Measuring interpersonal continuity in high-frequency home healthcare services.

AIM: To provide a method for assessing the degree of interpersonal continuity adapted to context and to measure and assess the degree of interpersonal continuity for long-term recipients dependent on daily home health care. BACKGROUND: Interpersonal continuity is important to the quality of care for long-term dependents. In high-frequency home healthcare services where patients receive daily care from many nurses or other health personnel over time, interpersonal continuity may be difficult to attain. DESIGN: A cross-sectional study with a descriptive design. METHODS: Information concerning 79 patients receiving long-term frequent care was collected during four weeks in a maximum variation sample of Norwegian municipalities, from January 2009-May 2010. We measured interpersonal continuity objectively using indices of dispersion and the next-day sequence of health personnel. For each measure, we computed the highest feasible level of continuity that could be attained in this home healthcare context given a standard shift plan. This level was then used as benchmark against which the actual level of continuity was assessed. RESULTS: Patients received on average 51 visits from a mean of 17 different carers during four weeks. The results revealed a low degree of interpersonal continuity in practice, far below what was feasible according to the benchmarks. CONCLUSION: High-frequency home health care was characterized by interpersonal discontinuity, but with potential for improvement. Objective measures of interpersonal continuity, when the benchmark is adapted to the context, are useful tools for planning and surveying continuity of care.

Real teams and their effect on the quality of care in nursing homes.

BACKGROUND: Use of teams has shown to be an important factor for organizational performance. However, research has shown that a team has to meet certain criteria and operate in a certain way to realize the potential benefits of team organizing. There are few studies that have examined how teams operate in the nursing home sector and their effect on quality of care. This study investigates the relationship between teams that meet an academic definition of the team concept and quality of care in nursing homes. METHODS: A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilized to test our research question: (1) self-report questionnaires to 444 employees, (2) interviews with 40 ward managers, (3) self-report questionnaires to 40 ward managers, (4) telephone interviews with 378 relatives, and (5) 900 hours of field observations. Use of teams in nursing home wards was assessed by field observations and by interviews with ward mangers. Quality of care was assessed by data from surveys and interviews with relatives and staff and through field observations. All data were aggregated to the ward level and two-level analyses were used to assess the relationships. RESULTS: The multi-level analyses showed that teams - as operationalized in the present study - were significantly positively related to two out of the three quality of care indices when controlled for ward size, days of sick leave and care level. One significant interaction effect was found between teams and days of sick leave, implying that the effect of teams decreased with higher numbers of days of sick leave. CONCLUSIONS: The results suggest that teams are related to higher levels of quality of care in nursing homes. However, the study shows that there is a substantial difference between real, functional teams that meet an academic definition of the concept and quasi teams, the latter having a significantly lower effect on quality of care. Hence, nursing home leaders, directors and ward leaders should be aware of the substantial differences betweens dysfunctional - or quasi - teams and real teams, and encourage the development of real functional teams to take advantage of the potential benefits of team organizing.

A collaborative chain out of phase.

INTRODUCTION: The aim of this study is to explore the obstacles to collaborations between nurses in hospital and municipal care in the discharge of hospital patients who need continuing care. METHODS: First, we conducted in-depth interviews of nurses in hospitals and nurses in municipal care. Second, we developed questionnaires and distributed them to a representative sample of Norwegian municipalities to study the representativeness of the most important findings from the interviews. RESULTS: Municipal care nurses reported that the information they receive from hospital departments usually is insufficient for a complete understanding of a patient's needs. Formal discharge reports from hospital serve as a post factum formalization and authorization of information collected by municipal nurses in an ad hoc fashion and via oral communication. Typically, formal information routines are out of phase with the information needed by municipal care professionals. CONCLUSIONS: Hospital information provided at discharge is neither sufficient nor timely with respect to the information needs of nurses in municipal care. Organizational efforts and the use of information technology might ease some obstacles, but several problems will remain because of differences in professional orientation and the contexts of care delivery.

Promoting coordination in Norwegian health care.

INTRODUCTION: The Norwegian health care system is well organized within its two main sectors-primary health and long-term care on the one hand, and hospitals and specialist services on the other. However, the relation between them lacks mediating structures. POLICY PRACTICE: Enhancing coordination between primary and secondary health care has been central in Norwegian health care policy in the last decade. In 2003 a committee was appointed to identify coordination problems and proposed a lot of practical and organisational recommendations. It relied on an approach challenging primary and secondary health care in shared geographical regions to take action. However, these proposals were not implemented. In 2008 a new Minister of Health and Care worked out plans under the key term "Coordination Reform". These reform plans superseded and expanded the previous policy initiatives concerning cooperation, but represented also a shift in focus to a regulative and centralised strategy, including new health legislation, structural reforms and use of economic incentives that are now about to be implemented. DISCUSSION: The article analyses the perspectives and proposals of the previous and the recent reform initiatives in Norway and discusses them in relation to integrated care measures implemented in Denmark and Sweden.

Leadership, staffing and quality of care in nursing homes.

BACKGROUND: Leadership and staffing are recognised as important factors for quality of care. This study examines the effects of ward leaders' task- and relationship-oriented leadership styles, staffing levels, ratio of registered nurses and ratio of unlicensed staff on three independent measures of quality of care. METHODS: A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilised: self-report questionnaires to 444 employees, interviews with and questionnaires to 13 nursing home directors and 40 ward managers, telephone interviews with 378 relatives and 900 hours of field observations. Separate multi-level analyses were conducted for quality of care assessed by relatives, staff and field observations respectively. RESULTS: Task-oriented leadership style had a significant positive relationship with two of the three quality of care indexes. In contrast, relationship-oriented leadership style was not significantly related to any of the indexes. The lack of significant effect for relationship-oriented leadership style was due to a strong correlation between the two leadership styles (r=0.78). Staffing levels and ratio of registered nurses were not significantly related to any of the quality of care indexes. The ratio of unlicensed staff, however, showed a significant negative relationship to quality as assessed by relatives and field observations, but not to quality as assessed by staff. CONCLUSIONS: Leaders in nursing homes should focus on active leadership and particularly task-oriented behaviour like structure, coordination, clarifying of staff roles and monitoring of operations to increase quality of care. Furthermore, nursing homes should minimize use of unlicensed staff and address factors related to high ratios of unlicensed staff, like low staff stability. The study indicates, however, that the relationship between staffing levels, ratio of registered nurses and quality of care is complex. Increasing staffing levels or the ratio of registered nurses alone is not likely sufficient for increasing quality of care.

Quality work in long-term care: the role of first-line leaders.

OBJECTIVE: To explore the first-line leaders' role in quality work in long-term care in Norway, in order to determine how that work is related to such success characteristics as leadership, staff, patients, performance, information and information technology. DESIGN: Cross-sectional telephone survey. The text was analysed using content analysis. SETTING: Thirty-two Norwegian municipalities stratified according to region and population size. PARTICIPANTS: Sixty-four first-line leaders in nursing homes and home-based care. Main outcome measure The clinical microsystem approach is used as a framework by defining and designing measureable variables. RESULTS: Thirty-six leaders described how they initiated and motivated employees to be active in quality work; the remaining leaders indicated that they played a passive role. The first-line leaders played a key role in implementing national quality policies and regulations. The quantity of other success characteristics was low. CONCLUSIONS: The municipalities delegated the responsibility of implanting national policies to the first-line leaders. Missing were key quality success criteria such as macro- and meso-perspectives for the municipality as a whole and co-operation with other leaders in the organization and fostering of relevant learning. Quality work was fragmented rather than comprehensive and systematic.

Quality improvement in a publicly provided long-term care system: the case of Norway.

OBJECTIVE: To explore the extent to which quality improvement activities are implemented in the Norwegian long-term care system for older people, and to determine if variations in the extent and scope of quality improvement activities are associated with the characteristics of the first-line care leaders, the sector or the size of the municipality. DESIGN: A cross-sectional telephone survey supplemented with information from public records and official municipal websites. Data were organized according to six total quality management components, and a sum score was developed to measure quality improvement. Variations in the extent of quality improvement activities were analysed using multivariate analysis. SETTING: Thirty-two Norwegian municipalities stratified according to region and population size. PARTICIPANTS: Sixty-four first-line leaders in nursing homes and home-based care. MAIN OUTCOME MEASURE: A sum score has been used as a measure of quality improvement activities. RESULTS: The unit's quality improvement activities varied by quality improvement components and by municipality. The technical component that requires training in tools and techniques was low; the general components as 'leader's involvement' and 'employee participation' were more common. The size of the populations of the municipalities showed a significant independent association with the scope of quality activities. CONCLUSIONS: The six quality improvement components varied from high to extremely low, and the large municipalities had more quality activities than small- or medium-sized municipalities.

[Health care sector in TV news]. / Helsevesenet på Dagsrevyen.

BACKGROUND: This paper documents how the main Norwegian TV news programme "Dagsrevyen" approaches the health care sector and discusses some effects its approach may have on public opinion. MATERIAL AND METHODS: Data on 1116 programmes aired between 1996 and 2003 period were analysed. Stories were coded by place in the news sequence, subject, who were interviewed, and what kind of message (positive, neutral, negative) the stories were giving. RESULTS: During the first years of the period in question, Dagsrevyen almost daily brought stories from the health care sector, often among its top stories. In the later years, the coverage was cut by 50%. Stories on the workings of the health care services, their funding, and the treatment of patients dominated. Patients and professionals, particularly doctors, were the most frequently interviewed. About one in two of the stories had a negative message, one in four a positive message. Stories presented early on in the programme were most often negative; this tendency did, however, become weaker over time. INTERPRETATION: The number of stories from the health care sector is mainly influenced by competition from other media and by programming policies. The angle of presentation chosen, the topics and the messages correspond to the ideals of "storytelling with pictures", which TV newscasters adopted in the mid-1990s. Repetitive negative coverage of the health care system contributes to forming public opinion and policy. This type of news coverage represents a pressure towards a search for new policies.

Trajectories of disability among the oldest old.

OBJECTIVES: This study analyzes trajectories of disability from onset until death in an 80+ population. METHODS: The study population (N = 434) consists of all persons born before 1902 living in the town of Larvik, Norway, in January 1981 (N = 434). By registering illnesses and activities of daily living (ADL) limitations, each participant was followed until the last one died in 1999. RESULTS: Main trajectories of disability were (a) serious dementia, (b) severely dependent, (c) frail, and (d) fairly healthy. Multivariate analyses show significant effects of gender and age but no effect of socioeconomic status (SES) and marital status on the probability of entering one of four main trajectories. DISCUSSION: Although there are many exceptions, the trajectory of disability among the oldest old most often takes a serious course, particularly among women.