How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative study.

BACKGROUND: Patient incident reporting systems have been widely used for ensuring safety and improving quality in care settings in many countries. However, little is known about the way in which incident data are used by frontline clinical staff. Furthermore, while the use of a systems perspective has been reported as an effective way of learning from incident data in a multidisciplinary team, the level of adaptability of this perspective to a different cultural context has not been widely explored. The primary aim of the study, therefore, was to investigate how healthcare practitioners in Japan perceive the reporting systems and utilize a systems perspective in learning from incident data in acute care and mental health settings. METHODS: A non-experimental, descriptive and exploratory research design was adopted with the following two data-collection methods: 1) Sixty-one semi-structured interviews with frontline staff in two hospitals; and 2) Non-participatory observations of thirty-seven regular incident review meetings. The two hospitals in the Greater Tokyo area which were invited to take part were: 1) a not-for-profit, privately-run, acute care hospital with approximately 500 beds; and 2) a publicly-run mental health hospital with 200 beds. RESULTS: While the majority of staff acknowledge the positive impacts of the reporting systems on safety, the observation data found that little consideration was given to systems aspects during formal meetings. The meetings were primarily a place for the exchange of practical information, as opposed to in-depth discussions regarding causes of incidents and corrective measures. Learning from incident data was influenced by four factors: professional boundaries; dealing with a psychological burden; leadership and educational approach; and compatibility of patient safety with patient-centered care. CONCLUSIONS: Healthcare organizations are highly complex, comprising of many professional boundaries and risk perceptions, and various communication styles. In order to establish an optimum method of individual and organizational learning and effective safety management, a fine balance has to be struck between respect for professional expertise in a local team and centralized safety oversight with a strong focus on systems. Further research needs to examine culturally-sensitive organizational and professional dynamics, including leader-follower relationships and the impact of resource constraints.

Multidisciplinary pharmacotherapy collaboration for home-based older adults with dementia: a study focusing on physicians, pharmacists, and nursing professionals.

BACKGROUND: It is imperative that a team consisting of a physician, pharmacist, and nursing professional provides pharmacotherapy support to achieve the optimal effect of pharmacotherapy for older adults with dementia. This study reviewed Japanese publications on the process of pharmacotherapy support practised by various professionals for home-based older adults with dementia and investigated healthcare professionals' perceived importance and practice of pharmacotherapy support. METHODS: This study aimed to shed light on basic pharmacotherapy support for behavioural and psychological symptoms among home-based older adults with dementia using multidisciplinary collaboration, through a literature review of Japanese publications. Based on the literature review, 13 items pertaining to basic pharmacotherapy support for home-based older adults with dementia were extracted. A mail-based, self-administered, anonymous questionnaire survey was conducted with professionals including physicians, pharmacists, and nursing professionals who provide pharmacotherapy support to home-based older adults with dementia. Participants rated 13 items on their perceived importance and practice of basic pharmacotherapy support using a four-point Likert scale. RESULTS: The results indicated that participants recognised the importance of all 13 items. At least 80% of all professionals indicated that they practised seven out of 13 items. Less than 80% of all professionals indicated they practised the other six items that should be provided after the commencement of pharmacotherapy. A relatively high proportion of nursing professionals (70%) indicated they practised the remaining six items. The 13 items were indeed deemed important for characterising pharmacotherapy support. However, in Japan, suboptimal support is provided following the commencement of medication. This may be because appropriate modifications to dementia care are not made as the patient's condition progresses. CONCLUSIONS: It is suggested that multidisciplinary collaboration focusing on the progression of dementia and the process of pharmacotherapy, especially after the commencement of pharmacotherapy, may help provide effective, continuous pharmacotherapy.

Practitioners' identification of informal caregivers' difficulties with activities of daily living interventions for older people with dementia in Japan.

BACKGROUND: Older people with dementia who cannot perform daily activities independently due to cognitive impairment need support at home and in the community. This study identified aspects of activities of daily living (ADL) interventions that advanced dementia care practitioners recognise as challenging for informal caregivers to perform. METHODS: We conducted a self-administered cross-sectional survey on advanced dementia care practitioners, including certified nurses, specialising in gerontological, community health, home care, and visiting nursing, nurses specialising in dementia certified by the Japanese Nursing Association, and dementia care leaders certified by prefectural governors. The participants rated a caregivers' extent of difficulty in aspects of ADL interventions on a four-point Likert scale. Factor analysis was performed to determine ADL intervention aspects that are recognised by advanced dementia care practitioners as challenging for informal caregivers. RESULTS: The highest loaded factors for mild, moderate, and severe cognitive impairment stages were 'right time to draw attention,' 'opportunities to perform ADL,' and 'communicating how to perform ADL without giving up,' respectively. Therefore, it is imperative to educate informal caregivers about the effects of cognitive impairment on ADL performance in people with dementia and enable them to provide concrete ADL interventions and tips to support the persons' autonomy and independence. The Cronbach's alpha values of the highest loaded factors for mild, moderate, and severe cognitive impairment stages were 0.851, 0.925, and 0.946, respectively. Moreover, the cumulative contribution ratios of each stage were 46.04%, 50.52%, and 47.36%, respectively. CONCLUSION: This study dealt with identifying informal caregivers' difficulties with ADL interventions across the stages of dementia. Informal caregivers should be supported on aspects of ADL interventions that are potentially difficult for them to perform. Useful educational content and approaches in training programs for informal caregivers should be developed to enable them to help people with Alzheimer's disease maintain ADL performance toward 'ageing in place' even as the disease progresses.

Difficulties and associated coping methods regarding visual hallucinations caused by dementia with Lewy bodies.

Individuals who have dementia with Lewy bodies present various symptoms that differ from those associated with Alzheimer's disease. Of the several characteristic symptoms of dementia with Lewy bodies, visual hallucinations often appear in the early stages of the disease, and some hallucinations cause people with dementia with Lewy bodies to experience unique difficulties in their daily lives. The aim of this paper is to clarify the visual hallucination-related difficulties experienced by people with dementia with Lewy bodies as well as their coping methods. Participants were 10 people with dementia with Lewy bodies who were living at home, with input also obtained from their family members. Data were collected through semi-structured interviews, and a qualitative content analysis was consequently performed. The qualitative analysis showed four primary difficulties in the period before a patient realizes that their visual hallucinations are a symptom of an underlying disease; these included "feeling something strange is happening" and "restrictions on activities." Realizing that what they were experiencing was not real was a significant turning point for the participants, with some discovering this by discussing their apparitions with their families. It was consequently determined that, after an individual realizes that their hallucinations are indicative of a more serious condition, two further difficulties arise, including the "inability to discuss the visual hallucinations with friends and family." With regard to coping methods, some participants reported rearranging their living environments to hide areas where hallucinations commonly appeared. This paper suggests that care is needed to help people with dementia with Lewy bodies recognize that their visual hallucinations are a manifestation of their illness. In particular, psychological support should be made available to address the anxiety caused by the appearance of visual hallucinations and to help patients adjust their environments to reduce or prevent the appearance of such hallucinations.

Characteristics of care methods for daily life disabilities in Alzheimer's type dementia that respect autonomy and independence.

AIM: To clarify the characteristics of appropriate care methods for people with daily life disabilities due to Alzheimer's type dementia. DESIGN: A cross-sectional survey study. METHODS: A survey was implemented targeting 2,156 advanced care practitioners for dementia. The postal, self-administered anonymous questionnaire was rated on a 4-point Likert scale to assess the benefits of care for daily life disabilities depending on severity. We conducted factor analysis to determine characteristics of the appropriate care. RESULTS: There were 568 valid responses, a valid response rate of 26.3%. The characteristics found were "Simplicity of necessities" and "Communication using verbal language on what should be done next" for mild cases; "Opportunities for completion of a task are provided with verbal communication," "Marks" and "Arrange the environment with verbal communication" for moderate cases; and "Explain the process in the order of each individual action," "Prevent non-starts and interruptions" and "Confirm intention" for severe cases.