maintaining evidenced-based care for older adults. Respite services are part of the selection of homecare offered to informal caregivers. Although current best practices around respite are rooted in person centeredness, there is no integrated synthesis of its flexible components. Such a synthesis could offer a better understanding of key characteristics of flexible respite and, as such, support its implementation and use.MethodsTo map the literature around the characteristics of flexible at-home respite for informal caregivers of older adults, a scoping study was conducted. Qualitative data from the review was analyzed using content analysis. The characterization of flexible at-home respite was built on three dimensions: WHO, WHEN and HOW. To triangulate the scoping results, an online questionnaire was distributed to homecare providers and informal caregivers of older adults.ResultsA total of 42 documents were included in the review. The questionnaire was completed by 105 participants. The results summarize the characteristics of flexible at-home respite found in the literature. Flexibility in respite can be understood through three dimensions: (1) WHO is tendering it, (2) WHEN it is tendered and (3) HOW it is tendered. Firstly, human resources (WHO) must be compatible with the homecare sector as well as being trained and qualified to offer respite to informal caregivers of older adults. Secondly, flexible respite includes considerations of time, duration, frequency, and predictability (WHEN). Lastly, flexible at-home respite exhibits approachability, appropriateness, affordability, availability, and acceptability (HOW). Overall, flexible at-home respite adjusts to the needs of the informal caregiver and care recipient in terms of WHO, WHEN, and HOW.ConclusionThis review is a step towards a more precise definition of flexible at-home respite. Flexibility of homecare, in particular respite, must be considered when designing, implementing and evaluating services.

A Good Investment: Expanding Capacity to Care for Older Adults in the Home and Community Care Sector Through Increased Personal Support Worker Wages.

Most older adults prefer to age in place, which for many will require home and community care (HCC) support. Unfortunately, HCC capacity is insufficient to meet demand due in part to low wages, particularly for personal support workers (PSWs) who provide the majority of paid care. Using Ontario as a case study, this paper estimates the cost and capacity impacts of implementing wage parity between PSWs employed in HCC and institutional long-term care (ILTC). Specifically, we consider the cost of increased HCC PSW wages versus expected savings from avoiding unnecessary ILTC placement for those accommodated by HCC capacity growth. The expected increase in HCC PSW retention would create HCC capacity for approximately 160,000 people, reduce annual health system costs by approximately $7 billion, and provide an 88 per cent return on investment. Updating wage structures to reduce turnover and enable HCC capacity growth is a cost-efficient option for expanding health system capacity.

Predicting Hospitalization Risk Among Home Care Residents in the United Kingdom: Development and Validation of a Machine Learning-Based Predictive Model

Preventable hospital admissions in elderly home care residents are a major socioeconomic burden, whilst early detection of deterioration may improve outcomes. Our goal was to develop and validate a machine learning-based algorithm to predict hospitalization risk among home care users. Our primary outcome was hospitalization. An existing risk score (1-5) was assessed for its discriminatory capacity over time. We subsequently developed a new machine learning model using carer concerns, service user demographics, and other home care data between January and July 2021. We randomly selected 150 service user records for validation, which were evaluated by both the model and 10 clinicians (9 doctors and 1 nurse) to compare prediction time and accuracy to human experts. Comparison between model and human was via area under the receiver operating characteristic curve (AUC). A score of 5 conferred an 8x higher likelihood of hospitalization in the subsequent 7 days (15.4% vs 1.8%, p < .05), compared to a score of 1. The new model and risk score increased performance, detecting 182 hospitalizations/month (3.7x chance). The AUC for the model was significantly higher than for clinicians (0.87 vs 0.41-0.57, respectively; p < .05). The model took <1 minute, while clinicians typically took over 40 minutes. A risk prediction model using carer concerns and other home care data features detects 3.7x more hospitalizations than chance. The model is faster and more accurate than human clinicians, enabling low-cost scale-up. This study supports linking the model to a triage and intervention service to reduce preventable hospitalizations in the home care sector.

Geographical and temporal variations in the provision of registered older people long-term care home places in Wales

Deep-seated problems facing the residential and nursing care home sector have been compounded by the impacts of the pandemic, underfunding and the cost-of-living crisis. This study aims to investigate how patterns of access to registered residential and nursing care places changed in the period spanning lockdowns and demonstrate how spatial analytical techniques can be used to examine the potential impacts of ongoing pressures on geographical patterns of access. Findings identify variations in access to provision hidden within aggregate figures that can help stakeholders monitor the current and projected availability of places as part of an overall package of care provision.

Towards an evaluation framework for inclusive technological innovation in social and health care services

With the COVID-19 pandemic came an influx of digital technologies introduced into the care home sector. Many care homes were not ready for digital changes, and subsequently, the inclusivity of these innovations was variable. We develop a holistic evaluation framework to assess the inclusivity of service innovations, including the well-being of care home residents and employees. We adopt a mixed methods approach using the ‘non-adoption, abandonment, and challenges to scale-up, spread, and sustainability − complexity assessment toolkit’ (NASSS-CAT) to evaluate the introduction of tablet computers into care homes across Scotland and assess the inclusivity of the innovation. The paper offers a theoretical synthesis by indicating how the seven dimensions of the NASSS-CAT can evaluate the six stages of the ladder of inclusive innovation. Results specify how the care home sector could be more inclusive of its residents and staff by co-creating innovation, developing staff training, and supporting the well-being/activities coordinators.

Developing the Principles of Falls Management in Care Homes: An expert Consensus Process

Context: Managing falls in care homes requires an individualised approach for each resident with involvement of staff from care homes and the wider health and social care system. A large randomised controlled trial evaluating an individualised falls management programme (Action FALLS) demonstrated positive findings. However, the delivery of the key components of such programmes is still unclear. Greater understanding of the core components of falls management programmes is needed to support future implementation research. Objective: To establish expert consensus on the core components of falls management for older care home residents. Methods: A modified Nominal Group Technique included the development of a draft set of principles through a scoping review of the grey literature (published elsewhere) and a one-off online nominal group with care home staff and clinicians. Following the group, a single online survey was circulated to gain agreement on the final principles. Findings: 10 participants (including healthcare professionals, care home managers, and care home staff) took part in the online nominal group. Thirty-five core principles of falls management were developed within the domains of theoretical approach, assessments, interventions, training, time points, wider systems, and governance and reporting. Limitations: Since a small number of experts took part in this consensus process from a large and diverse care home sector, it is important to consider the principles as providing support for future implementation work. Implications: These core principles provide a foundation to guide care homes in managing falls in care home residents. Further research is needed to develop implementation strategies and test the feasibility of embedding the principles in routine practice.

What do private providers of home care want? An analytical framework

ABSTRACT Private for-profit home care providers are key participants in European long-term care regimes. Yet, their policy preferences toward market making and market development remain under-researched. We present an analytical framework that identifies and explains those preferences. It outlines three key types of policies that shape home care markets: regulatory, financial and labour policies. We illustrate private providers’ views on those policies by reference to Ireland’s home care regime. Irish home care is a compelling case for this study. A major package of regulatory reforms is currently being introduced and private providers have outlined clear preferences about it. Our paper is based on interviews with 14 leading individuals involved in the home care sector. We find and explain how private providers wish to increase regulation over their activities; to split purchaser and provider roles; to reduce private forms of financing; and to expand the pool of labour available to them. We discuss how those preferences shed light on the political economic power dynamics that shape the Irish care regime. Our analytical framework may be applicable to other welfare markets at different stages of development and in other institutional contexts.

Shifting the Safety Culture: Evaluation of a Novel Approach to Understanding and Responding to Workplace Harassment and Violence Experienced by Homecare Workers.

Workplace violence and harassment are commonplace for healthcare workers and most incidents are unreported. Normalization of these experiences, lack of confidence in reporting systems, and fear of the consequences of reporting contribute to the invisibility of these experiences. Challenges are exacerbated in homecare settings and for precarious workforces including Personal Support Workers (PSWs). We created, piloted, and evaluated an intervention to enhance safety culture and encourage reporting of workplace violence and harassment. A multi-stakeholder steering committee designed an intervention combining policy changes, a pre-visit screening tool, education, and brief end-of-visit reporting. This was piloted with a PSW care team which provided >55,000 client visits during the 32-week intervention. Operational metrics characterized screening, education, and reporting uptake. Pre- and post-intervention surveys characterized PSWs' experiences with workplace violence and harassment, reporting experiences, training history and intervention feedback. PSWs reported increased comfort discussing workplace violence and harassment, and increased confidence managing client-to-worker incidents. The screening went smoothly with most clients in private homes. Most PSWs (75%) engaged at least once with end-of-visit reporting and nearly half submitted reports regularly. During the pilot, 21% of PSWs reported incidents and 52% of reports shared client-specific strategies for managing these situations. Changes in comfort and behavior with reporting indicated a shift toward a more open culture surrounding workplace violence and harassment. Tools created for this intervention and lessons for implementation are shared for consideration by occupational health practitioners throughout the homecare sector.

Systemic failures in nursing home care-A scoping study.

MEDLINE, EMBASE, PSYCHINFO, CINAHLand SCOPUS were searched using the terms: (nursing home care OR residential aged care OR nursing home) AND (organisational failure OR institutional failure OR systemic failure), limited to English language articles, including all years up to the end of February 2021. In addition, we used snowballing of article references and Google searches of the grey literature. System-focused articles were defined as those that explored how an issue at one system level impacted other system levels, or how an issue impacted at least two different agents at the same system level. Thirty-eightarticles addressed systemic issues as defined in four different contexts: United States (14), Canada (2), Australia (11) and European countries (11). Only four studies reported whole-of-system findings, whereas the remaining 34 more narrowly addressed systemic features of specific nursing home issues. The thematic analysis identified 29 key systemic issues across five system layers which consistently appear across every country/health system context. The negative outcomes of these systemic failings include: high rates of regulatory reprimands for unacceptable or unsafe practices; dissatisfaction in care experiences on the part of residents, families, and care staff-including a fear of being sent to a nursing home; and the perception amongst staff that nursing homes are not preferred places to work. The key issues affecting nursing home residents, and the care home sector more generally, are systemic in nature arising from two key issues: first, the lack of shared agreement on the care home system's purpose; and second, the lack of clear governance and accountability frameworks for system regulation and performance at a national level. Addressing these two key issues must be the starting point for any 'real' nursing home system redesign that can achieve a seamlessly integrated system that delivers the outcomes nursing home residents and their families expect. 'Systems thinking' is required to simultaneously improve care quality and outcomes for residents, strengthen regulation and accountability, and enable financial viability.

‘Trying to patch a broken system’: Exploring institutional work among care professions for interprofessional collaboration

Abstract There is a growing interest in understanding when and why interprofessional collaborations are well functioning, especially within healthcare systems. However, more knowledge is needed about how professionals affect and contribute to these collaborations when they engage in them. To address this shortcoming, this study aims to contribute to professional and organizational studies of interprofessional collaboration by providing novel insights into how professionals engage in and contribute to interprofessional collaborations. It builds on a theoretical perspective of examining professionals’ everyday collaboration practices through the interplay between temporal-oriented agency and institutional work. It applies this perspective to a case study of interprofessional collaboration between personal workers (PWs), nurses, and therapists in the home care sector in Denmark. Overall, the findings show that the professionals engaged in and contributed to the interprofessional collaboration by ‘trying to patch a broken system’. All three professional groups did this primarily by ‘adopting new practices to deal with inept institutionalized practices’ to maintain collaboration. Additionally, some PWs ‘failed to enact institutionalized practices’ to disrupt the collaboration, and some nurses and therapists ‘invented and established mechanisms’ to create new arrangements for the collaboration. Based on the findings, the study demonstrates that certain dimensions of agency are associated with certain types of institutional work. Furthermore, the study suggests that the interplay between agency and institutional work varies between professional groups, influenced by their relative autonomy.

Building resilience of staff in care homes: preliminary findings of an exploratory study

Background/Aims Careers in the care home sector have seen innumerable challenges, along with sustaining and growing resilience in the workforce. The aim of this study was to understand the experiences of resilience for care home staff working in one health board area in Scotland. Methods In this exploratory study, five care homes with scores of 6 (1 being the lowest quality, 6 being excellent) within any category available from the Care Inspectorate reports over the previous 12 months were selected and staff members were invited to participate in interviews. Results A total of four staff members from four care homes agreed to participate. Through thematic analysis, three main themes were identified: emotional factors enhancing resilience in staff within care homes; the value of community and the care home family; and encouragement and meaningful interactions from and with others. Conclusions Laughter and happiness for both staff and residents were highlighted and resilience was seen not only at an individual level, but was also attributed to effective team working.

UK homecare providers' views about, and experiences of, digitalisation: A national survey.

Using digital systems to support the management and delivery of social care is a priority for UK governments. This study explored progress towards, and experiences of, digitalisation in the homecare sector and providers' views on contributing client data to a national policy/research dataset. Over 150 UK homecare providers completed an on-line survey (October-December 2022). The survey was hosted on Qualtrics and comprised fixed- and free-text response questions. The recruited sample aligned with the profile of UK homecare providers in terms of use of digital systems, organisation type and size. Almost all respondents (95.5%) were using digital systems, in part or exclusively, to support care delivery. However, many (42.7%) reported a desire to further digitalise or a dissatisfaction with existing systems. Findings highlight the time and work involved in choosing a a software system, with the decision regarded as relatively high risk. Over 50 different software systems were being used across the sample. Most respondents (72.5%) supported the creation of a national dataset on homecare users. However, support and recompense are likely to needed to secure buy-in from what is a predominantly private sector context. Findings suggest a complex and changing situation, with numerous different digital systems being used and the sector at different stages of digitalisation. The high-pressure, low margin context of UK homecare appeared to be exerting an influence on progress towards digitalisation. Evaluations of government strategies to stimulate and support digitalisation in this diverse and predominantly private sector context will be valuable.

Occupational safety in homecare organizations: the design and implementation of a train-the-trainer program

ABSTRACT Homecare workers face significant occupational risks, necessitating effective safety training programs. This paper presents a comprehensive Train-the-Trainer (TTT) program developed to enhance occupational safety in homecare organizations. Through an analysis of 229 reported safety events, the frequency and type of incidents, such as injuries during handling, road crashes, slips, trips, and falls, were identified and primarily attributed to human errors and violations. Based on the results, a TTT program was designed and implemented. The TTT successfully engaged Health, Safety, and Environment managers, fostering collaborative activities, knowledge sharing, and resource discussions. The program modules address critical areas, including distractions and inattentions, fatigue, time pressure, frustration and aggressiveness, and safety behaviors. This innovative approach provides valuable insights for organizations seeking to improve homecare workers’ safety. The findings add to the broader comprehension of occupational safety in the homecare sector, proposing a pragmatic framework for future interventions.

Empowering nurses: exploring self-managed organizations in Indian healthcare

BackgroundGiven India’s high patient load on the existing healthcare setup, as well as political, social, and organizational challenges, the nursing sector is facing various problems, therefore leading to substandard nursing experiences leading to poor patient care at the parallel healthcare setups, specifically homecare. This paper presents self-managed organizations (SMOs) characterized by a horizontal management structure as an effective alternative to existing hierarchical management structures overladen with bureaucracy. Therefore, we are exploring the strategies at self-managed homecare organizations that can make nursing a better and more productive experience.MethodThis study utilized Constructivist Grounded Theory (CGT), employing semi-structured interviews to explore nursing dynamics in horizontal organizational structures. It delved into crucial aspects like finances, organizational structure, value systems, information flow, and conflict resolution within SMOs. The methodology involved theoretical sampling, prioritizing expert self-management knowledge over mere representativeness. Seven nurses, twelve management members, and fifteen patients from self-managed homecare organizations contributed to the examination of nursing experiences. Constant comparative analysis of data led to the identification of the Qualitative Success Enablers (QSEs), revealing three themes: Insightfulness, Enhancing Nursing Experience through Job Enrichment, and Autonomy-Enabled Intrapreneurship.ResultsThe findings indicate that the horizontal management structure represented by the studied organization in India has shown considerable success in times laden with uncertainties during the COVID-19 pandemic, especially during the delta wave, which revealed the frailty of existing healthcare infrastructure. The organization successfully maintained a better nursing experience and gained patient and employee satisfaction, as revealed by in-depth semi-structured interviews and constant comparative analysis.ConclusionIn a world of unique challenges, we stand on the brink of significant transformations. SMOs are vital in India’s homecare sector for enhancing nursing experiences and overall organizational performance. Fostering a trust-based environment within SMOs is integral to delivering effective services. The autonomy to design nursing jobs, insightfulness, and innovativeness in the nursing job through suitable training activities, various job enrichment methods, and finding meaningfulness in a job through softer aspects of caregiving result in an enhanced nursing experience at SMOs. This groundbreaking approach can be extended to other homecare organizations in India, relieving the strain on the existing healthcare system.

Exploring Resilience in Care Home Nurses: An Online Survey.

Resilience is considered a core capability for nurses in managing workplace challenges and adversity. The COVID-19 pandemic has brought care homes into the public consciousness; yet, little is known about the resilience of care home nurses and the attributes required to positively adapt in a job where pressure lies with individuals to affect whole systems. To address this gap, an online survey was undertaken to explore the levels of resilience and potential influencing factors in a sample of care home nurses in Northern Ireland between January and April 2022. The survey included the Connor-Davidson Resilience Scale, demographic questions and items relating to nursing practice and care home characteristics. Mean differences and key predictors of higher resilience were explored through statistical analysis. A moderate level of resilience was reported among the participants (n = 56). The key predictors of increased resilience were older age and higher levels of education. The pandemic has exposed systemic weakness but also the strengths and untapped potential of the care home sector. By linking the individual, family, community and organisation, care home nurses may have developed unique attributes, which could be explored and nurtured. With tailored support, which capitalises on assets, they can influence a much needed culture change, which ensures the contribution of this sector to society is recognised and valued.

The care home sector: a chance for career progression.

The care home sector: a chance for career progression.