Nursing leadership and management in home care: A qualitative scoping review.

AIM: The purpose is to identify and synthesize the challenges of first-line nurse managers in home care concerning their managerial and leadership role, as described in current qualitative research literature. BACKGROUND: Increased responsibilities and shifting tasks in home care lead to challenges for first-line nurse managers. These challenges must be identified and evaluated to ensure quality care provision. EVALUATION: A scoping review mapped current qualitative research on first-line nurse managers in home care, focusing on their managerial and leadership role. A systematic search was conducted in CINAHL, Medline, EMBASE, and SweMed+. A thematic analysis was conducted on the four included studies. KEY ISSUE(S): First-line nurse managers' role in home care involves multiple responsibilities. Four themes emerged: "professional responsibilities," "relational responsibilities," "economic and organizational responsibilities," and "juggling responsibilities-a demanding balance." CONCLUSION(S): Findings provide new knowledge on how first-line nurse managers balance responsibilities in their role in the home care context-a complex context different from institutional settings like hospitals and long-term care. A focus on first-line nurse managers' support needs is necessary. Furthermore, an extensive research gap concerning first-line nurse managers' leadership and management role in home care indicates a need to increase knowledge from a range of perspectives. IMPLICATIONS FOR NURSING MANAGEMENT: To develop sustainable and robust nursing leadership and management in home care, there is a need to (a) clarify first-line nurse managers' role and set boundaries around their responsibilities and (b) strengthen support from superiors, which will help empower first-line nurse managers in their daily work.

Experiences using an instrument for non-technical skills in nurse anaesthesia education: a focus group study.

BACKGROUND: Although there is an increasing amount of research on the use of structured behavioural assessment instruments for non-technical skills in a simulation or clinical setting, there is currently little research into how healthcare professionals experience using these instruments. The structured behavioural assessment instrument, Nurse Anaesthetists' Non-Technical Skills-Norway, has recently been introduced to nurse anaesthesia education as a means of developing and assessing non-technical skills in clinical practice. The aim of this study was therefore to explore the experiences of Norwegian student nurse anaesthetists, their mentors and clinical supervisors on using the instrument in clinical practice. METHODS: This study has a qualitative descriptive design. Data was collected through semi-structured interviews with four focus groups comprising twelve student nurse anaesthetists and thirteen mentors and clinical supervisors. The interviews were recorded and then transcribed verbatim. Data was analyzed using qualitative content analysis and an inductive approach. RESULTS: Six categories were identified that represented the manifest content. One main theme: Forging a path towards clinical excellence was identified representing the latent content, and three themes that described the participants' experiences with using the instrument: Promotion of excellent non-technical skills: Raising awareness of non-technical skills ensured professional suitability and shaping of a professional identity; internalizing the skills could lead to changes in behaviour. Promotion of cooperative learning: Mentoring was more structured, based on a common language and understanding and clearly defined roles; measurable progress enabled a more reliable and objective evaluation. Promotion of organizational acceptance: A lack of familiarity with the instrument, and challenges with scoring and the terminology impeded acceptance. CONCLUSION: Increased awareness of non-technical skills when using Nurse Anaesthetists' Non-Technical Skills-Norway contributes to a professionalization of the nurse anaesthetist role and mentoring/learning process in nurse anaesthesia education. Using Nurse Anaesthetists' Non-Technical Skills-Norway promotes the ideal of clinical excellence, not only as an assessment instrument but also by guiding the student's learning process. Despite a high level of commitment to using the instrument there is a need to promote further acceptance in the anaesthetic departments.

Educating for Excellence: A Cohort Study on Assessing Student Nurse Anesthetist Non-Technical Skills in Clinical Practice.

Non-technical skills play an integral role in providing safe and excellent anesthesia. Currently there is little standardization in the assessment of non-technical skills in clinical practice, although various instruments exist. The aim of this study was to explore the use of the Nurse Anaesthetists' Non-Technical Skills-Norway (NANTS-no) structured assessment instrument in developing and assessing non-technical skills in clinical practice. This cohort study had a longitudinal design. Twenty student nurse anesthetists' nontechnical skills were assessed by their mentors (N=31) and clinical supervisors (N=7) at three time-points over a 12-month period, after providing anesthesia to a patient. A 5-point rating scale was used for both the experts' assessments and students' self-assessments. Development of non-technical skills over time was estimated using linear mixed-effect models. The students demonstrated a significant overall development of non-technical skills (P<.001), achieving an expert assessment of 4.5 at the end of their education. The students significantly underestimated their clinical performance compared with the experts' assessments (P<.001). The structured behavioral assessment instrument appears to be reliable for assessing student nurse anesthetists' non-technical skills in clinical practice. This study may have implications for systematic assessment of non-technical skills in Norway and other countries.

The core qualities and competencies of the intensive and critical care nurse, a meta-ethnography.

AIM: To develop a conceptual framework of the core qualities and competencies of the intensive and critical care nurse based on the experiences of intensive care patients, their relatives and the intensive and critical care nurses. DESIGN: Meta-ethnography. DATA SOURCES: A comprehensive, systematic search in seven databases supplemented with hand, citation and reference search. Sources published from 2007 to 2019 were included. REVIEW METHODS: Noblit and Hare's understanding of meta-ethnography and the work of the eMERGE project have directed the synthesis. RESULTS: Nineteen studies were included and synthesized into a conceptual framework. Overarching theme: 'feeling safe and being safe', subtheme: 'creating confidence and motivation' and conceptual categories (CCs): 'technical skills and biophysical knowledge'; 'inter/intra professional teamwork skills'; 'communication skills (with patients and their relatives)'; 'constant and attentive bedside presence'; 'creating participative care'; 'creating confidence through daily care'; 'creating a good atmosphere and having a supportive and encouraging attitude'; and 'building relationship to maintain self-esteem'. CONCLUSION: By including the perspectives of intensive care patients, their relatives and intensive and critical care nurses, the core qualities and competencies comprise elements of both patient safety and the feeling of safety. The framework outlines concepts necessary to ensure person-centred and safe intensive care. Further research should involve each perspective to validate and strengthen the findings. IMPACT: The development of standards and competence guidelines expressing the learning outcomes and qualification of intensive and critical care nurses should be based on input from intensive care patients, their relatives and intensive and critical care nurses. A variety of core qualities and competencies are necessary to create confidence and motivation, and to make the patient feel safe and be safe. This conceptual framework might form a basis for development of a program or assessment tool to facilitate excellence in education and practice in intensive care.

Psychometric Testing of a Structured Assessment Instrument for Non-technical Skills (NANTS-no) for Use in Clinical Supervision of Student Nurse Anesthetists.

BACKGROUND: This study evaluated psychometric properties of a structured behavioral assessment instrument, Nurse Anaesthetists' Non-Technical Skills-Norway (NANTS-no). It estimated whether reliable assessments of nontechnical skills (NTS) could be made after taking part in a workshop. An additional objective was to evaluate the instrument's acceptability and usability. METHODS: An explorative design was used. Nurse anesthetists (n = 46) involved in clinical supervision attended a 6-hour workshop on NTS, then rated NTS in video-recorded simulated scenarios and completed a questionnaire. RESULTS: High reliability and dependability were estimated in this setting. Participants regarded the instrument as useful for clinical supervision of student nurse anesthetists (SNAs). CONCLUSIONS: Findings suggest that NANTS-no may be reliable for performing clinical assessments of SNAs and encouraging critical reflection. However, further research is needed to explore its use in clinical settings.

Safe and competent nursing care: An argument for a minimum standard?

There is no agreed minimum standard with regard to what is considered safe, competent nursing care. Limited resources and organizational constraints make it challenging to develop a minimum standard. As part of their everyday practice, nurses have to ration nursing care and prioritize what care to postpone, leave out, and/or omit. In developed countries where public healthcare is tax-funded, a minimum level of healthcare is a patient right; however, what this entails in a given patient's actual situation is unclear. Thus, both patients and nurses would benefit from the development of a minimum standard of nursing care. Clarity on this matter is also of ethical and legal concern. In this article, we explore the case for developing a minimum standard to ensure safe and competent nursing care services. Any such standard must encompass knowledge of basic principles of clinical nursing and preservation of moral values, as well as managerial issues, such as manpower planning, skill-mix, and time to care. In order for such standards to aid in providing safe and competent nursing care, they should be in compliance with accepted evidence-based nursing knowledge, based on patients' needs and legal rights to healthcare and on nurses' codes of ethics. That is, a minimum standard must uphold a satisfactory level of quality in terms of both professionalism and ethics. Rather than being fixed, the minimum standard should be adjusted according to patients' needs in different settings and may thus be different in different contexts and countries.

Visibility of nursing in policy documents related to health care priorities.

AIM: To explore the visibility of nursing in policy documents concerning health care priorities in the Nordic countries. BACKGROUND: Nurses at all levels in health care organisations set priorities on a daily basis. Such prioritization entails allocation of scarce public resources with implications for patients, nurses and society. Although prioritization in health care has been on the political agenda for many years, prioritization in nursing seems to be obscure in policy documents. METHODOLOGY: Each author searched for relevant documents from their own country. Text analyses were conducted of the included documents concerning nursing visibility. RESULTS: All the Nordic countries have published documents articulating values and criteria relating to health care priorities. Nursing is seldom explicitly mentioned but rather is included and implicit in discussions of health care prioritization in general. CONCLUSION: There is a need to make priorities in nursing visible to prevent missed nursing care and ensure fair allocation of limited resources. IMPLICATIONS FOR NURSING MANAGEMENT: To highlight nursing priorities, we suggest that the fundamental need for nursing care and what this implies for patient care in different organisational settings be clarified and that policymakers explicitly include this information in national policy documents.

Collaboration between home care staff, leaders and care partners of older people with mental health problems: a focus on personhood.

BACKGROUND: Collaboration with care partners is a political aim in recent white papers in Norway and internationally. Home care services regularly work closely with care partners, but there are many indications that the collaboration does not work satisfactorily. AIM: To explore home care staff and leaders' experiences of collaborating with care partners of older people with mental health problems through a personhood perspective. METHODS: The study had a qualitative design and comprised eight health professionals in two focus groups and in-depth interviews with three leaders in one home care district. The data were analysed using a thematic framework analysis building on previous research on personhood. criteria for reporting qualitative reporting guidelines were used to ensure comprehensive reporting. RESULTS: Four themes were identified in the analysis: 'non-negotiated relationships', 'contradictory agendas', 'weak paternalism' and 'moral compromise'. CONCLUSION: There seems to be a lack of facilitation of collaborative relationships through all levels of the home care organisation. The interactions between care partners and home care staff sometimes appear to produce low or negative levels of emotional energy, and situations where the personhood of neither of them is respected occurs. Paying attention to the four modes of being as a framework for understanding personhood creates the foundation for a person-centred approach that enhances the potential of creating stronger partnership in care relationships.

Patient classification systems used to classify nursing intensity and assess nursing staffing resources in home health care: A scoping review.

OBJECTIVES: To identify the patient classification systems used to classify nursing intensity in the assessment of nursing staffing resources currently used in home health care, with a special emphasis on validity, reliability and staff allocation. DESIGN: Scoping review of internationally published and grey literature, based on a methodological framework by Arksey and O'Malley. DATA SOURCES: Searches of the electronic databases Cinahl, Medline, Embase and SweMed, the websites Google and Google Scholar and hand searches of reference lists occurred. Eligibility criteria included (A) a focus on patient classification systems measuring nursing intensity and workload in home health care and (B) published in English between January 2007 and March 2019. In level one testing two team members screened titles and abstracts, in level two testing two team members determined which papers should undergo a full text review. Data were extracted using structured extraction by one team member and verified by two other members. RESULTS: Thirteen peer-reviewed articles and grey literature documents were identified, from Canada, Ireland, the UK, the USA, Scotland, Turkey and the Netherlands. Four patient classification systems had been tested for both validity and reliability. Validity was tested through face validity, predictive validity, concurrent validity or content validity index. Reliability was tested through stability, internal consistency, observer agreement or inter rater reliability. One patient classification system had been tested only for reliability, through interrater reliability and observer agreement. Two patient classification systems had been evaluated through summative evaluation; one qualitatively through focus group interviews and one through semi-structured interviews. Only one patient classification system had been validity and reliability tested and evaluated. Overall, the patient classification systems in the included papers (13) were considered to have benefits and to be appropriate for the measurement of patients' needs, workload and allocation of staff, although specific information was not always given. CONCLUSION: Little has been published on validity or reliability tested patient classification systems linked to staffing allocation in home health care in the past decade. Limited research was seen where a patient classification system was considered to be fully operational in home health care.

Invisible cornerstones. A hermeneutic study of the experience of care partners of older people with mental health problems in home care services.

OBJECTIVES: To explore the lived experiences and support needs of the care partners of older people with mental health problems living at home with assistance from home care services. Care partners face significant challenges in their care role and they often feel unsupported. An understanding of their experiences may help improve home care to support their needs. METHOD: An exploratory qualitative approach was used. The study is based on the SRQR and COREQ reporting guidelines. In-depth interviews were conducted with six Norwegian care partners from two municipalities. Data were collected during 2012-2013 and 2016. The data were analysed using Gadamer's hermeneutics. RESULTS: Three themes were identified: "invisible cornerstones," "dimensions of collaboration" and "unwanted roles." CONCLUSION: Few or no routines for collaboration exist between care partners and home care, and the care partners seem to have little knowledge of legal rights. They request more information, spare time and the opportunity to remain in their original family role. However, their main focus is for the patient to receive the necessary help from home care. Home care have restricted resources for meeting these needs and share a sense of powerlessness and lack of influence over their own everyday life with the care partners. There is a need for a systematic, person-centred approach to collaboration. A correlation is necessary between what is communicated at the system level and the means of realising this in practice for home care to meet care partners' needs.

Ethical elements in priority setting in nursing care: A scoping review.

BACKGROUND: Nurses are often responsible for the care of many patients at the same time and have to prioritise their daily nursing care activities. Prioritising the different assessed care needs and managing consequential conflicting expectations, challenges nurses' professional and moral values. OBJECTIVE: To explore and illustrate the key aspects of the ethical elements of the prioritisation of nursing care and its consequences for nurses. DESIGN, DATA SOURCES AND METHODS: A scoping review was used to analyse existing empirical research on the topics of priority setting, prioritisation and rationing in nursing care, including the related ethical issues. The selection of material was conducted in three stages: research identification using two data bases, CINAHL and MEDLINE. Out of 2024 citations 25 empirical research articles were analysed using inductive content analysis. RESULTS: Nurses prioritised patient care or participated in the decision-making at the bedside and at unit, organisational and at societal levels. Bedside priority setting, the main concern of nurses, focused on patients' daily care needs, prioritising work by essential tasks and participating in priority setting for patients' access to care. Unit level priority setting focused on processes and decisions about bed allocation and fairness. Nurses participated in organisational and societal level priority setting through discussion about the priorities. Studies revealed priorities set by nurses include prioritisation between patient groups, patients having specific diseases, the severity of the patient's situation, age, and the perceived good that treatment and care brings to patients. The negative consequences of priority setting activity were nurses' moral distress, missed care, which impacts on both patient outcomes and nursing professional practice and quality of care compromise. CONCLUSIONS: Analysis of the ethical elements, the causes, concerns and consequences of priority setting, need to be studied further to reveal the underlying causes of priority setting for nursing staff. Prioritising has been reported to be difficult for nurses. Therefore there is a need to study the elements and processes involved in order to determine what type of education and support nurses require to assist them in priority setting.

The third person in the room: The needs of care partners of older people in home care services-A systematic review from a person-centred perspective.

AIMS AND OBJECTIVES: To identify and synthesise the needs of care partners of older people living at home with assistance from home care services. BACKGROUND: "Ageing in place" is a promoted concept where care partners and home care services play significant roles. Identifying the needs of care partners and finding systematic ways of meeting them can help care partners to cope with their role. DESIGN/METHODS: This study is based on the PRISMA reporting guidelines. The systematic review of qualitative and quantitative studies was guided by the Joanna Briggs Institute methodology. RESULTS: In total, 16 studies were included in the review, eleven qualitative and five quantitative. Three main categories were revealed in the analysis: the need for quality interaction, the need for a shared approach to care and the need to feel empowered. CONCLUSION: Care partners of older people have several, continuously unmet needs. A person-centred perspective can contribute new understandings of how to meet these needs. A knowledge gap has been identified regarding the needs of care partners of older people with mental health problems. There is a need to develop a tool for systematic collaboration between home care services and care partners, so that the identified needs can be met in a more thorough, systematic and person-centred way. RELEVANCE TO CLINICAL PRACTICE: The carers in home care services need competence to identify and meet the needs of care partners. The implementation of person-centred values in home care services can contribute to meet the needs of care partners to a greater extent than today. Future research on the needs of care partners of older people with mental health problems needs to be undertaken.

Care-managers' professional choices: ethical dilemmas and conflicting expectations.

BACKGROUND: Care-managers are responsible for the public administration of individual healthcare decisions and decide on the volume and content of community healthcare services given to a population. The purpose of this study was to investigate the conflicting expectations and ethical dilemmas these professionals encounter in their daily work with patients and to discuss the clinical implications of this. METHODS: The study had a qualitative design. The data consisted of verbatim transcripts from 12 ethical reflection group meetings held in 2012 at a purchaser unit in a Norwegian city. The participants consist of healthcare professionals such as nurses, occupational therapists, physiotherapists and social workers. The analyses and interpretation were conducted according to a hermeneutic methodology. This study is part of a larger research project. RESULTS: Two main themes emerged through the analyses: 1. Professional autonomy and loyalty, and related subthemes: loyalty to whom/what, overruling of decisions, trust and obligation to report. 2. Boundaries of involvement and subthemes: private or professional, care-manager or provider and accessibility. CONCLUSIONS: Underlying values and a model illustrating the dimensions of professional responsibility in the care-manager role are suggested. The study implies that when allocating services, healthcare professionals need to find a balance between responsibility and accountability in their role as care-managers.

Ethical challenges related to next of kin - nursing staffs' perspective.

BACKGROUND: Patients in clinical settings are not lonely islands; they have relatives who play a more or less active role in their lives. OBJECTIVES: The purpose of this article is to elucidate the ethical challenges nursing staff encounter with patients' next of kin and to discuss how these challenges affect clinical practice. RESEARCH DESIGN: The study is based on data collected from ethical group discussions among nursing staff in a nursing home. The discussions took place in 2011 and 2012. The data were analysed and interpreted by using hermeneutic methodology. ETHICAL CONSIDERATIONS: All the data have been anonymised and handled with confidentiality. Written informed consent was obtained from all participants. FINDINGS: Ethical challenges relating to patients' next of kin were found to be an issue frequently discussed in the groups. Our findings indicate that next of kin have different characteristics, categorised as 'the professionals' and 'the shadows'. In this article, we will describe the next of kin's characteristics and the ethical challenges and practical implications that nursing staff experience in this connection. DISCUSSION: We will discuss the findings in the light of the four basic principles of medical ethics and propose interventions to help nurses manage ethical challenges related to next of kin. CONCLUSION: The study reveals the need to enhance nursing staffs' communicative and ethical skills on an individual level, but most importantly, to establish routines in clinical settings for informing and following up next of kin in a systematic and structured way.

Rationing home-based nursing care: professional ethical implications.

The purpose of this study was to investigate nurses' decisions about priorities in home-based nursing care. Qualitative research interviews were conducted with 17 nurses in home-based care. The interviews were analyzed and interpreted according to a hermeneutic methodology. Nurses describe clinical priorities in home-based care as rationing care to mind the gap between an extensive workload and staff shortages. By organizing home-based care according to tight time schedules, the nurses' are able to provide care for as many patients as possible. Furthermore, legal norms set boundaries for clinical priority decisions, resulting in marginalized care. Hence, rationing care jeopardizes important values in the nurse-patient relationship, in particular the value of individualized and inclusive nursing care. The findings are highly relevant for clinical practice, since they have major implications for provision of nursing care. They revive debates about the protection of values and standards of care, and nurses' role and responsibility when resources are limited.

Fair nursing care when resources are limited: the role of patients and family members in Norwegian home-based services.

The purpose of the study was to investigate nurses' priority decisions and the provision of home-based nursing care services. Interviews were conducted with 17 nurses in various positions in this service. The data were interpreted and analyzed according to interpretive hermeneutic methodology. The authors particularly address the nurses' descriptions of the role of the patient and his or her family members for the provision of home-based care. Cooperative patients and family members represent an important resource for care and can make it possible for nurses to provide services for all the patients on an egalitarian basis and to prioritize those who live alone. However, demanding and resourceful patients and family members may "rule" the service at the expense of other patients who also have legitimate care needs--a practice that the nurses describe as unfair. In this article, the authors discuss how a fair and impartial distribution of common benefits can be achieved without some parties being unjustly treated.