Unregulated Care Providers Research Articles

Perceptions of and Experiences in a Clinical Externship Program During the COVID-19 Pandemic.

The clinical externship program for nursing students was developed and implemented during the COVID-19 pandemic at a multi-site healthcare organization. The program aimed to address the critical shortage of health human resources by hiring qualifying undergraduate nursing and diploma program practical nursing students as unregulated care providers to meet staffing needs. The program incorporated a structured orientation, providing a mix of e-learning modules, in-person learning and shifts with an assigned preceptor. The program also included guidelines to define roles and responsibilities, ensuring safe integration of externs into the healthcare setting. A qualitative study design was employed using semi-structured interviews to explore the perceptions and experiences of the clinical externs (CEs), the extern mentor coordinators and the unit managers involved in the program. Five major themes emerged from the study, including the importance of orientation and the need for increased role clarity. The findings underscore the value of this opportunity both for nursing students as CEs and the broader healthcare system. This study provides valuable insights for nurse leaders aiming to develop or expand clinical externship programs, highlighting their potential to address health human resource challenges and enhance the preparedness and integration of nursing students into the healthcare workforce.

Reducing falls among residents of retirement homes: A DNP project.

Falls among older adults (OAs) living in retirement homes (RHs) in Canada are a major public health concern due to high morbidity and mortality as well as significant healthcare expenditures. This quality improvement (QI) initiative, conducted for the author's Doctor of Nursing Practice (DNP) project, aimed to decrease fall rates and ED transfers related to falls among OAs in six RHs across the Greater Toronto Area in Ontario, Canada through a multipart intervention with two primary goals. First, the project aimed to facilitate RH NPs' implementation of a comprehensive fall risk assessment and fall prevention strategy in their practice by incorporating the Stopping Elderly Accidents, Deaths & Injuries (STEADI) toolkit into their armamentarium. Second, it sought to enhance the knowledge of the RHs' registered practical nurses (RPNs), personal support workers (PSWs), and unregulated care providers (UCPs) in assessing fall risk and incorporating fall prevention strategies in their daily practice. By improving NP, RPN, PSW, and UCP knowledge and increasing (by 20%) RPN, PSW, and UCP use of fall prevention strategies, this QI initiative successfully reduced fall rates in the RHs by 40.4%, with no falls requiring transfer to the ED, in the postintervention period. The results of this project highlight the need for an interdisciplinary approach to fall risk reduction in RHs that includes implementation of multifactorial intervention strategies as well as effective organizational policies and procedures for maximum impact.

Upskilling programmes for unregulated care providers to provide diabetic foot screening for systematically marginalised populations: how, why and in what contexts do they work? A realist review

ObjectiveWe aimed to understand how, why and in what context upskilling programmes for unregulated care providers (UCPs) to provide foot screening for systematically marginalised groups living with diabetes were implemented.DesignWe...

Understanding how and why upskilling programmes for unregulated care providers can support health equity in underserved communities: a realist review protocol

IntroductionFoot ulcers are one of the most devastating complications of diabetes mellitus leading to leg amputations. In Canada, systematically marginalised and racialised populations are more prone to developing foot ulcers...

Nursing students' experiences with clinical placement in residential aged care facilities: a systematic review of qualitative evidence.

The objective of this systematic review was to synthesize the best available evidence on nursing students' experiences with clinical placement in residential aged care facilities. Nursing education programs play a key role in preparing future nurses to care for the growing number of older adults who will require health care. A key component of this preparation involves ensuring that curricula optimize student learning through carefully designed clinical learning practice experiences. Residential aged care facilities provide students with opportunities to work exclusively with older adults. Studies that address clinical placements in residential aged care facilities highlight both the benefits and concerns of student learning and professional development. Insight into student experiences of clinical placements in residential aged care facilities can help inform nursing curricula and contribute to a better understanding of how best to prepare students to care for an aging population. This review considered all qualitative studies that included undergraduate and diploma nursing students. Nursing students included individuals or groups identified as nursing students independent of the type of program, level of learning, or time spent in the setting. A three-step search strategy was used to identify English language qualitative primary research studies. Two reviewers independently appraised the included studies using the JBI Critical Appraisal Checklist for Qualitative Research. Key findings were extracted and classified as unequivocal or credible. Fourteen qualitative studies were included, published between 2003 and 2018. A total of 53 findings were extracted and aggregated into seven categories. From the seven categories, two synthesized findings were developed: the evolution of learning and embracing opportunity. This review captured student experiences of clinical placement in residential aged care facilities. The findings highlight the importance of students entering the setting with knowledge of how to care for older adults and being able to respond to challenging resident behavior. Equally important is the need for students to understand the roles and contributions of all care staff in the setting, including nurses and unregulated care providers. Although the residential aged care setting can be a challenging learning environment for students, it also offers opportunities for student growth and professional development, especially when there are clearly articulated learning outcomes and appropriate role models available.

Unregulated care providers\u2019 engagement in palliative care to older clients and their families in the home setting: a mixed methods study

BackgroundUnregulated care providers (UCPs) are at the forefront of direct client care in the community. Their services are required to meet the demand for home-based palliative care from a growing older population, yet understanding of UCPs involvement in care is limited. The study aimed to identify the types and frequencies of tasks performed by UCPs in home-based palliative care to older clients (> 65 years) and their families and to describe UCPs’ engagement in care, and barriers and facilitators to their work.MethodsA mixed method approach was used comprising a quantitative retrospective chart review of UCPs’ tasks (n = 66), qualitative content analysis of progress notes from clients’ charts (n = 85), and thematic analyses of in-depth interviews with UCPs (n = 10).ResultsA thematic structure was derived from analyses and integration of data from the chart review and interviews. The themes reflect the physical, affective, and relational aspects of UCPs involvement in the care of clients and families at the end of life. The findings indicate that although a significant proportion (63%) of the 13, 558 UCP tasks identified were directed toward meeting clients’ physical care needs, their presence in the home, made UCPs an important source of information on the client’s condition; observing and appraising the situation. Further, the nature of their work and frequent interactions with clients and families also presented opportunities for UCPs to provide emotional support; a role UCPs felt was integral to their work.ConclusionsThe study highlights the challenging nature of palliative care to older clients and their families whose needs are often complicated, situated within the unique environment of home care where supervision of UCPs is at a distance. Challenges and facilitators to UCPs’ work in this context are discussed with recommendations to support UCPs in their roles.

The role of unregulated care providers in home care: A scoping review.

Health care needs of individuals living in the community are increasing. To meet the rising need, unregulated care providers are providing more complex patient care. The aim of this review is to articulate the unregulated care provider role by identifying patient care activities offered by unregulated care providers in home care. A scoping review was conducted. One thousand and eleven published manuscripts were identified in CINAHL, Ageline and MEDLINE. Eleven additional manuscripts were identified through hand searching. Manuscripts were screened for relevancy and data were abstracted to address the research question. Twenty-eight studies originating from Canada, Sweden, Belgium, UK, USA and New Zealand were included. Three categories of patient care activities provided by unregulated care providers were found: (1) personal care and core skills; (2) delegated tasks and added skills; and (3) specialty roles. Unregulated care providers predominantly provide assistance with personal care and activities of daily living. However, unregulated care providers also provide care outside their training, including care once provided by nurses. Guidelines clearly articulating responsibilities of nurses transferring care activities to unregulated care providers should be developed. Processes and policies regarding evaluation and supervision of unregulated care providers providing added skills should be developed to ensure appropriate monitoring and support.

The role of unregulated care providers in Canada-A scoping review.

This scoping review explored: (i) the role of unregulated care providers in the healthcare system; (ii) their potential role on interprofessional teams; (iii) the impact of unregulated care provider's role on quality of care and patient safety; and (iv) education and employment standards. Unregulated care providers in Canada assist older adults with personal support and activities of daily living in a variety of care settings. As the care needs of an aging population become increasingly complex, the role of unregulated care providers in healthcare delivery has also evolved. Currently, many unregulated care providers are performing tasks previously performed by regulated health professionals, with potential implications for quality of care and patient safety. Information is fragmented on the role, education and employment standards of unregulated care providers. A scoping review was conducted following the methods outlined by Arksey and O'Malley (International Journal of Social Research Methodology, 8, 2005, 19) and Levac, Colquhoun, and O'Brien (Implementation Science, 5, 2010, 69). An iterative search of published and grey literature was conducted from January 2000 to September 2016 using Medline, CINAHL, SCOPUS and Google. Inclusion and exclusion criteria were applied to identify relevant studies published in English. The search yielded 63 papers for review. Results highlight the evolving role of unregulated care providers, a lack of recognition and a lack of authority for unregulated care provider decision-making in patient care. Unregulated care providers do not have a defined scope of practice. However, their role has evolved to include activities previously performed by regulated professionals. Variations in education and employment standards have implications for quality of care and patient safety. Unregulated care providers are part of an important workforce in the long-term care and community sectors in Canada. Their evolving role should be recognised and efforts made to leverage their experience on interprofessional teams and reduce variations in education and employment standards. This study highlights the evolving role of unregulated care providers in Canada and presents a set of recommendations for implementation at micro, meso, and macro policy levels.

HOME HEALTH AIDES’ ROLE IN PRESSURE ULCER PREVENTION AMONG THE ELDERLY AT HOME: A SCOPING REVIEW

The purpose of this scoping literature review was to explore current knowledge about the role of home health aides (HHAs) in pressure ulcer prevention among the elderly receiving homecare. HHAs are unregulated care providers that constitute 70% of the home care work force in Canada. They are part of the patient’s circle of care but not members of the interdisciplinary pressure ulcer prevention team. The literature review was used to identify sources of evidence, map key concepts, and determine research gaps. Key search terms “homecare services”, “pressure ulcers”, “home health aides”, and “aged” were used to search 11 databases. Eight sources were retrieved: one textbook chapter and seven peer-reviewed journal articles. All documents were charted and analyzed using a descriptive summary and qualitative content analysis. The results suggest that HHAs’ role in pressure ulcer prevention at home is unclear. Five themes emerged from literature: need for training and education, nurse as an educator, interdisciplinary care approach, relationship between HHAs patient and family, and beliefs of HHAs about their role. Potential for enhancing HHA roles were identified in: observing patient’s health condition; coaching patients and family on positioning, ambulation, and nutrition; assisting health care providers; and reporting to the interdisciplinary team, patients and caregivers. In conclusion, the HHAs could play more important role in pressure ulcer prevention in homecare. Further research is recommended to create interventions with increased engagement of HHAs and explore their efficacy.

The role of unregulated care providers in managing heart failure patients in long-term care facilities.

Heart failure is a complex syndrome in which abnormal heart function results in clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion. Heart failure is common among long-term care residents, and is associated with significant morbidity and acute care utilisation. Heart failure guidelines endorse standard therapies, yet long-term care residents are less likely to receive recommended treatments. The objective of this study is to understand the perceptions and potential role of unregulated care providers in contributing to better heart failure management among long-term care residents. Focus group interviews. This qualitative study employed focus groups to explore perceptions from 24 unregulated care providers in three Ontario, Canada long-term care homes, about barriers to the optimal management of heart failure. Three overarching concepts emerged characterising unregulated care providers' experiences in caring for residents with heart failure in long-term care: (1) the complexity of providing heart failure care in a long-term care setting, (2) striving for resident-centred decision making and (3) unregulated care providers role enactment nested within an interprofessional team in long-term care. These concepts reflect the complex interplay between individual unregulated care providers and residents, and heart failure-related, socio-cultural and organisational factors that influence heart failure care processes in the long-term care system. Optimising the management of heart failure in long-term care is contingent on greater engagement of unregulated care providers as active partners in the interprofessional care team. Interventions to improve heart failure management in long-term care must ensure that appropriate education is provided to all long-term care staff, including unregulated care providers, and in a manner that fosters greater and more effective interprofessional collaboration. Active and collaborative engagement unregulated care providers has the potential to improve the management of heart failure in long-term care residents.

Dying With Carolyn: Using Simulation to Improve Communication Skills of Unregulated Care Providers Working in Long-Term Care.

This article examines the development, implementation, and evaluation of a pilot project utilizing high-fidelity simulation (HFS) to improve frontline staff members' confidence and skills to communicate about death and dying in long-term care homes. The target group was unregulated care providers who provide palliative care for residents and their families. Eighteen participants engaged in the educational intervention and evaluation. Results supported the effectiveness of HFS as an educational tool for unregulated health care providers. Quantitative data showed statistically significant improvements in participants' self-efficacy scores related to communicating about death and dying and end-of-life care. Qualitative data indicated that the experience was a valuable learning opportunity and helped participants develop insights into their own values, beliefs, and fears providing end-of-life care. HFS is therefore recommended as an innovative training strategy to improve palliative care communication in long-term care homes.

Report of a pilot study of quality improvement in nursing homes led by healthcare aides

Objective: Healthcare aides (unregulated care providers), who deliver the majority of direct care in Canadian nursing homes, have high levels of emotional exhaustion and cynicism. However, they also have remarkably high levels of job efficacy. Strategies to empower this workforce may reduce cynicism and draw on their high levels of job efficacy. The primary objective of this study was to act as proof-of-principle to determine whether quality improvement teams led by healthcare aides could be established in nursing homes and function on a daily basis. Methods: This study was a pilot test of a complex intervention using a mixed methods approach. We used a combination of education, networking and coaching to engage staff teams in quality improvement in 1 of 3 areas (pain control, skin care or behaviour management). We measured healthcare aides’ quality of work life, informal communication and research (best practice) use before and after the intervention. To understand the effect of quality of care at the bedside we used risk-adjusted quality indicators derived from Resident Assessment Instrument - Minimum Data Set 2.0 data. Results: A total of 10 teams participated in the intervention. At least 70% of the teams succeeded in learning and applying the improvement model and methods for local measurement. For 50% of the teams, data showed measurable improvement in the clinical areas. There were no significant differences between pre and post measures of survey variables. Conclusions: We have demonstrated the ability of healthcare aides to engage in quality improvement initiatives at the bedside in a collaborative environment and advance our results as an important contribution to person-centered healthcare.

Unregulated provider perceptions of audit and feedback reports in long-term care: cross-sectional survey findings from a quality improvement intervention

BackgroundAudit with feedback is a moderately effective approach for improving professional practice in other health care settings. Although unregulated caregivers give the majority of direct care in long-term care settings, little is known about how they understand and perceive feedback reports because unregulated providers have not been directly targeted to receive audit with feedback in quality improvement interventions in long-term care. The purpose of this paper is to describe unregulated care providers’ perceptions of usefulness of a feedback report in four Canadian long-term care facilities.MethodsWe delivered monthly feedback reports to unregulated care providers for 13 months in 2009–2010. The feedback reports described a unit’s performance in relation to falls, depression, and pain as compared to eight other units in the study. Follow-up surveys captured participant perceptions of the feedback report. We conducted descriptive analyses of the variables related to participant perceptions and multivariable logistic regression to assess the association between perceived usefulness of the feedback report and a set of independent variables.ResultsThe vast majority (80%) of unregulated care providers (n = 171) who responded said they understood the reports. Those who discussed the report with others and were interested in other forms of data were more likely to find the feedback report useful for making changes in resident care.ConclusionsThis work suggests that unregulated care providers can understand and feel positively about using audit with feedback reports to make changes to resident care. Further research should explore ways to promote fuller engagement of unregulated care providers in decision-making to improve quality of care in long-term care settings.

An Action-Based Approach to Improving Pain Management in Long-Term Care

The study purposes were twofold: (1) to explore barriers to pain management and those associated with implementing a pain management program in long-term care (LTC); and (2) to develop an interprofessional approach to improve pain management in LTC. A case study approach included both qualitative and quantitative components. We collected data at two LTC sites using seven focus groups for the licensed nurses, unregulated care providers and physicians, and 10 interviews with other health care provider groups, administration, and residents. We reviewed documents and administered a short survey to study participants to assess perceptions of barriers to pain management. The findings revealed barriers to effective LTC pain management at the resident/family, health care provider, and system levels. We then developed a six-tiered model with proposed interventions to address these barriers. This model can guide the development of innovative approaches to improving pain management in LTC settings.

Figuring it Out in the Moment: A Theory of Unregulated Care Providers' Knowledge Utilization in Dementia Care Settings

Within the context of knowledge translation, the disconnect between the results of research and the practice patterns of nursing care providers has not been reported in the context of institutional dementia care practice. Therefore, little is known about how knowledge about best dementia care practice, defined broadly as the person-centered approach, gets used by institutional nursing care providers. Unregulated care providers provide the majority of nursing care for older people with Alzheimer's disease and related disorders living in long-term care facilities. The purpose of this grounded theory study was to explore the process whereby these workers use knowledge about person-centered care in their dementia care practice. Transcribed data from tape-recorded interviews with 20 unregulated care providers among eight long-term care facilities in Ontario, Canada, were coded and categorized at progressively more abstract levels until concepts and the relationships among them were integrated in a middle-range theory of knowledge utilization. The theory of Figuring it Out in the Moment illustrates how unregulated care providers in dementia care settings practice in the context of unpredictability, variability, and personal threat. Their use of knowledge about person-centered care is dependent on the existence of certain individual and relational conditions that interrelate with four separate, but interconnected, phases of clinical decision-making and action. As a middle-range theory, Figuring it Out in the Moment is concrete and pragmatic information for promoting evidence-based dementia care not included in existing overarching knowledge utilization frameworks. Areas for further investigation include how knowledge utilization is conceptualized, as well as the influences of practitioners' clinical decision-making, the nature of caregiving with particular client populations, and the characteristics of individuals alone and in relationship on the utilization of best practice knowledge.

Influenza Vaccination and Decisional Conflict among Regulated and Unregulated Direct Nursing Care Providers in Long-Term–Care Homes

The purpose of this study was to determine whether direct nursing care providers have decisional conflict about receiving influenza vaccinations and characteristics associated with decisional conflict. The researchers used a self-administered questionnaire mailed to direct nursing care providers in two long-term-care organizations. Most direct nursing care providers in both organizations (80% and 93%, respectively) intended to get the influenza vaccine. Unregulated direct nursing care providers had more decisional conflict than regulated providers, especially related to feeling uninformed about the pros and cons of influenza vaccination. Unclear valuing of the pros and cons of influenza vaccination was related to the age of the direct care providers in both organizations. Decisional conflict and influenza vaccination practices may be determined, in part, by age and by the culture of a health care organization. A decision aid to improve knowledge and clarify values may improve decision quality and increase influenza vaccination rates.

A study of family day care providers: Attitudes toward regulation

This study seeks to fill a gap in the existing literature concerning family day care by exploring the issue of regulation from the perspective of both regulated and unregulated providers. The study draws on data collected from questionnaires distributed to 235 regulated and 110 unregulated family day care providers, and interviews conducted with 30 regulated and 40 unregulated providers, in Vermont. The data from the two sets of questionnaires reveal significant differences in demographic variables, working conditions, and career orientations between the two groups. Regulated providers choose to comply with regulation because they perceive it to be their legal obligation and because they desire the benefits that are associated with doing so. The primary reasons given for failure to register among unregistered providers included a belief that it was not required of them and a belief that regulation conferred no benefits. Although many unregulated providers had only partial information about regulatory requirements, many of them were offering services in a manner that would enable them to become registered if this were their choice. The implications of the findings for regulatory strategies are discussed.